Presented by,

Tan Yee Mun

Codillia Cheong Kai Shim
Wong Pui Seen
Tutorial Contents
Anatomy, embryology and physiology of the
respiratory and immune systems
Definition of wheeze and the differential diagnoses of
conditions causing it
Definition, pathophysiology, clinical features,
investigations,management and outcome of asthma
including acute exacerbations in children
Epidemiology of asthma in children in Malaysia
Grading of severity of chronic asthma and an acute
exacerbation
Tutorial Contents
Drugs and devices used in asthma
Allergic disorders: allergic rhinitis, allergic
conjunctivitis, atopic
eczema, urticaria, anaphylaxis, food and drug allergy,
insect bite hypersensitivity
Pathophysiology, clinical features, investigations,
management, complications and outcome of foreign
body inhalation in children
The clinical approach to a child with wheeze

Anatomy of Respiratory tract
Respiratory tract are
divided into
Upper respiratory tract
Entrance to larynx
Lower respiratory tract
Larynx to alveoli (trachea
to lungs)

Embryology
What structural aspects must be considered
in the process of respiration?

Trachea
Primary bronchi
Secondary bronchi
Tertiary bronchi
Bronchioles
Terminal bronchioles
Respiratory bronchioles with
start of alveoli outpouches
Alveolar ducts with outpouchings
of alveoli
conductive
portion
exchange
portion
External
Respiration
Internal
Respiration
Anatomy of Immune System
Physiology of Immune System
To discriminate self form non-self and to eliminate the
foreign substance
To protect the host against foreign antigen
Definition of Wheeze
Polyphonic(multiple pitch) noise coming from the
airways believed to represent many airways of different
dimensions vibrating from abnormal narrowing.
Differential Diagnoses of
Conditions that can cause
Wheezing
Transient early wheezing
Atopic asthma
Non-atopic asthma
Recurrent aspiration of feeds
Inhaled foreign body
Cystic fibrosis
Recurrent anaphylaxis in a child with food allergies
Congenital abnormality of lung, airway or heart
Idiopathic
Asthma
Definition of Asthma

Chronic airway inflammation leading to increase
airway responsiveness that leads to recurrent episodes
of wheezing, breathlessness, chest tightness and
coughing particularly at night or early morning.
Often associated with widespread but variable airflow
obstruction that is often reversible either
spontaneously or with treatment.
Reversible and variable airflow limitation as
evidenced by >15% improvement in PEFR (Peak
Expiratory Flow Rate), in response to administration of
a bronchodilator.

Recommendations to define pre-
school wheezing
2 main categories:
Episodic (viral) wheeze.
only wheeze with viral infections and are well between
episodes.
Multiple trigger wheezers
have discrete exacerbations and symptoms in between
these episodes. Triggers are smoke, allergens, crying,
laughing and exercise.

The presence of atopy (eczema, allergic rhinitis and
conjunctivitis) in the child or family supports the diagnosis
of asthma .

However, the absence of these conditions does not
exclude the diagnosis.

Pathophysiology of asthma

Clinical Features of Asthma
Symptoms worse at night and in the early morning
Symptoms that triggers (eg: exercise, pets, dust, cold
air, emotions, laughter)
Intervals symptoms (between acute exacerbation)
Personal or family history of an atopic disease
Positive response to asthma therapy.
Harrisons sulci
Depression at the base of
the thorax with muscular
insertion of the diaphragm
are called Harrisons sulci,
and are associated with
chronic obstructive airways
disease such as asthma
during childhood.
Management
Aim of management-
- To allow the child to lead a normal life by controlling
the symptoms and preventing exacerbations,
optimising pulmonary function, while minimizing
treatment and side effects.
Outcome of Asthma
Majority has a good prognosis.
Those more severe, persistent asthma cases , develop
longitudinal changes in lung function. ( impaired lung
function in childhood and decline in lung function in
adulthood)
Early intervention of anti-inflammatory therapy may
improve the short-term outcome of asthma.
Disease progression to nonreversible airflow
obstrcution may be observed in minority.

