Childhood Asthma

Nepthalie Ordonez, MD, FPPS, FPAPP

PEDIATRIC PULMONOLOGIST
 Definition of Asthma

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(GINA 2006)
Diagnosis of Asthma
 Is it Asthma?

Recurrent episodes of wheezing

Troublesome cough at night
Cough or wheeze after exercise
Cough , wheeze or chest
tightness after exposure to
airborne allergens or
pollutants
Colds “ go to the chest ” or
take more than 10 days to
clear
 Asthma Diagnosis
History and patterns of symptoms
Measurements of lung function
- Spirometry
- Peak expiratory flow
Measurement of airway responsiveness
Measurements of allergic status to identify
risk factors
Extra measures may be required to diagnose
asthma in children 5 years and younger and
the elderly
 Asthma Diagnosis
Therapeutic Trial

5 days SABA + steroids

Indications:

1. Children 5 years and younger

2. Pulmonary function tests like spirometry and
PEFR measurement are not feasible/available.
CASE 1

6 year old male

2 days cough/colds with low grade fever
known asthmatic, no maintenance meds
last attack 5 months ago


 Chief complaint:
 difficulty of breathing
 Pertinent P.E. :

awake, talks in sentences

 HR: 98 RR: 42 BP: 80/60 T:37.5 C
Sa02 (room air) 96%

 Chest: no retractions, (+) expiratory

wheezes
fine crackles ® lower lung field

Full pulses, (-) cyanosis (-) clubbing

DIAGNOSIS?
GINA 2002, 200-2007

Classification of Asthma Exacerbation

MILD MODERATE SEVERE RESPIRATORY
ARREST
IMMINENT

Breathless Walking Talking At rest

Infants – softer Infants- Stops
shorter cry feeding
Can lie flat Prefers sitting *Hunched forward

Talks in Sentences Phrases Words

Alertness May be agitated Usually agitated Usually agitated

Respiratory Rate Increased Increased *Often >30/minBradypnea

GUIDE TO RATES OF BREATHING ASSOCIATED WITH

RESPIRATORY DISTRESS IN AWAKE CHILDREN
AGE NORMAL RATE
> 2 months < 60/min
2-12 months < 50/min
1-5 years < 40/min
6-8 years < 30/min
GINA 2002, 2006-2007

Classification of Asthma Exacerbation

MILD MODERATE SEVERE RESPIRATORY

ARREST IMMINENT

Accessory None Present Present Present

Muscles & Thoraco-abdominal
Suprasternal Movement
Retraction

Wheeze Audible with Audible with Audible w/o Absence of wheeze

stethoscope stethoscope stethoscope with decreased to
absent breath sounds

Pulses/min <100 100-120 >120 Bradycardia

GUIDE TO LIMITS OF NORMAL PULSE RATE IN CHILDREN

Age Normal Limits
Infants 2-12 months <160/min
Preschool 1-2 years <120/min
School Age 2-6 years <110/min
GINA 2002/2006

Classification of Asthma Exacerbation

MILD MODERATE SEVERE RESPIRATORY
ARREST
IMMINENT

Pulses Paradoxus Absent May be present Often present Absence suggests

<10mm Hg 10—20mm Hg 20-40mm Hg respiratory muscle
fatigue

PEF  80% 60-79% <60%

%predicted
Or
%personal best

PaO2RA Normal 60mm Hg <60mmHg

test NOT usually Possible Cyanosis
necessary

PaCO2 45 mm Hg 45 mm Hg >45 mm Hg possible

respiratory failure

SaO2 RA 95% 90-94% <90%

Hypercapnea (hypoventilation) develops more rapidly in young children
 Final Diagnosis
Bronchial asthma
in mild exacerbation
Acute respiratory tract infection
GINA 2006 Management of Asthma Exacerbation in Acute Care

Initial Assessment
History, Physical Examination(auscultation, use of accessory muscles,
HR, RR, PEF or FEV1, O2 saturation, ABG’s if patient in extremis)
Initial Treatment
Oxygen to achieve O2 saturation ≥90% (95% in children)
Inhaled rapid β2-agonist continuously for one hour
Systemic GCS, if no immediate response, or if patient recently took
Oral GCS, or if episode is severe
SEDATION is CONTRAINDICATED in the treatment of an exacerbation

