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Asthma is a leading cause of chronic illness in childhood, responsible for a significant proportion of school days lost because of chronic

illness. Asthma is the most frequent admitting diagnosis in children's hospitals and results nationally in 5{endash}7 lost school days/yr/child. As many as 10{endash} 15% of boys and 7{endash} 10% of girls may have asthma at some time during childhood. Before puberty approximately twice as many boys as girls are affected; thereafter, the sex incidence is equal. Asthma can lead to severe psychosocial disturbances in the family. With proper treatment, however, satisfactory control of symptoms is almost always possible. There is no universally accepted definition of asthma; it may be regarded as a diffuse, obstructive lung disease with (1) hyperreactivity of the airways to a variety of stimuli and (2) a high degree of reversibility of the obstructive process, which may occur either spontaneously or as a result of treatment. Also known as reactive airway disease, the asthma complex probably includes wheezy bronchitis, viral-associated wheezing, and atopic related asthma. In addition to bronchoconstriction, inflammation is an important pathophysiologic factor; it involves eosinophils, monocytes, and immune mediators and has resulted in the alternative designation of chronic desquamating eosinophilic bronchitis. Both large (>2 mm) and small (<2 mm) airways may be involved to varying degrees. Irritability or hyper-reactivity of the airways, while not limited to asthmatic patients, appears to be an intrinsic part of the disease and is present to some degree in almost all asthmatic subjects. This hyper-responsiveness manifests itself as bronchoconstriction following exercise; on natural exposures to strong odors or irritant fumes such as sulfur dioxide, tobacco smoke, or cold air; and upon intentional exposures in the laboratory to inhalations of histamine or parasympathomimetic agents such as methacholine (Mecholyl). This heightened airway irritability is a sensitive objective indicator of asthma and is present to some degree when patients are asymptomatic, free of abnormal physical findings, and capable of normal findings on spirometry. Airway hyper-reactivity relates to the overall severity of the disease. It varies from patient to patient but generally is relatively stable over time in the same patient except for temporary fluctuations; increased reactivity occurs during viral respiratory infections, following exposure to air pollutants and to allergens or to occupational chemicals in sensitized individuals, and following administration of b{beta}-receptor antagonists. An acute decrease in airway irritability follows administration of b{beta}-receptor agonists, theophylline, and anticholinergics, and decreased irritability follows chronic administration of cromolyn, nedocromil, or systemic or inhaled corticosteroids. Data on the inheritance of asthma are most compatible with polygenic or multifactorial determinants. A child with one affected parent has about a 25% risk of having asthma; the risk increases to about 50% if both parents are asthmatic. However, asthma is not universally present among monozygotic twins. Lability of bronchoconstriction with exercise is concordant in identical twins but not in dizygotic twins. Bronchial lability in response to exercise testing also has been demonstrated in healthy relatives of asthmatic children. A genetic predisposition combined with environmental factors may explain most cases of childhood asthma. EPIDEMIOLOGY. Asthma may have its onset at any age; 30% of patients are symptomatic by 1 yr of age, whereas 80{endash}90% of asthmatic children have their first symptoms before 4{endash} 5 yr of age. The course and severity of asthma are difficult to predict. The majority of affected children have only occasional attacks of slight to moderate severity, managed with relative ease. A minority experience severe, intractable asthma, usually perennial rather than seasonal; it is incapacitating and interferes with school attendance, play activity, and day-today functioning. The relationship of age of onset to prognosis is uncertain; most severely affected children have onset of wheezing during the 1st yr of life and family histories of asthma and other allergic diseases (particularly atopic dermatitis). These children may have growth retardation unrelated to corticosteroid administration, chest deformity secondary to chronic hyperinflation, and persistent abnormalities on pulmonary function testing. The prognosis for young asthmatic children is generally good. Ultimate remission depends partly upon growth in the cross-sectional diameter of the airways. Longitudinal studies indicate that about 50% of all asthmatic children are virtually free of symptoms within 10{endash} 20 yr, but recurrences are common in adulthood. In children who have mild asthma with onset between 2 yr and puberty, the remission rate is about 50%, and only 5% experience severe disease. In contrast, children with severe asthma characterized by chronic steroid-dependent disease with frequent hospitalizations rarely improve, and about 95% become asthmatic adults. Whether the

hyperirritability of their airways ever disappears is unknown; abnormal responsiveness to methacholine inhalation in formerly asthmatic patients has been found as long as 20 yr after symptoms have abated. Both prevalence and mortality from asthma have increased during the last 2 decades. The causes of the increased prevalence are unknown, but some of the factors associated with both onset of asthma and increased mortality have been identified. Risk factors for the occurrence of asthma include poverty, black race, maternal age less than 20 yr at the time of birth, birthweight less than 2,500 gm, maternal smoking (more than one-half pack per day), small home size (<eight rooms), large family size ({greater than or equal}six members), and intense allergenic exposure in infancy (more than 10 m{mu}g of house dust mite allergen Der p I per gram of dust collected from homes). Additional risk factors may include frequent respiratory infections in early childhood and less than optimal parenting. Sensitization to inhalant allergens can occur in infancy, but it becomes increasingly frequent beyond 2 yr of age and is demonstrable in most children beyond 4 yr of age who require emergency room visits for wheezing. Risk factors for death from asthma include underestimation of severity of asthma, delay in implementation of appropriate treatment, underuse of bronchodilators and corticosteroids, black race, noncompliance with recommendations for management, psychosocial dysfunction and stress that may interfere with compliance or perception of increasing airway obstruction, sedation, and excessive allergenic exposure. Recent emergency treatment or recent admission to a hospital for asthma increases the risk of fatal asthma. Patients subject to sudden, severe airway obstruction and those with chronic, steroid-dependent asthma are at especially high risk for fatal asthma. PATHOPHYSIOLOGY. Manifestations of the airway obstruction in asthma are due to bronchoconstriction, hypersecretion of mucus, mucosal edema, cellular infiltration, and desquamation of epithelial and inflammatory cells. Various allergic and nonspecific stimuli, in the presence of hyper-reactive airways, initiate the bronchoconstriction and inflammatory response. These stimuli include inhaled allergens (dust mites, pollens, soybean or castor bean proteins), other vegetable proteins, viral infection, cigarette smoke, air pollutants, odors, drugs (nonsteroid anti-inflammatory agents, b{beta}-receptor antagonists, metabisulfite), cold air, and exercise. The pathology of severe asthma includes bronchoconstriction, bronchial smooth muscle hypertrophy, mucous gland hypertrophy, mucosal edema, infiltration of inflammatory cells (eosinophils, neutrophils, basophils, macrophages), and desquamation. Pathognomonic findings include Charcot-Leyden crystals (lysophospholipase from eosinophil membranes), Curschmann spirals (bronchial mucous casts), and Creola bodies (desquamated epithelial cells). Newly synthesized and stored mediators are released from local mucosal mast cells following nonspecific stimulation or the binding of allergens to specific mast cell-associated immunoglobulin (Ig) E. Mediators such as histamine, leukotrienes C4, D4, and E4, and platelet activating factor initiate bronchoconstriction, mucosal edema, and the immune responses (see Chapter 133). The early immune response results in bronchoconstriction, is treatable with b{beta}2-receptor agonists, and may be prevented by mast cell{endash}stabilizing agents (cromolyn or nedocromil). The late immune response occurs 6{endash} 8 hr later, produces a continued state of airway hyper-responsiveness with eosinophilic and neutrophilic infiltration, can be treated and prevented by steroids, and can be prevented by cromolyn or nedocromil. Obstruction is most severe during expiration because the intrathoracic airways normally become smaller during expiration. Although the airway obstruction is diffuse, it is not entirely uniform throughout the lungs. Segmental or subsegmental atelectasis may occur, aggravating mismatching of ventilation and perfusion (Fig. 137 {endash}1 Fig. 137{endash}1). Hyperinflation causes decreased compliance, with consequently increased work of breathing. Increased transpulmonary pressures, necessary for expiration through obstructed airways, may cause further narrowing or complete premature closure of some airways during expiration, thus increasing the risk of pneumothorax. Increased intrathoracic pressure may interfere with venous return and reduce cardiac output, which may be manifested as a pulsus paradoxus. Mismatching of ventilation with perfusion, alveolar hypoventilation, and increased work of breathing cause changes in blood gases (see Fig. 137{endash}1 Fig. 137{endash}1). Hyperventilation of some regions of the lung compensates initially for the higher carbon dioxide tension in blood that perfuses poorly ventilated regions.

