Asthma in Children

Dr. Vinia Rusli SpA

• Asthma is a disease of airway
inflammation characterized
by hyperresponsiveness and
airflow obstruction that lead
to symptoms such as cough
and wheezing

Introduction
 • A chronic inflammatory disorder of the airways
• Many cells and cellular elements play a role
• Chronic inflammation is associated with airway
hyperresponsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest
tightness, and coughing
• Widespread, variable, and often reversible airflow
limitation

Global Initiative for Asthma (GINA)

Definition of Asthma
• Pedoman Nasional Asma Anak 2004

• Asma adalah mengi berulang dan/atau

batuk persisten dengan kharakteristik
sebagai berikut: timbul secara
episodik, cenderung pada malam/dini
hari (nokturnal), musiman, setelah
aktivitas fisik, serta terdapat riwayat
asma atau atopi lain pada pasien
dan/atau keluarganya.

Indonesia (UKK Respirologi IDAI)

• The prevalence of asthma rose steadily from 1980 - late 1990s,
when it reached a plateau.
• Worldwide prevalence of asthma in children : ±13%.

• USA 2007 :
 6.7 million children (9% of children 0- 17 years) had asthma.
 12.8 million days of missed school (2003)
 198,000 hospitalizations in 2004 (3% of all pediatric admissions).
 750,000 emergency department (ED) visits in 2004 (2.8% of all
pediatric ED visits).

Epidemiology & Burden of Disease

• The natural history of asthma is variable.
• Most individuals who develop chronic asthma, measured
by a decrease in lung function and persistence of
symptoms, have a genetic predisposition.
• In addition, exposure of the airway epithelium to
environmental insults in such susceptible individuals
contributes to the development, severity, and persistence
of asthma.

Natural History
 Genetic susceptibility
Adjuvant factors:
Tobacco smoke, Pollutants

Lack of protective factors:

Infection ?
Immunisation ? Allergic sensitisation
Nutrition ?
Allergen
exposure

Airway/skin
hyperresponsiveness
Trigger factors:
Pollutants
Exercise
Infection
Diseases

Eur All Update, 1999

• Inherent to asthma is airway inflammation that is mediated by
a variety of cell subtypes, resulting in hyperresponsive
airways, ultimately limiting airflow and causing variable
symptoms.

• Initial airway bronchoconstriction is followed by airway

edema and exaggerated mucus production, accompanied by
airway hyperresponsiveness, and followed by chronic changes
in the airway epithelium (airway remodeling).

• Current medical management targets various points along this

continuum. However, no clear evidence suggests that early or
aggressive treatment with anti-inflammatory medications, such
as inhaled corticosteroids, can prevent airway remodeling.

Pathogenesis & Pathophysiology

• Airway inflammation is mediated by a
variety of cytokines and chemokines
(cytokines that are specific for chemotaxis
and activation of leukocytes).
• Cytokines are produced by a number of cell
types, including lymphocytes, eosinophils,
and mast cells.
• Proinflammatory cytokines : IL-4, IL-5,
and IL-13, produced primarily by the Th2
lymphocytes, are believed to trigger the
intense inflammation of allergic asthma.
• An imbalance between Th1 and Th2
lymphocytes (specifically, decreased Th1
activity with increased Th2 activity)
contributes to chronic inflammatory
asthma.
Cells & Mediators
• Chemokines play a key role
in inflammation.
• These proteins recruit
proinflammatory cells,
including Th2 lymphocytes,
mast cells, neutrophils, and
eosinophils.
• Eosinophils and mast cells
produce proinflammatory
cytokines as well as
leukotrienes, which cause
bronchoconstriction.
Asthma Inflammation: Cells and Mediators
Environment Genetic susceptibility

P
CHRONIC INFLAMMATION A
with infiltration of lymphocytes, eosinophils, T
mast cells & epithel cells
H
O
Desquamation of epithels, thickening &
L
O
disorganization of tissues of the airway wall
(Remodeling)
G
Y
AIRWAY WALL THICKENING
Pathophysiology
• Initial evaluation should begin with a detailed medical history,
including the pattern of symptoms and observed precipitating
factors (asthma triggers).
• Past medical history should include information about risk
factors for asthma (particularly atopy), prior exacerbations,
treatments used, and their effects.
• A positive family history of parental asthma substantially
increases the risk of asthma in a child.
• Evaluation also should include an assessment of the impact of
asthma on the child and family.
• The physical examination of a child who has asthma often
yields normal findings, although there may be signs of atopy,
such as eczema or allergic rhinitis, which are strongly
associated with asthma.

Evaluation
• Characterized by intermittent, recurrent symptoms of airway
obstruction that is at least partially reversible.
• Common symptoms include cough (which may be the only
symptom), wheezing, difficulty breathing, and “chest
tightness.”
• Symptoms often occur or worsen in the presence of common
asthma “triggers,” such as exercise, changes in the weather,
viral respiratory infections, and exposure to allergens or airway
irritants (eg, environmental tobacco smoke).

• Asthma is particularly difficult to diagnose in infants and

toddlers.
• Recurrent wheezing episodes are common in young children &
many diseases can cause symptoms similar to those seen in
asthma.

Diagnosis
• Upper airway disease :
 allergic rhinitis
 sinusitis
• Extrinsic or intrinsic
obstruction of the large
airways (eg, tracheomalacia,
vascular ring, mass, or foreign
body).
• Recurrent aspiration or
gastroesophageal reflux
Differential Diagnosis
• Obstruction of the small
airways: bronchiolitis,
cystic fibrosis, congestive
heart failure, and chronic
lung disease of prematurity.
• Recurrent episodes of
bronchiolitis may occur in
young children and
sometimes are difficult to
distinguish from asthma.
PNAA, 2004:
Entry point diagnosis asma:

Cough and/or wheeze” with:

Episodic
Nocturnal
Reversible
Atopic history
• Class. Diseases • Severity of attacks
Infrequent episodic Mild
asthma Moderate
Frequent episodic Severe
asthma Respiratory arrest
Persistent asthma imminent

Classification of asthma
• AVOIDANCE
• Education (communication, information, education)
• Medication
 Short term
 Long term

 Goal : optimal growth & development of the child

Management
• Minimal (ideally no) chronic symptoms
• Minimal (infrequent) exacerbations
• No emergency visits
• Minimal (ideally no) use of as needed ß2 -agonist
• No limitations on activities (exercise)
• (Near) Normal lung function
• Minimal (or no) adverse effects from medicine

Goal of asthma management

(general)
Pengobatan Asma (dahulu)
Pengobatan
Asma
(sekarang)
• The prevalence of asthma and the burden of disease
remain high, despite efforts to improve public awareness
about and medical management of asthma.

• Asthma is a disease of airway inflammation that has a

variable natural history.

• Atopy is the most important risk factor for the

development of asthma.

Summary