Reassess after 1 hour : PE, PEF, O2

saturation & other tests as needed

Criteria for MODERATE Episode: Criteria for SEVERE Episode:

PEF 60-80% predicted/personal best History of risk factors for near fatal
Physical exam: moderate symptoms, asthma
Accessory muscle use PEF < 60% predicted/personal best
Treatment: PE: severe symptoms at rest, chest
O2, retraction
Inhaled β2 agonist + anticholinergic NO improvement after initial treatment
every 60 min Treatment:
Oral GCS O2,
Continue treatment for 1-3 Inhaled β2 agonist + anticholinergic
hours,provided Systemic GCS
There is improvement IV Magnesium
Continuation next slide
GINA 2006
Cont. (S2)
Management of Asthma Exacerbation in Acute Care
Reassess after 1 – 2 hours

Good Response within 1-2 hours: Incomplete Response within 1-2 Poor Response within 1-2 hours:
Response sustained 60 minutes hours: Risk factors fro near fatal asthma
after last treatment Risk Factors for near fatal asthma PE : symptoms severe, drowsiness,
PE normal: no distress PE : mild to moderate signs confusion
PEF > 70% PEF < 60% PEF : < 30%
O2 saturation > 90% (95% in O2 saturation: NOT IMPROVING PCO2: > 45mmHg
children) PO2: < 60mmHg
ADMIT to ACUTE CARE Setting
Oxygen ADMIT to INTENSIVE Care
Inhaled β2-agonist ± anticholinergic Oxygen
Systemic GCS Inhaled β2-agonist+anticholinergic
Intravenous Magnesium IV GCS
Monitor PEF, O2 saturation, Pulse Consider IV β2 agonist
Consider IV theophylline
Possible intubation
mechanical ventilation
Improved: Criteria for Discharging Home
PEF > 60% predicted / personal best
Sustained on oral/inhaled medications
Reassess at Intervals
HOME TREATMENT:
Continue inhaled β2 agonist
Consider in most cases, oral GCS Poor Response:
Consider adding a combination inhaler Admit to intensive Care
Patient education: take medicine correctly Incomplete response in 6-12 hours
review action plan Improved Consider admission to Intensive Care
close medical check up If No improvement within hours

After 3 doses of Salbutamol nebulization,
patient’s symptoms improved .
2 hours later at the ER observation room,
patient now is asymptomatic with clear
breath sounds and able to feed
GINA 2006
Cont. (S2)
Management of Asthma Exacerbation in Acute Care
Reassess after 1 – 2 hours

Good Response within 1-2 hours: Incomplete Response within 1-2 Poor Response within 1-2 hours:
Response sustained 60 minutes hours: Risk factors fro near fatal asthma
after last treatment Risk Factors for near fatal asthma PE : symptoms severe, drowsiness,
PE normal: no distress PE : mild to moderate signs confusion
PEF > 70% PEF < 60% PEF : < 30%
O2 saturation > 90% (95% in O2 saturation: NOT IMPROVING PCO2: > 45mmHg
children) PO2: < 60mmHg
ADMIT to ACUTE CARE Setting
Oxygen ADMIT to INTENSIVE Care
Inhaled β2-agonist ± Oxygen
anticholinergic Inhaled β2-
Systemic GCS agonist+anticholinergic
Intravenous Magnesium IV GCS
Monitor PEF, O2 saturation, Pulse Consider IV β2 agonist
Consider IV theophylline
Possible intubation
Improved: Criteria for Discharging Home mechanical ventilation
PEF > 60% predicted / personal best
Sustained on oral/inhaled medications
Reassess at Intervals
HOME TREATMENT:
Continue inhaled β2 agonist
Consider in most cases, oral GCS Poor Response:
Consider adding a combination inhaler Admit to intensive Care
Patient education: take medicine correctly Incomplete response in 6-12 hours
review action plan Improved Consider admission to Intensive Care
close medical check up If No improvement within hours

CASE 2
7year old male
Past medical history:
- nocturnal cough >1x/week for
the past 3 months
- daytime dyspnea on
exertion>1x/week
- able to attend P.E. classes
No maintenance medications
Responds well with Salbutamol inhalation
DIAGNOSIS?
 GINA 2002 Guidelines