However, it cannot compensate for hypoxemia while breathing room air because of the patient's inability to increase the partial pressure of oxygen and oxyhemoglobulin saturation. Further progression of airway obstruction causes more alveolar hypoventilation, and hypercapnia may occur suddenly. Hypoxia interferes with conversion of lactic acid to carbon dioxide and water, causing metabolic acidosis. Hypercapnia increases carbonic acid, which dissociates into hydrogen ions and bicarbonate ions, causing respiratory acidosis. Hypoxia and acidosis can cause pulmonary vasoconstriction, but cor pulmonale resulting from sustained pulmonary hypertension is not a common complication of asthma. Hypoxia and vasoconstriction may damage type II alveolar cells, diminishing production of surfactant, which normally stabilizes alveoli. Thus, this process may aggravate the tendency toward atelectasis. ETIOLOGY. Asthma is a complex disorder involving autonomic, immunologic, infectious, endocrine, and psychologic factors in varying degrees in different individuals. The control of the diameter of the airways may be considered a balance of neural and humoral forces. Neural bronchoconstrictor activity is mediated through the cholinergic portion of the autonomic nervous system. Vagal sensory endings in airway epithelium, termed cough or irritant receptors, depending upon their location, initiate the afferent limb of a reflex arc, which at the efferent end stimulates bronchial smooth muscle contraction. Vasoactive intestinal peptide (VIP) neurotransmission initiates bronchial smooth muscle relaxation. VIP may be a dominant neuropeptide involved in maintaining airway patency. Humoral factors favoring bronchodilation include the endogenous catecholamines that act on b{beta}-adrenergic receptors to produce relaxation in bronchial smooth muscle. When local humoral substances such as histamine and leukotrienes are released through immunologically mediated reactions, they produce bronchoconstriction, either by direct action on smooth muscle or by stimulation of the vagal sensory receptors. Locally produced adenosine, which binds to a specific receptor, may contribute to bronchoconstriction. Methylxanthines are competitive antagonists of adenosine. Asthma may be due to abnormal b{beta}-adrenergic receptor-adenylate cyclase function, with decreased adrenergic responsiveness. Reports of decreased numbers of b{beta}-adrenergic receptors on leukocytes of asthmatic patients may provide a structural basis for hyporesponsiveness to b{beta}-agonists. Alternatively, increased cholinergic activity in the airway has been proposed as a defect in asthma, perhaps due to some intrinsic or acquired abnormality in irritant receptors, which seem in asthmatic patients to have lower than normal thresholds for response to stimulation. Neither theory reconciles all the data. In individual patients a number of factors generally contribute in varying degrees to the activity of the asthmatic process. Immunologic Factors. In some patients with so-called extrinsic or allergic asthma, exacerbations follow exposure to environmental factors such as dust, pollens, and danders. Often but not always, such patients have increased concentrations both of total IgE and of specific IgE against the allergen implicated. In other patients with clinically similar asthma, there is no evidence of IgE involvement; skin tests are negative and IgE concentrations low. This form of asthma, which is seen most often in the first 2 yr of life and in older adults (late-onset asthma), has been called intrinsic. The distinction between intrinsic and extrinsic asthma may be artificial because the basic immune mediator-induced mucosal injury is similar in both groups. Extrinsic asthma may be associated with more easily identified stimuli of mediator release than intrinsic asthma. Patients of all ages with asthma usually have elevated serum IgE levels, suggesting an allergic-extrinsic component in most patients. Although increased IgE levels may be due to atopy, chronic nonspecific stimulation of the mast cell allergen-induced late-phase immune reactions creates a prolonged nonspecific airway hyper-reactivity, which can produce bronchospasm in the absence of identifiable extrinsic factors. Viral agents are the most important infectious triggers of asthma. Early in life respiratory syncytial virus (RSV) and parainfluenza virus are most often involved; in older children rhinoviruses have also been implicated. Influenza virus infection assumes importance with increasing age. Viral agents may act to initiate asthma through stimulation of afferent vagal receptors of the cholinergic system in the airways. An IgE response to RSV can occur in infants and children with RSV-associated wheezing but not in those whose RSV respiratory disease is without associated wheezing. Wheezing with RSV infection may unmask a predisposition to asthma.

