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Bronchial Asthma

Diagnosing and Management

Mani santhoshkumar
12th sem Pediatrics
What is Asthma?
• Disease of chronic
inflammatory disorder of the
• Characterized by
• Airway inflammation
• Airflow obstruction
• Airway
• Reversible process
Asthmatic Inflammation
Normal Early Asthmatic Late Asthmatic Subacute/Chronic
Airway Response Response Inflammation

Inhaled trigger
chemotactic factors


Bronchoconstriction Recruitment and Neural &

Mast Cells activation of vascular
Alveolar macrophages inflammatory cells effects
Mucosal Odema
Mucous Secretion
What Causes Asthma?
• Asthma is a complex trait
• Heritable and environmental factors contribute to its
• The inheritance of Asthma is most compatible
 with one affected parent ………..25% risk
 with two affected parents ……….50% risk
• Onset appears early in life and severity remains
• Multiple interacting genes
• At least 20 distinct chromosomal regions with linkage
to asthma and asthma related traits have been identified:
Chromosome 5q31 , ADAM33 , PHF11
Neuroendocrine Mechanisms-
Stress and Asthma
• Common clinical observations of adverse relationship
between stress and human disease
• Adverse effects of psychological stress on asthma have
been documented.
• Depression and stress can augment humoral immunity and
favor production of IgE
• Growing set of data provide evidence for association
between chronic psychological stress and the pathogenesis
of atopy and asthma
Potential Risk Factors1
• Host factors • Environmental factors (cont)
• Genetic predisposition • Tobacco smoke
• Atopy • Air pollution
• Airway • Respiratory infections
• Male Gender • Socioeconomic status
• Race/Ethnicity • Family size
• Maternal smoking • Diet and drugs
• Environmental factors • Obesity
• Indoor allergens
• Outdoor allergens
• Occupational sensitizer
Wheezing in Infants
• Group 1: Low Lung function: children improve
within a few years and "outgrow" their asthma
• Group 2: Non-Atopic, viral-induced asthma:
also outgrow asthma after a somewhat longer
period of time (nonatopic wheezing).
• Group 3: Atopic Asthma: in contrast, children
who will go on to develop persistent wheezing
beyond infancy and early childhood usually
have a family history of asthma and allergies
and present with allergic symptoms very early
in life (atopy-associated asthma).
Differential Diagnosis of Wheezing
• Asthma
• Congenital Anomalies with airway impingement: Vascular
rings, tracheobronchial obstruction, mediastinal mass
• H-Type Tracheoesophageal Fistula
• Bronchopulmonary dysplasia
• Cystic fibrosis
• Gastroesophageal reflux
• Aspiration
• Foreign Body Aspiration
• Heart Failure
• Sinusitis and allergic rhinitis
• Bronchiolitis
• Pertussis
• Tuberculosis
• Immune system Disorders
Diagnosing Asthma-Not Easy
• Clinical diagnosis supported by the certain historical,
physical and laboratory findings
• History of episodic symptoms of airflow obstruction
(e.g.. breathlessness, wheezing, and COUGH)
especially if triggered by inhaled allergen or
exercise-response to therapy!
• Physical: wheeze, hyperinflation, tachypnea with
prolonged expiration
• Laboratory:
 esinophilia of blood and sputum
 High IgE level
 Allergy skin test
 PFT >4 year, exhaled nitric oxide (eNO), spirometry
 ABGs and pH
• Exclude other possibilities
Diagnosing Asthma in Young Children
– Asthma Predictive Index
• > 4 episodes/yr of • Major criteria
wheezing lasting more • Parent with asthma
than 1 day affecting • Physician diagnosed
sleep in a child with atopic dermatitis
one MAJOR or two
MINOR criteria • Minor criteria
• Physician diagnosed
allergic rhinitis
• Eosinophilia (>4%)
• Wheezing apart from
Asthma: Goals of Treatment1
• Control chronic and nocturnal symptoms
• Maintain normal activity levels and exercise
• Maintain near-normal pulmonary function
• Prevent acute episodes of asthma
• Minimize emergency department (ED)
visits and hospitalizations
• Avoid adverse effects of asthma medications
Steps of Therapy
• Step 1: intermittent- use SABA
• Step 2: mild persistent-use SABA plus one of:
ICS OR montelukast OR cromolyn alternatives
• Step 3: moderate persistent: SABA + ICS +
LABA and/or montelukast
• Step 4: severe persistent: SABA + LABA+ ICS
and/or montelukast + alternate day
• Step down:
Step down treatment when good control
achievement + SABA
• Consult asthma specialist if step 3 or higher
(consider at step 2)
Maintaining Control
• Monitor carefully- every 6 months if stable,
more often if not
• If stable after 3 months, try to reduce therapy
(usually by 25-50%)
• Inhaled steroids are safe even in the young at
mild to moderate doses with only a slight
decrease in growth velocity. Higher doses have
been shown to affect growth, cause cataracts
and reduce bone density
• Response to therapy is very important in this
age group!
Status Asthmaticus
Is acute severe and life threating asthma defined as an
increasing severe asthma that is not response to drugs that
are usually effective
Sign of Severity:
 Too breathless to feed or speak
 RR>50/min
 PR>140 bpm
 Pulsus paradoxus >15
 PEFR <50% predicted
Signs of life-threating:
 Restless due hypoxia
 Drowsiness (hypercabnea)
 Exhaustion
 Cyanosis
 Silent chest
 PEFR<33%
Treatment of Status Ashmaticus
O2 (high flow) 6L/min
Nebulized SABA
(salbutamol .05-.15 mg/kg at interval 20-30 min
for one hour then should be continued every 1-2 hour)

No Response
Check PCo2 and pH Response

Oral predinsolone
2- IV Hydrocortisone
3- +/-nebulized Ipratropium
Divided for 3-5 days
4-Nebulized SABA every
1-2 hour should be cont. ß2-agonists and O2
5-adequate hydration Improved As required
6- +/- Antibiotics

No improvement
Discharge plan
Artificial Respiration
Inhaled Corticosteroid
• Preferred treatment alone or in combination
for all persistent categories of asthma
• Safe when use is monitored
• Reduces asthma symptoms, bronchial
hyperreactivity, exacerbations and
hospitalizations, need for rescue
• Improves lung function, quality of life
• May prevent airway remodeling….!!
Asthma Prevention
• There has been remarkable progress in
pharmacotherapy, education and environmental
measures in treating asthma
• However, no single action has been demonstrated
to decrease the risk of developing asthma
• Genetic and environmental influences
• Prevention will depend on factors influencing the
development and progression of asthma
Is Environmental Control Helpful?
• Single allergen reduction not
• “…Treatment by means of
allergen avoidance requires the
definition of what patients are
allergic to, and additional
measures beyond the use of
mattress covers and education”
Thomas Platts-Mills