Severity-based approach may be used in:

1.Initial assessment of an asthma patient
2.Classification of asthma patients with:
a. no previous consult
b. no maintenance medication
c. newly-diagnosed asthma patient
3.Research purposes
 Classify Asthma Based on Severity:
(GINA 2002)

Severity INTERMITTENT PERSISTENT

Mild Moderate Severe
Daytime Symptoms < 1x a week 1x/wk Daily Daily
Affects daily Limits daily
activities activities
Nighttime Symptoms  2x/month >2x/month >1x/week Frequent

PEF  80% 80% >60-<79% <60%

predicted predicted predicted predicted

PEF Variability  20% 20-30% >30% >30%

variability variability variability variability

FEV1  80%  80% 60-79% <60%

Final Diagnosis ?
 MODERATE
Persistent Asthma
Asthma Therapy
 GINA ASTHMA GUIDELINES 2002
Recommended Medications by Level of Severity: Children
All Steps: In addition to daily controller therapy, rapid-acting inhaled β2 agonist* should be taken
as needed to relieve symptoms, but should not be taken more than 3 to 4 times a day.

INTERMITTENT PERSISTENT
MILD MODERATE SEVERE
Daily Controller None IGCS IGCS IGCS >800µg BUD
Medications necessary 100-400mcg 400-800mcg PLUS one or more
BUD budesonide of the following, if
needed:
Sustained- IGCS < 800µg BUD
release PLUS sustained-release - Sustained-release
Other Theophylline, Theophylline, OR theophylline
- Long Acting Inhaled
Treatment β2 agonist
OR IGCS< 800µg BUD
Options PLUS long acting inhaled - Leukotriene
Cromone, β2-agonist, OR modifier
 - Oral glucocortico-
OR IGCS >800µg BUD, OR steroid

Leukotriene IGCS <800µg PLUS
modifier leukotriene modifier

In all steps: Once control of asthma is achieved and maintained for at least 3months, a gradual
reduction of the maintenance therapy should be tried in order to identify the minimum therapy
required to maintain control
 Asthma Plan of Care
Spirometry
DailyPEFR monitoring
Home medications:
1. Salbutamol as needed for
symptoms
2. Maintenance medication:
Fluticasone + Salmeterol 25/125ug
BID dosing for 3 months
Follow-up after 4 weeks or earlier if
symptoms worsen.
After 4 weeks, patient followed-up:


(-) nocturnal cough

(-) daytime dyspnea on exertion
(-) use of Salbutamol medication
able to sleep and eat well
plays in school with no worries
Diagnosis?
 Asthma Classification
(Long Term Management)
 GINA 2002
Based on severity: Intermittent
Persistent

GINA 2006/2007
Based on control: Controlled
Partly Controlled
Uncontrolled
 Levels of Asthma Control
(GINA 2006)
Characteristic Controlled Partly controlled Uncontrolled
( All of the ( Any present in any
following ) week )

Daytime symptoms None ( 2 or less / More than 3 or more

week ) twice / week features of
partly
Limitations of None Any controlled
activities asthma
Nocturnal None Any present in
symptoms / any week
awakening
Need for rescue / None ( 2 or less / More than
“ reliever ” week ) twice / week
treatment
Lung function Normal < 80 % predicted or
( PEF or FEV 1 ) personal best ( if
known ) on any day
Exacerbation None One or more / year 1 in
any week
Bronchial Asthma
CONTROLLED
 REDUCE
LEVEL OF CONTROL TREATMENT OF ACTION

maintain and find lowest

controlled
controlling step
consider stepping up to
partly controlled gain control

INCREASE
uncontrolled step up until controlled

exacerbation treat as exacerbation

REDUCE INCREASE
TREATMENT STEPS
STEP STEP STEP STEP STEP
1 2 3 4 5
Asthma Action Plan
 Action Plan
The asthma action plan is a written asthma
management plan that is jointly prepared by
the doctor and the patient.