Endocrine Factors. Asthma may worsen in relation to pregnancy and menses, especially premenstrually, or may have its onset in women at the menopause. It improves in some children at puberty. Little else is known about the role of endocrine factors in the etiology or pathogenesis of asthma. Thyrotoxicosis increases the severity of asthma; the mechanism is unknown. Psychologic Factors. Emotional factors can trigger symptoms in many asthmatic children and adults, but "deviant" emotional or behavioral characteristics are not more common among asthmatic children than among children with other chronic disabling illnesses. On the other hand, the effects of severe chronic illness such as asthma on children's views of themselves, their parents' views of them, or their lives in general can be devastating. Emotional or behavioral disturbances are related more closely to poor control of asthma than to the severity of the attack itself; accordingly, skillful medical intervention can have an important impact. CLINICAL MANIFESTATIONS. The onset of an asthma exacerbation may be acute or insidious. Acute episodes are most often caused by exposure to irritants such as cold air and noxious fumes (smoke, wet paint) or exposure to allergens or simple chemicals, for example, aspirin or sulfites. When airway obstruction develops rapidly in a few minutes, it is most likely due to smooth muscle spasm in large airways. Exacerbations precipitated by viral respiratory infections are slower in onset, with gradual increases in frequency and severity of cough and wheezing over a few days. Because airway patency decreases at night, many children have acute asthma at this time. The signs and symptoms of asthma include cough, which sounds tight and is nonproductive early in the course of an attack; wheezing, tachypnea, and dyspnea with prolonged expiration and use of accessory muscles of respiration; cyanosis; hyperinflation of the chest; tachycardia and pulsus paradoxus, which may be present to varying degrees depending upon the stage and severity of the attack. Cough may be present without wheezing, or wheezing may be present without cough; tachypnea also may be present without wheezing. Manifestations will vary depending on the severity of the exacerbation (Table 137 {endash}1 Table 137{endash}1). When the patient is in extreme respiratory distress, the cardinal sign of asthma, wheezing, may be strikingly absent; in such patients, only after bronchodilator treatment gives partial relief of the airway obstruction can enough movement of air occur to evoke wheezing. Shortness of breath may be so severe that the child has difficulty walking or even talking. The patient with severe obstruction may assume a hunched-over, tripod-like sitting position that makes it easier to breathe. Expiration is typically more difficult because of premature expiratory closure of the airway, but many children complain of inspiratory difficulty as well. Abdominal pain is common, particularly in younger children, and is due presumably to the strenuous use of abdominal muscles and the diaphragm. The liver and spleen may be palpable because of hyperinflation of the lungs. Vomiting is common and may be followed by temporary relief of symptoms. During severe airway obstruction respiratory effort may be great, and the child may sweat profusely; a low-grade fever may develop simply from the enormous work of breathing; fatigue may become severe. Between exacerbations the child may be entirely free of symptoms and have no evidence of pulmonary disease on physical examination. A barrel chest deformity is a sign of the chronic, unremitting airway obstruction of severe asthma. Harrison sulci, an anterolateral depression of the thorax at the insertion of the diaphragm, may be present in children with recurrent severe retractions. Clubbing of the fingers is rarely observed in uncomplicated asthma, even in severe asthma. Clubbing suggests other causes of chronic obstructive lung disease such as cystic fibrosis. DIAGNOSIS. Recurrent episodes of coughing and wheezing, especially if aggravated or triggered by exercise, viral infection, or inhaled allergens, are highly suggestive of asthma. However, asthma can also cause persistent coughing in children with no history of wheezing because flow rates are insufficient to generate wheezing, airway obstruction is relatively mild, or caretakers are unable to recognize wheezing. Symptoms may have been ascribed erroneously to "allergic cough," "allergic bronchitis," "wheezy bronchitis," or "chronic bronchitis." Pulmonary function testing before and after administration of methacholine or a bronchodilator or before and after exercise may help establish the diagnosis of asthma. Examination during an episode of severe symptoms may also be helpful if improvement occurs following bronchodilator therapy. Furthermore, when treated by measures that are specific for asthma, affected children show remarkable improvement, strongly suggesting that the cough is a sign of asthma.

Laboratory Evaluation. Eosinophilia of the blood and sputum occurs with asthma. Blood eosinophilia of more than 250{endash}400 cells/mm3 is usual. Asthmatic sputum is grossly tenacious, rubbery, and whitish. An eosinmethylene blue stain usually discloses numerous eosinophils and the granules from disrupted cells. Few diseases in children other than asthma are likely to cause eosinophilia in sputum. Sputum cultures are generally not helpful in asthmatic children because bacterial superinfection is rare and cultures are frequently contaminated with oropharyngeal organisms. Serum protein and immunoglobulin concentrations are generally normal in asthma except that IgE levels may be increased. Allergy skin testing and rast (radioallergosorbent test) or other in vitro determinations of specific IgE are useful in identifying potentially important environmental allergens (Chapter 134). Inhalation bronchial challenge testing is only rarely done to explore the clinical significance of allergens implicated by skin testing, because the allergenic challenge can provoke a late-phase asthmatic response, the procedure is time consuming, and only a single allergen can be tested at a time. When the diagnosis of asthma is uncertain, testing for hyper-responsiveness to the bronchoconstrictive effect of methacholine or histamine may be helpful in children old enough to cooperate in pulmonary function testing. Methacholine provocative testing should not be performed when baseline pulmonary function is abnormal; the response to bronchodilator therapy is more appropriate. The response of the asthmatic patient to exercise testing is quite characteristic (Chapter 321). Running for 1{endash}2 min often causes bronchodilation in patients with asthma, but prolonged strenuous exercise causes bronchoconstriction in virtually all asthmatic subjects when breathing dry, relatively cold air. Demonstration of this abnormal response to exercise is diagnostically helpful and helps to convince patients and parents of the importance of preventive treatment. Treadmill running at 3{endash} 4 miles/hr up a 15% grade while breathing through the mouth for at least 6 min elicits airway obstruction in most patients with asthma, especially if the exercise has caused an increase in pulse rate to at least 180 beats/min. Measurement of pulmonary function immediately before exercise, immediately after exercise, and 5 and 10 min later usually discloses decreases in peak expiratory flow rate (PFR) or forced expiratory volume in 1 sec (FEV1) of at least 15% without premedication. If exercise causes no airway obstruction, repeat testing on other days when relative humidity is low usually elicits a positive response in patients with asthma. Exercise testing should be deferred whenever significant airway obstruction is already present. If possible, bronchodilators and cromolyn should be withheld for at least 8 hr before testing; slow-release theophylline should not be administered 12{endash} 24 hr prior to testing. Every child suspected of having asthma does not require roentgenograms of the chest, but these are often appropriate to exclude other possible diagnoses or complications, such as atelectasis or pneumonia. Lung markings are commonly increased in asthma. Hyperinflation occurs during acute attacks and may become chronic when airway obstruction is persistent. Atelectasis may occur in as many as 6% of children during acute exacerbations and is especially likely to involve the right middle lobe, where it may persist for months. Repeated chest roentgenograms during exacerbations usually are not indicated in the absence of fever, unless there is suspicion of a pneumothorax, or tachypnea greater than 60 beats/min, tachycardia of more than 160 beats/min, localized rales or wheezing, or decreased breath sounds. Pulmonary function testing (Chapters 321 and 324.8) is valuable in the evaluation of children in whom asthma is suspected. In those known to have asthma, such tests are useful in assessing the degree of airway obstruction and the disturbance in gas exchange, in measuring response of the airways to inhaled allergens and chemicals or exercise (bronchial provocation testing), in assessing the response to therapeutic agents, and in evaluating the long-term course of the disease. Assessments of pulmonary function in asthma are most valuable when made before and after administration of an aerosol bronchodilator, a procedure that indicates the degree of reversibility of the airway obstruction at the time of the testing (Chapters 321 and 324.8). An increase of at least 10% in PFR or FEV1 after aerosol therapy is strongly suggestive of asthma. Failure to respond does not exclude asthma and may be due to status asthmaticus or to near-maximal pulmonary function. In mild cases of asthma in remission, no abnormalities may be detected. In others a variety of abnormalities may be found (see Table 137{endash}1 Table 137{endash}1). Total lung capacity, functional residual capacity, and