Epidemiology
Estimated prevalence of asthma in Malaysia is
4.2%. (The Star, May 2011)

International Studies on Asthma and Allergy
(ISAAC) has shown the prevalence of asthma
among school children is 10%. (Protocol Ed3)

Among children up to 14 yrs old has a
prevalence rate of 4.5% and age 15 years and
above is 4.1%. (The Star, May 2011)



Prevalence of childhood asthma is 24%, particullarly in
Malays and those living in urban areas. (Selangor,
2011)

A study of symptom control and severity of Asians
under 16 years old shows that 2.5% controlled while
53.4% uncontrolled asthma.(MIMS, Jul 2014)

As for severity, 24.5% had moderate to severe
persistent symptoms.
Participants of uncontrolled asthma were the most
frequent users of anti-asthmatic medication and
urgent healthcare services. (MIMS, Jul 2014)

Hospitalization was the most important factor
affecting life quality of Malaysian parents with
asthmatic child.
Grading of severity in asthma
1. Intermittent
Daylight symptoms less than once a week
Noctural symptoms less than once a month
No exercise induced symptoms
Brief, infrequent exacerbation not affecting sleep and
activity
Normal lung function
2. Persistent

Criteria Mild Moderate Severe
Daylight
Symptoms
>once a week Daily Daily
Noctural
Symptoms
>2x a month >once a week Daily
Exercise induced
symptom
Present Present Daily
Exacerbation
(affecting sleep
and activity)
> 1x/month >2x/month Frequently,
>2x/month
PERF/FEV1 >80% 60% - 80% <60%
PEFR: Peak Expiratoty Flow Metre FEV1: Forced Expiratory Vol in 1 sec
Acute exacerbation
Assessment of severity:
i. Diagnosis: cough,wheezing, breathless

ii.Triggering factor: food, exercise, drugs

iii.Severity: RR, RE, consious lvl.

Criteria for admission
Failure to respond to standard home treatment.
Failure to respond to nebulised beta 2 agonist.
Relapse with 4 hours of nebulised beta 2 agonists.
Severe acute asthma.
Drugs
Bronchodilators
Beta 2 Agonist (SABA, LABA)
Anticholinergic (Ipratropium bromide)
Inhaled Corticosteroids
Leukotriene receptor agonist (oral)
Theophylline
Prednisolone (Oral steroids)
Anti-IgE injection (Omalizumab)
Mnemonics
A - Adrenergics (Beta 2 Agonist)
- Albuterol
S - Steroids
T - Theophyline
H - Hydration (IV)
M - Mask O2
A - Anticholinergics
- Ipratropium bromide
Inhaler
Nebulizer

Only used in acute asthma where
oxygen is needed in addition to inhaled
drugs.
Allergic Disorders
Allergy - an altered state of reactivity to common
environmental antigens.
Most patients with allergy produce IgE antibodies to the
antigens; familial predisposition to allergic diseases

Allergic rhinitis
Allergic conjuntivitis
Ectopic eczema
Urticaria
Anaphylaxis
Food and drug allergy
Insect bite hypersensitivity
Sudden onset
if the chest does not rise when ventilation is first
attempted.
The most serious complication is complete obstruction
of the airway, recognized as sudden respiratory distress
followed by inability to speak or cough.

Three stages of symptoms:
1. Initial event violent paroxysms of coughing,
choking, gagging, and persistent monophonic wheeze.
2. Asymptomatic interval the foreign body
becomes lodged, reflexes fatigue, and the immediate
irritating symptoms subside.
3. Complications obstruction, erosion, or infection.
Complications include lung abcess, fever, cough,
hemoptysis, pneumonia, and atelectasis.
Most airway foreign bodies lodge in a bronchus (right
bronchus in 58% of cases); laryngeal or tracheal
locations occur in 10% of cases.
Bronchoscopy
x-ray
CT or MRI

Abdominal thrust using
Heimlich maneuver
Back blows and chest thrusts
Infant younger than 1 yr
Conscious child - permits to cough
spontaneously until coughing is not
effective (or aphonic), respiratory
distress and stridor increase
Unconscious - the airway is opened
with the head-tilt/chin-lift maneuver,
and ventilation is attempted.
If there is still no chest rise, a
combination of 5 back blows and 5
chest thrusts is administered.
Child older than 1 yr
A conscious child is administered a series of 5
abdominal thrusts (Heimlich manoeuvre) with the
child standing or sitting.
If the child is unconscious, this is done with the child
lying down.

1. Stand behind the patient
2. Encircle arms around the upper part of the abdomen
just below the patients rib cage
3. Give a sharp, forceful squeeze, forcing the diaphragm
sharply into the thorax.
Obstructive emphysema (air trapping) and shift
of the mediastinum toward the opposite side.
Clinical Approach to a Child with Wheeze
Age
Gradual or sudden onset, duration
Transient early wheezing or persistent and recurrent
wheezing
Preterm, maternal smoking
Allergens (dust mites, pollens, pets etc), other allergic
disorders, family history of allergic disorder, asthma
Feeds
References
European Respiratory Journals [Outcome of asthma :
longitudinal changes in lung function]
Illustrated Textbook of Paediatrics
Paediatrics Protocols