This written instruction to the patient should be

updated every visit as changes in peak flow
measurements or asthma severity category
may occur.
ASTHMA ACTION PLAN
Name_________________________
Parent________________________
Guardian______________________
Address_______________________
Home phone___________________
Work phone____________________
Peak Flow Monitoring
Personal Best Peak Flow_____
Monitoring times ____ ____ ____
DATE ACCOMPLISHED________
This plan will help you control your
- asthma and know what to do if you have
an asthma episode.
- Keeping your asthma under control will
help you:
- Take part in normal physical activity like
being active in exercise and in sports.
-Sleep through the night without having
asthma episodes.
- Prevent asthma attacks.
- Have the best possible peak flow number.
- Avoid side effects from medicines.
Instructions to ER
Physician_____________________
Phone No. __________________
Hospital _____________________
Phone No. __________________
Whenever possible, stay away from the
things that bring on your asthma
symptoms.
Identify triggers (check all that apply)
___Exercise
___Stress
___Respiratory infections
___Strong odor
___Changes in temperature
___Tobacco/smoke
___Allergen
___Others
Three ways to control your asthma:
1. Follow your GREEN zone plan everyday
to prevent most asthma
symptoms from starting.
2. Recognize your symptoms of an an acute
asthma attack.
Follow the YELLOW zone plan to
prevent a asthma attack from
getting worse.
3. In cases of emergency , follow the RED
zone plan.
* See your doctor regularly.
* This action plan will need to be updated as
the patient’s condition changes
ASTHMA ACTION PLAN
Name_________________________
Parent________________________Guardian______________________
Address_______________________
Home phone___________________Work phone____________________

Peak Flow Monitoring

Personal Best Peak Flow ________Monitoring times ____ ____ ____

DATE ACCOMPLISHED________

This plan will help you control your asthma and know what to do if you have
an asthma episode.

Keeping your asthma under control will help you:

•Take part in normal physical activity like being active in exercise and in sports.
•Sleep through the night without having asthma episodes.
•Prevent asthma attacks.
•Have the best possible peak flow number.
•Avoid side effects from medicines.
Whenever possible, stay away from the things that bring on your asthma
symptoms.

Identify triggers (check all that apply)

___Exercise ___Stress
___Respiratory infections ___Strong odor
___Changes in temperature ___Tobacco/smoke
___Allergen ___Others

Three ways to control your asthma:

1. Follow your GREEN zone plan everyday to prevent most asthma
symptoms from starting.
2. Recognize your symptoms of an an acute asthma attack.
Follow the YELLOW zone plan to prevent a asthma attack from
getting worse.
3. In cases of emergency , follow the RED zone plan.

* See your doctor regularly.

* This action plan will need to be updated as the patient’s condition changes
 Action
Plan
GREEN ZONE: Doing Well
- No symptoms day and night (cough, wheeze,
chest tightness and shortness of breath)
- Can do usual activities
- Peak flow meter __________
(>80 % of your personal best or predicted)

ACTION:
- Continue with your current
medication as prescribed below:
YELLOW ZONE: Acute Attack
- Presence of at least 1 of the following: (cough,
wheeze, chest tightness or shortness of breath)
- Waking at night due to asthma
- Can do some but not all usual activities
- Peak flow meter: _____ to _____
(60 to 79% of your personal best)
ACTION:
-Take your quick-relief inhaled brochodilator_______________
every 20 minutes up to 3 doses until relieved
- Proceed to ER for further evaluation & possible admission if:
1. getting worse at anytime
2. if no relief after 3 doses of inhaled  2 agonist
On your way to ER, continue your quick relief inhaled
bronchodilator every 20 minutes and take 1 dose of oral steroids
as follows:__________________
RED ZONE: EMERGENCY!!!
- Presence of any:(Trouble walking or talking due to
shortness of breath, lips and fingernails are blue)
-Quick relief medicines have not helped
-Cannot do usual activities
-Symptoms are getting worse
-Peak flow meter: _____ (< 60 % of your personal best)

ACTION:
- Proceed to ER
- Take immediately 1 dose of your quick relief inhaled
bronchodilator and continue your inhaled bronchodilator
every 20 minutes while in transit
- Take 1 dose oral steroids as follows:
 TAKE HOME MESSAGE :
GINA 2002 classification is based on severity.
GINA 2006 classification is based on control.

Inhaled B2 agonist is still the mainstay treatment of
patients in acute exacerbation across all severity
classification. In non-responders, combination of
B2agonist and anticholinergics is recommended.

Inhaled Steroids remain to be the cornerstone in the

long term management of asthma.

Thank you