residual volume are increased. Vital capacity is usually decreased. Dynamic tests of air flow, forced vital capacity (FVC), FEV1, PFR, and maximum expiratory flow between 25 and 75% of the vital capacity (FEF25{endash} 75%) may also show reduced values, which return toward normal after administration of aerosolized bronchodilators. With the availability of small, relatively inexpensive instruments that measure peak expiratory flow rate (MiniWright Peak Flow Meter, Healthscan Assess Plus peak flow meter), it is feasible to monitor expiratory flow rate at home two to three times each day. This provides objective measurements of the degree of airway obstruction between office visits. A fall in peak expiratory flow predicts the onset of an exacerbation and encourages early intervention with additional drug therapy. Determination of arterial blood gases and pH is important in evaluation of the patient with asthma during an exacerbation requiring hospitalization. During remission, partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2), and pH may be normal. In symptomatic periods, low PO2 is regularly found and may persist days to weeks after an acute episode is over. Determination of oxygen saturation by pulse oximetry is helpful in determining the severity of an acute exacerbation. PCO2 is generally low during the early stages of acute asthma. As the obstruction worsens, PCO2 rises; this is an ominous sign. Blood pH remains normal (or sometimes slightly alkalotic owing to hyperventilation) until the buffering capacity of the blood is exhausted, and then acidosis develops. As airway obstruction and hypoxia become more severe, a mixed respiratory and metabolic acidosis develops owing to hypercarbia and lactic acidosis, respectively. DIFFERENTIAL DIAGNOSIS. Most children who have recurrent episodes of coughing and wheezing have asthma. Other causes of airway obstruction include congenital malformations (of the respiratory, cardiovascular, or gastrointestinal systems), foreign bodies in the airway or esophagus, infectious bronchiolitis, cystic fibrosis, immunologic deficiency disease, hypersensitivity pneumonitis, allergic bronchopulmonary aspergillosis, and a variety of rarer conditions that compromise the airway, including endobronchial tuberculosis, fungal diseases, and bronchial adenoma (Table 137{endash}2 Table 137{endash}2). Very rarely in the United States, tropical eosinophilia and other parasitic infections may involve the lung and mimic asthma. ASTHMA IN EARLY LIFE. Wheezing in the infant merits special mention because it is common and presents substantial diagnostic and therapeutic problems. A significant number of children subsequently shown to have asthma have had symptoms of obstructive airway disease early in life (30% younger than 1 yr and 50{endash} 55% younger than 2 yr). A number of anatomic and physiologic peculiarities of early life predispose to obstructive airway disease: (1) a decreased amount of smooth muscle in the peripheral airways compared to adults may result in less support; (2) mucous gland hyperplasia in the major bronchi compared to adults favors increased intraluminal mucus production; (3) disproportionately narrow peripheral airways up to 5 yr of age result in decreased conductance relative to adults and render the infant and young child vulnerable to disease affecting the small airways; (4) decreased static elastic recoil of the young lung prediposes to early airway closure during tidal breathing and results in mismatching of ventilation and perfusion and hypoxemia; (5) highly compliant rib cage and mechanically disadvantageous angle of insertion of diaphragm to rib cage (horizontal vs. oblique in the adult) increase diaphragmatic work of breathing; (6) decreased number of fatigue-resistant skeletal muscle fibers in the diaphragm leave the diaphragm poorly equipped to maintain high work output; and (7) deficient collateral ventilation with the pores of Kohn and the Lambert canals deficient in number and size. The infant and young child are therefore predisposed to the development of atelectasis distal to obstructed airways. The combination of these factors with the normal susceptibility of infants and children to viral respiratory infections renders this age group particularly vulnerable to lower respiratory tract obstructive disease. The clinical, roentgenographic, and blood gas findings in asthma and bronchiolitis are quite similar. It is helpful to remember that the incidence of bronchiolitis caused by RSV peaks during the first 6 mo of life, principally during the cold weather months, and that second and third attacks are uncommon. Some clinicians have proposed using the response to epinephrine or albuterol aerosols to help decide whether an episode is asthma or bronchiolitis, with a favorable response favoring asthma. The validity of this test has not been established; the degree of

response may be related more to the severity of the obstructive process than to its underlying nature. Trials of epinephrine or other bronchodilators are worthwhile, however, as discussed later. The onset of symptoms is rather typical. Previously well infants or young children develop what may seem to be a cold with rhinorrhea, rapidly followed by irritability, cough, tachypnea, and wheezing. The symptoms may progress rapidly and often require hospitalization. During infancy, respiratory tract infections with viruses or Chlamydia may cause symptoms of airway obstruction that can be confused with asthma. Bacterial infections of the lower airway are rare, and the concept that allergic reactions to bacteria cause asthma is unproved. A child with recurrent episodes of coughing and wheezing associated with bacterial infections should be investigated for cystic fibrosis or immunologic deficiency. Chronic aspiration caused by swallowing dysfunction (usually in developmentally delayed children) or gastroesophageal reflux also may cause recurrent cough and wheezing in early life. Symptoms of respiratory distress often occur with or shortly after feeding, and a chest roentgenogram is commonly abnormal. Rarer causes of obstructive airway disease in early life include obliterative bronchiolitis (usually a sequela of a severe viral insult, most often adenovirus) and bronchopulmonary dysplasia (see Table 137{endash}2 Table 137{endash}2). The role of food allergy as a major cause of obstructive airway symptoms during early life is controversial. Positive skin tests for IgE-mediated sensitivity to foods are very unusual in asthmatic infants, but when present, they indicate the need for temporary elimination of the suspected food, usually milk, wheat, or egg from the diet of the asthmatic patient. After elimination from the diet for 3 wk, challenge with the implicated food may be appropriate to confirm the clinical relevance of the positive skin test. Challenge may be necessary two or three times after temporary dietary elimination to ensure clinical relevance. Challenge is contraindicated in patients with a history of anaphylaxis after ingestion of the food. Confirmed food allergy indicates a need for dietary elimination for at least 6 mo (Chapters 135 and 145). For an infant who has had several episodes of obstructive airway disease, a history of asthma, hay fever, or atopic dermatitis in mother, father, or siblings is an important predictor of subsequent obstructive airway problems. Eczema is also frequently associated with the subsequent appearance of asthma. Eosinophilia >400 cells/mm3 (and especially >700 cells/mm3) and high serum IgE concentrations predict continuing respiratory tract problems. TREATMENT. Asthma therapy includes basic concepts of avoiding allergens, improving bronchodilation, and reducing mediator-induced inflammation. Systemic or topical inhaled medications are used, depending upon the severity of the episode. The principles of avoidance of allergens outlined under treatment of allergic rhinitis also serve the child with asthma. The hyper-reactivity of the asthmatic airway as an additional factor is dealt with by minimizing exposure to nonspecific irritants such as tobacco smoke, smoke from wood-burning stoves, and fumes from kerosene heaters and to strong odors such as wet paint and disinfectants, and by avoiding ice-cold drinks and rapid changes in temperature and humidity. Maintenance of humidified air is important in dry, cold climates in the winter, but relative humidity should not exceed 50% because house dust mites thrive at higher humidity. If the clinical history suggests IgE-mediated sensitivity to inhalant allergens that cannot be avoided or can be only partially avoided, immunotherapy should be considered; its indications and evidence for its efficacy in asthma are discussed in Chapter 135. Treatment of acute asthma based on severity and location (home, emergency department, in-patient hospital) is summarized in Figures 137{endash}2 to 137{endash}4 Figures 137{endash}2 to 137{endash}4. Pharmacologic therapy is the mainstay of treatment of asthma. Oxygen administered by mask or nasal prongs at 2{endash}3 L/min is indicated in most children during acute asthma. Not only is the PO2 reduced during an acute episode, but drugs used in therapy (b{beta}-adrenergic agonists or intravenous aminophylline) may cause a transient fall in PO2 secondary to worsening of ventilation-perfusion mismatching, which occurs because these agents cause pulmonary vasodilatation and increased cardiac output. Injection of epinephrine had been the treatment of choice for acute asthma for many years, but bronchodilator aerosols are now preferable.

When epinephrine is used, a dose of 0.01 mL/kg of the 1:1,000 (1.0 mg/mL) concentration of the aqueous preparation may be given. It may be necessary to repeat the same dose once or twice at intervals of 20 min to obtain optimal relief. In infants and small children a dose of 0.05 mL is often effective. The unpleasant side effects of epinephrine (pallor, tremor, anxiety, palpitations, and headache) can frequently be minimized if doses of no more than 0.3 mL are given at any age. Terbutaline, a more selective b{beta}2-agonist (Chapter 135), is available in an injectable form and is an alternative to epinephrine. The usual dose of 0.01 mL/kg of the 1:1,000 (1 mg/mL) concentration does not cause peripheral vasoconstriction and has a longer duration of activity, up to 4 hr. The maximum dose of terbutaline by subcutaneous injection is 0.25 mL; this dose may be repeated once if necessary after 20 min. Inhalation of bronchodilator aerosols is rapidly effective in relieving the signs and symptoms of asthma. Aerosols have the advantage that substantially less drug is given than would be required by the subcutaneous route; the unpleasant side effects of injected drugs such as epinephrine are avoided. Furthermore, despite airway obstruction, which may limit aerosol delivery to peripheral airways, aerosol therapy is probably more effective than epinephrine in reversing bronchoconstriction. Albuterol (Proventil, Ventolin) solution is safe and effective at a dose of 0.15 mg/kg (maximum 5 mg) followed by 0.05{endash} 0.15 mg/kg at intervals of 20{endash}30 min until response is adequate. Albuterol is available as a 0.5% solution (5 mg/mL) to be diluted with 2{endash}3 mL normal saline and as a prediluted 2.5-mg unit dose, 0.083% (0.83 mg/mL). Nebulization with oxygen at 6 L/min prevents hypoxemia that might be related to the treatment. Edetate disodium and benzalkonium chloride, found in some solutions of albuterol and metaproterenol for nebulization, can cause bronchoconstriction in occasional asthmatic patients; Ventolin Nebules contain neither. If the response to epinephrine or bronchodilator aerosol is not satisfactory, aminophylline may be given intravenously in a dose of 5 mg/kg for 5{endash} 15 min at a rate no greater than 25 mg/min. This dose (which will increase the serum theophylline concentration by no more than 10 m{mu}g/mL at the peak) is safe in the patient who has had no theophylline in the past few hours. If there is reason to believe that the patient may already have a significant serum theophylline concentration, the intravenous dose should be held until the theophylline level is known. Thereafter, a theophylline dose of 1 mg/kg should increase the serum level by about 2 m{mu}g/mL. There is little additional benefit to be gained from adding theophylline to optimal b{beta}2 aerosol therapy, but this combination may be helpful in patients with very severe airway obstruction or those receiving less than maximal treatment with inhaled b{beta}2-adrenergic agonists. Addition of theophylline increases the likelihood of adverse side effects. Most acute exacerbations of asthma respond to this treatment regimen. Unless the patient either is corticosteroid dependent or has had corticosteroids in the recent past, administration of steroids as part of the emergency room treatment program may be unnecessary. In borderline cases, however, when the decision is made to send the child home rather than to hospitalize him or her, a prescription of prednisone in decreasing doses over 5{endash} 7 days may hasten resolution of the exacerbation and causes no harm. The patient should be discharged from the emergency room with sufficient oral medication to continue therapy at home, and appropriate arrangements should be made for follow-up. Good ambulatory management will almost always reduce the need for emergency room visits for acute asthma. Overall, 70% of children treated in the emergency room remain well at home; however, 10{endash}20% experience relapse within 10 days, and 15{endash} 20% are hospitalized. Steroid therapy reduces the relapse and hospitalization rates. Status Asthmaticus If a patient continues to have significant respiratory distress despite administration of sympathomimetic drugs with or without theophylline, the diagnosis of status asthmaticus should be considered. Status asthmaticus is a clinical diagnosis defined by increasingly severe asthma that is not responsive to drugs that are usually effective. High-risk factors for severe status asthmaticus and for death from asthma are listed in Table 137 {endash}3 Table 137{endash}3. A patient in whom the diagnosis is made should be admitted to a hospital, preferably to an intensive care unit, where the condition can be carefully monitored. The severity should be determined initially (see Table 137{endash}1 Table 137{endash}1) and monitored at regular intervals. An indwelling arterial catheter

may be indicated. Baseline complete blood count and serum electrolytes should be measured. Because hypoxemia and acid-base disturbances may predispose to cardiac arrhythmias and potentially cardiotoxic drugs (theophylline, adrenergics) will be used, cardiac monitoring is almost always indicated. Analysis of arterial blood for PO2, PCO2, and pH is also indicated. For these determinations well-arterialized capillary blood is adequate but less desirable than arterial blood, particularly if the patient has received epinephrine, which constricts the peripheral vascular bed. Patients in status asthmaticus are hypoxemic. Oxygen in carefully controlled concentrations is therefore always indicated to maintain tissue oxygenation. It may be administered very effectively by nasal prongs or mask at a flow rate of 2{endash}3 L/min. A concentration of oxygen sufficient to maintain a partial pressure of arterial oxygen of 70{endash}90 mm Hg or oxygen saturation greater than 92% is optimal. A mist tent should not be used; the water does not reach the lower airway to any significant extent, and mists have an irritant effect on the airways of many asthmatic patients, leading to coughing and worsening of the wheezing. Furthermore, it is not possible to observe a patient who is enveloped in a dense fog. Dehydration may be present, owing to inadequate fluid intake, greatly increased insensible water loss as a result of tachypnea, and the diuretic effect of theophylline. Care should be taken not to overhydrate the patient because increased secretion of antidiuretic hormone occurs during status asthmaticus, promoting fluid retention, and because the large negative peak-inspiratory pleural pressures that occur in children favor accumulation of fluid in the interstitial spaces around the small airways. No more than 1{endash}1.5 times maintenance levels of fluid should be given usually. Sodium bicarbonate, 1.5{endash} 2 mEq/kg, may be administered if the arterial pH is less than 7.3, there is a metabolic acidosis, and serum sodium is less than 145 mEq/L. Because b{beta}2-adrenergic agents may produce hypokalemia, potassium should be added to the intravenous solution after the patient voids. Bronchodilator sympathomimetic aerosol therapy initiated in the emergency room should be continued. Aminophylline, 4{endash}5 mg/kg, may be given intravenously over 20 min every 6 hr. Alternatively, a 5-mg/kg loading dose followed by constant infusion in a dose of 0.75{endash} 1.25 mg/kg/hr may be administered. If the patient has received aminophylline intravenously in the emergency room, the loading dose should be omitted. It is essential to adjust the aminophylline dose by monitoring serum theophylline concentrations because there are many physiologic derangements that occur during the course of status asthmaticus that may affect the disposition of theophylline. If the every 6-hr regimen is used, serum samples should be obtained 1 hr after the intravenous injection and just before the next dose. During constant infusion, theophylline concentration should be monitored at least at 1, 6, 12, and 24 hr as a basis for dose adjustments and 6 and 12 hr after any change in dosage or every 24 hr while receiving intravenous theophylline. A steady-state serum concentration of approximately 12{endash} 15 m{mu}g/mL should be sought. Because age affects theophylline kinetics, the starting dose for a continuous infusion of aminophylline varies as follows: 0.5 mg/kg/hr at 1{endash} 6 mo, 1.0 mg/kg/hr at 6{endash}11 mo, 1.2{endash}1.5 mg/kg/hr at 1{endash}9 yr, and 0.9 mg/kg/hr over 10 yr of age. Adrenergic drugs are best administered by aerosol as previously described. Administration of b{beta}-agonists by inhalation at intervals of 20 min or continually is safer than administration by intravenous infusion and is probably equally effective. Nonetheless, some authorities recommend terbutaline by subcutaneous (0.01 mg/kg; 0.3 mg maximum) or by intravenous (10 m{mu}g/kg bolus; 0.4{endash}0.6 m{mu}g/kg/min continuous infusion increasing by 0.2 m{mu}g/kg/min to 3{endash}6 m{mu}g/kg/min) administration for severe status asthmaticus. Treatment with an antimuscarinic such as atropine sulfate given in combination with a nebulized b{beta}-agonist can be more effective than treatment with either alone, although the peak bronchodilation from atropine is reached more slowly than that of the b{beta}-agonist. Nebulization of atropine sulfate at doses of 0.05{endash} 0.1 mg/kg is safe for most children, but maximal doses of 0.025 mg/kg may be more appropriate for adolescents and adults because of the possible side effects, including tachycardia and mental confusion. Inhalation of nebulized atropine is usually safe at intervals of 4 hr. Ipratropium bromide causes fewer side effects than atropine. Nebulization at doses of 0.25 mg every 6 hr is safe for children at least 6 yr old, and 0.5 mg every 6 hr is safe for children older than 12 yr.

Corticosteroids, such as methylprednisolone (Solu-Medrol), 1{endash}2 mg/kg every 6 hr, should be administered. Because it has less effect on mineral metabolism when given in high doses and a lower cost for an equivalent anti-inflammatory dose, methylprednisolone is preferable to hydrocortisone. Corticosteroids can sometimes reverse tolerance to b{beta}-agonists within 1 hr, but maximal effects of steroids are usually delayed for 6 hr. Steroids improve oxygenation, decrease airway obstruction, and shorten the time needed for recovery. Treatment is guided by serial measurement of blood gases and pH every few hours, or more often if indicated. If gas and pH analysis both indicate that respiratory failure is impending, an anesthesiologist should be alerted, and facilities and equipment should be available for tracheal intubation and respiratory support. Mechanical ventilation should be anticipated; elective tracheal intubation with diazepam (Valium), vecuronium, and atropine premedication is safer than emergency intubation. Respiratory care should include patient paralysis on a volume-cycled ventilator with short inspiratory and long expiratory times, a 10- to 15-mL/kg tidal volume, 8{endash}15 breaths/min, and peak pressures of less than 60 cm H2O. The goals are to improve oxygenation, maintain PCO2 between 40 and 60 mm Hg, and avoid barotrauma. Positive end-expiratory pressure is added in the recovery phase to prevent atelectasis. Sedation during mechanical ventilation may be accomplished with Valium, midazolam (Versed), or ketamine (which at doses of 1{endash} 2.5 mg/kg/hr is a sedative-analgesic-anesthetic with bronchodilator activity). Halothane anesthesia produces prompt bronchodilation but is difficult to administer in an intensive care unit. It should be reserved for the most severe cases of status asthmaticus. Sedation of nonventilated patients with status asthmaticus is hazardous. Tranquilizers, morphine, and other opiates are also contraindicated because of their depressant effects on the respiratory center. The best sedative for the patient is the presence of a competent, compassionate physician and nurse at the bedside and decreased airway obstruction with relief of hypoxia and hypercarbia. Chest roentgenograms should be obtained in all severe cases and repeated as indicated to detect complications such as mediastinal emphysema or pneumothorax. Routine administration of antibiotics has not been shown to alter the course of status asthmaticus in children or to reduce the incidence of infectious complications. Daily Management of the Asthmatic Child On the basis of the history, physical examination, laboratory data, pulmonary function testing, and need for medication, patients may be classified as having mild, moderate, or severe asthma. The daily management of these different degrees of illness varies (see Chapter 135; Figs. 137{endash} 2 to 137{endash}4 Figs. 137{endash}2 to 137{endash}4). MILD ASTHMA. Children with mild asthma have exacerbations of varying frequency, up to twice each week, with decreases in peak expiratory flow rate of not more than 20% and respond to bronchodilator treatment within 24{endash}48 hr. Generally, medication is not required between exacerbations for very mild asthma with symptoms less than every 2 wk, when the child is essentially free of symptoms of airway obstruction. Children with mild asthma have good school attendance, good exercise tolerance, and little or no interruption of sleep by asthma. They have no hyperinflation of the chest; their chest roentgenograms are essentially normal. Pulmonary function testing may show mild, reversible airway obstruction, with little or no increase in lung volume. MODERATE ASTHMA. Children with moderate asthma have symptoms more frequently than those with mild disease and often have cough and mild wheezing between more severe exacerbations. School attendance may be impaired, exercise tolerance will be diminished because of coughing and wheezing, and the child may lose sleep at night, particularly during exacerbations. Such children will generally require continuous rather than intermittent bronchodilator therapy to achieve satisfactory control of symptoms or continuous treatment with cromolyn, nedocromil, or an inhaled corticosteroid to reverse bronchial hyper-responsiveness. Hyperinflation may be evident clinically and roentgenographically. Signs of airway obstruction on physiologic testing are more marked than in the mild group; lung volumes may be increased. SEVERE ASTHMA. Children with severe asthma have virtually daily wheezing and more frequent and more severe exacerbations; they require recurrent hospitalization, which is rarely required for mild or moderate asthma.

Severely affected children may miss significant amounts of school, have their sleep interrupted often by asthma, and have poor exercise tolerance. They have chest deformities as a result of chronic hyperinflation, which is evident on roentgenograms. Bronchodilator medication will be required continuously, and regimens may include the regular systemic or aerosol administration of corticosteroids. Physiologic testing will show more severe airway obstruction than in mild or moderate asthma, less reversibility in response to aerosol bronchodilators, and more severe disturbances of lung volumes. Table 137{endash}2 Table 137{endash}2, Table 137{endash}3 Table 137{endash}3, and Table 137{endash}4 Table 137{endash}4 summarize treatment of acute asthma. Children with mild asthma should receive bronchodilator medication only when symptomatic, and most exacerbations may be satisfactorily treated with adrenergic agents, preferably by aerosol (albuterol, metaproterenol, terbutaline, pirbuterol, or bitolterol) or, rarely, by injection (aqueous epinephrine, terbutaline). Use of a chamber such as an AeroChamber or InspirEase enhances delivery of drug to the lower airways when a metered-dose inhaler is used by younger children who are unable to coordinate actuation of the inhaler with inhalation. Such chambers permit effective administration of b{beta}-agonists from metered-dose inhalers to children as young as 3 yr of age. Slow inhalation also increases delivery to the lungs because a rapid inhalation causes impaction of drug particles in the pharynx. Breath holding for up to 10 sec after inhalation of the drug also favors deposition in the lungs. When moderate or severe airway obstruction is present, nebulization with an air compressor such as the Proneb with part LC jet or the DeVilbiss No. 561 Pulmo-Aide is often more effective than use of a metered-dose inhaler with a chamber. The apparent advantage of nebulization over metered-dose inhaler is largely due to the different doses administered. Nebulization with such a compressor permits effective delivery of aerosols even to infants. b{beta}-Agonist liquids for oral administration are also available for treatment of infants and young children. Theophylline may be added to an oral regimen when indicated. Drug therapy usually can be discontinued after a few days. Exercise-induced asthma is most effectively prevented by inhalation of an adrenergic drug immediately before exercise. Inhaled albuterol usually affords protection for 4 hr; inhaled salmeterol (not labeled for patients younger than 12 yr by the U.S. Food and Drug Administration [FDA]), for 12 hr. Salmeterol should be administered at least 30 min before exercise. Inhalation of cromolyn or nedocromil shortly before exercise is also effective in preventing exerciseinduced asthma. For children with moderate asthma who require round-the-clock therapy, two inhalations of an adrenergic aerosol every 4{endash}6 hr, or two inhalations of salmeterol every 12 hr, often suffices. Theophylline may be added. Dose and dosing regimen should be individualized. Some experienced allergists reserve monitoring of serum theophylline concentrations for those patients who fail to show a favorable bronchodilator response or who have symptoms of toxicity (gastrointestinal or central nervous system) with average dosages. When slow-release (S-R) formulations of theophylline are used, the peak plasma concentration (assuming that a constant fraction of drug is absorbed, which may not be the case) occurs 4{endash} 8 hr after the dose, at which time a blood sample for monitoring should be obtained. Peak concentration may not occur until 12 hr after a bedtime dose of an S-R preparation because of delayed nocturnal absorption. Blood sampling should be delayed until after a day or so of therapy with S-R drugs to ensure that a steady state has been achieved. Some children can be treated successfully on an every-12-hr schedule, but others metabolize theophylline particularly rapidly and experience marked fluctuations in serum concentration. These peaks and troughs of concentration are minimized by dividing the 24-hr dose into equal 8-hr doses. Younger children (aged 1{endash}9 yr) generally eliminate theophylline more rapidly than older children and adolescents and hence require a higher daily dose on a mg/kg basis. Nonetheless, it is safest to begin with a dose of 14{endash}16 mg/kg/24 hr in most children. If this dose is well tolerated, one may increase by 25% increments at 3- to 4-day intervals to average doses for age as necessary to control symptoms (see Table 135 {endash}2 Table 135{endash}2, 137{endash}4 137{endash}4). If adequate control of symptoms is not achieved at the maximum doses or if adverse effects become evident, adjustment in the dosing regimen must be guided by determination of the serum theophylline concentration. Rapidly absorbed liquids and uncoated tablets, while suitable for children with mild asthma who require a few days of therapy for an exacerbation, have no place in the therapeutic regimen of children who require round-the-clock

theophylline therapy because wide fluctuations in serum theophylline concentrations are observed when rapidly absorbed products are used. Which of the S-R products to use depends upon the dosage form (tablet vs capsule) and the amount of drug needed (see Table 137{endash}4 Table 137{endash}4). Capsule formulations that can be opened are virtually tasteless, should not be chewed, may be mixed with moist food, and are particularly suitable for young children. Crushing an S-R tablet destroys its constant-release properties. Exacerbations of asthma in patients receiving round-the-clock theophylline medication should be treated with adrenergic drugs, as described earlier for children with mild asthma (see Fig. 137{endash}2 Fig. 137{endash}2). Cromolyn powder inhaled four times a day from a Spinhaler or cromolyn aerosol delivered by a metered-dose inhaler or nedocromil (not FDA labeled for patients younger than 12 yr) is useful in children with mild to moderate asthma. A solution of cromolyn is available for home nebulization regimens for young children subject to recurrent attacks of asthma. Cromolyn and albuterol or metaproterenol solutions may be mixed together in the nebulizer for ease of administration if concurrent administration of a bronchodilator is necessary. In certain children with moderate asthma, significant flare-ups occur from time to time that may require the use of corticosteroids for a few days. Early use of steroids in the child who is known to become severely ill may reduce the need for hospitalization. Early intervention with bronchodilator drugs (with or without steroids, depending upon the clinical setting) is important in the management of all asthmatic children, regardless of the severity of their conditions. Steroids should be given in adequate doses (1{endash} 2 mg/kg/24 hr of prednisone or prednisolone in two to three doses) and should be discontinued as quickly as possible, for example, within 5{endash}7 days; a long "weaning" period following acute asthma is unnecessary. In patients who only rarely require steroid administration, return of normal hypothalamic-pituitary-adrenal function is hastened by the prompt discontinuation of the drug when the acute episode is over. Inhaled topical steroid preparations are also effective for children with moderately severe asthma. In a minority of children who have severe asthma despite the management guidelines outlined here, unacceptable degrees of coughing and wheezing persist, severely limiting the child's play activities and school attendance. In such children the judicious administration of oral corticosteroids on an alternate-day basis and as an inhaled aerosol frequently results in significant amelioration of symptoms and allows the child to lead a normal life without suffering the adverse effects of corticosteroids. If alternate-day therapy is indicated because of either chronic disability or the severity or frequency of attacks of status asthmaticus, the patient is given 5{endash} 7 days of intensive daily therapy and then switched to an alternate-day regimen with a short-acting steroid (prednisone, prednisolone, or methylprednisolone). A 12-yr-old child might be given 60 mg, 40 mg, 30 mg, 20 mg, and 10 mg of prednisone/24 hr over a 5-day period for an exacerbation of asthma, to be followed by alternate-day therapy at a dose of 20 mg/24 hr given as a single dose at 7.00{endash} 8.00 A.M. every 48 hr. If the patient responds well to this regimen, the prednisone may be reduced by 5 mg per dose at 10- to 14-day intervals until the lowest dose compatible with acceptable control of symptoms is reached, usually 5{endash}10 mg on alternate days. Concurrent therapy with aerosol adrenergic drugs, theophylline, or cromolyn should be continued because this reduces the dose of steroid required. Low-dose alternate-day therapy is associated with minimal adverse effects and thus may be justified in a disease that can be life threatening and capable of causing chronic invalidism. Use of steroid therapy should not, however, substitute for or delay comprehensive management of the disease. Inhalational corticosteroids, such as beclomethasone dipropionate (Vanceril, Beclovent), flunisolide (AeroBid), and triamcinolone (Azmacort), may provide an alternative to the use of every-other-day oral corticosteroid medication. Inhalational corticosteroids may be more effective than oral steroids in reversing bronchial hyper-responsiveness and may therefore be indicated even in patients who also require continual treatment with oral steroids. Beclomethasone, which is effective in microgram doses, is rapidly inactivated in the liver into metabolites devoid of glucocorticoid activity. Accordingly, systemic effects in children given less than 14 m{mu}g/kg/24 hr (usual dose is two inhalations or 84 m{mu}g four times a day) are minimal. Oropharyngeal candidiasis rarely occurs. Its frequency and that of other adverse effects are diminished by rinsing the mouth and expectorating after inhaling the aerosol and inhaling the aerosol through a chamber or spacer. Effective use of inhaled steroid requires a degree of compliance by the patient not often found in children younger than 6{endash} 7 yr. Studies of adults who have received beclomethasone for up to 7 yr have shown no evidence of epithelial atrophy or thinning of

underlying connective tissue, and there have been no long-term adverse effects of the drug on the pharynx and airways. Continual treatment with an inhaled corticosteroid or with cromolyn is indicated for any child with symptoms of asthma occurring as frequently as weekly except for exercise-induced asthma preventable by pretreatment with a b{beta}-agonist, cromolyn or nedocromil. Home monitoring of peak expiratory flow rate two to three times a day facilitates early detection of airway obstruction in patients with severe asthma and in patients with infrequent symptoms that may progress to severe airway obstruction. Graphing the results of monitoring will establish the child's diurnal variation and permit the physician to suggest treatment guidelines that anticipate decreases in peak expiratory flow rate. Daily changes in flow rate may also indicate a need for changes in continual treatment regimens. Whatever the degree of severity of the asthma, a personalized, written crisis plan is helpful (Fig. 137 {endash}5 Fig. 137{endash}5). This can remind patients and parents about what to do in an emergency. Emotional tensions surrounding asthma are best handled by unhurried discussion with the parents of the child's difficulty, by avoidance of overdramatization of the child's illness, and by careful examinations with the parents of those areas in which parent and child seem to be in conflict. The use of tranquilizers or sedatives as a substitute for more direct attempts to solve emotional problems should be avoided. As the asthma is brought under control, the emotional climate is often improved. Various factors may exacerbate asthma or make the disease difficult to treat: gastroesophageal reflux, allergic bronchopulmonary aspergillosis, nonsteroidal anti-inflammatory agents, pregnancy, and sinusitis. Chronic sinusitis may be due to noninfectious immune-mediated inflammation or to bacterial infection. Treatment of sinusitis with antibiotics, intranasal steroids, and oral or topical (3{endash} 5 days) decongestants for 3 wk may improve bronchoconstriction as well as sinusitis. Asthma education programs, for example, ACT (Asthma Care Training) and Superstuff, are being used in comprehensive asthma management. Their goal is to increase knowledge of asthma and its treatment on the part of both the child and parent, to improve communication within the family and with the physician and nurse, to improve compliance with the treatment plan, and to decrease the need for use of emergency room or hospital. Prevention of Deaths from Asthma Death from childhood asthma is rare, but asthma mortality rates have been increasing. In the United States asthma mortality rates increased from 1.2/100,000 general population in 1979 to 2.0 in 1991. Among children 10{endash}14 yr old the asthma mortality rate increased from 0.1 in 1979 to 0.5/100,000 in 1987, the greatest proportional increase for any age group. Rates have been three to nine times as high in black children as in whites. Increases have also occurred in many other countries. Reasons for these increases in mortality are unknown. Possible causes include increased prevalence of asthma; increased indoor air pollution as a result of tighter construction of homes with emphasis on energy conservation; excessive exposure to allergen; psychosocial dysfunction that may interfere with perception of airway obstruction and with compliance with recommended management; delays in implementation of appropriate treatment for acute asthma; lack of access or utilization of medical care, including preventive care; over-reliance on bronchodilator inhalers leading to delayed treatment with steroids or other therapy until patients are in extremis; unavailability of epinephrine for patients unable to use inhalers effectively; inappropriate use of the metered-dose inhaler; and failure to provide continuity of care or education about what to do for an unusually severe episode of asthma. Most but not all deaths from asthma are preventable with appropriate care. It is possible to identify many of those at greatest risk for death from their histories, for example, respiratory failure with hypercapnia, loss of consciousness caused by asthma, or psychosocial dysfunction in the patient or family. These patients require especially close monitoring and psychotherapy when indicated. Each should carry a written emergency protocol

indicating current medications and recommended emergency treatment as guidance for emergency personnel who may be unfamiliar with the patient. They should also have a written crisis plan indicating what they should do in an emergency. This should include which medications to use, which doses to use at what intervals, how to reach their physicians, and where to get further assistance. A Medic-Alert emblem can be helpful if such a patient is found unconscious or unable to indicate the nature of the illness. Such patients should be provided with injectable epinephrine in a convenient preparation (e.g., EpiPen or EpiPen Jr.) for use in an emergency when inhalation therapy is ineffective or inappropriate, but use of the EpiPen should not delay transport to an emergency facility.

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