Bronchial Asthma In Children

Asthma is a chronic inflammatory condition of lung airways characterized by Bronchial hyper responsiveness and reversible airflow obstruction, leading to episodic airflow obstruction resulting in recurrent cough, wheeze and shortness of breath (Paroxysmal dyspnoea).

All that wheezes is not asthma. Wheezing is very common and almost 1/3^rd baby by 3^rd b’day and ½ of baby wheeze by 6^th b’day. It is the most common chronic illness in children and prevalence varies from 1 to more than 30 % in different populations and incidence is increasing every year. Asthma prevalence has doubled in last two decades. It is the common cause of school absenteeism, poor scholastic performance due to nocturnal symptoms, disturbed sleep, day sleep and restrictive activity. It is more common in urban areas and boys. 

Risk factors for Asthma

Definite (All studies show statistical significance)

1. Genetic predisposition to atopy 
2. Genetic predisposition to hyper responsiveness 
3. Family history of Asthma/Atopy 
4. Early lung disease / Bronchiolitis
5. Increased IgE
   
6. Positive skin test(RAST)
7. Maternal smoking
8. Concurrent Allergic Rhinitis/Atopic Dermatitis (Early onset < 01 yr) 
9. House dust / Mite
10. Male

Probable (Multiple studies are in favour, occasional not)

1. Immediate / Early food reactivity
2. Increased humidity / House dampness
3. Pets at home (Furred animals)
4. Eosinophilia (Adult > children)
5. LBW
6. Black race
7. Obesity

Possible (Equal studies are in favour / against)

1. Air pollution 
2. Skin test reactive to Milk / Eggs /peanuts < 01 yr 
3. Not breastfed
4. Paternal smoking
5. Cockroach allergy
6. Childhood Obesity 
7. Day care attendance 
8. Central city residence
9. Low Socioeconomic status
10. Cooking wood / charcoal
11. Increased IgE levels 
12. Maternal young age

 

Global Initiative for Asthma (GINA) Guidelines 2007

EXECUTIVE SUMMARY MANAGING ASTHMA IN CHILDREN

1.The concept of difficult-to-treat asthma, who often relatively insensitive to the effects of glucocorticoids, is introduced and developed at various points throughout the report.

2.Lung function testing by spirometry or peak expiratory flow (PEF) continues to be recommended as an aid to diagnosis and monitoring. Measuring the variability of airflow limitation is given increased prominence, as it is the key to both asthma diagnosis and the assessment of asthma control.

3.The previous classification of asthma by severity into Intermittent, Mild Persistent, Moderate Persistent, and Severe Persistent is now recommended only for research purposes.

4.The current recommendation for classification of asthma is by level of control: Controlled, Partly controlled, or uncontrolled. This reflects an understanding that asthma severity involves not only the severity of the underlying disease but also its responsiveness to treatment, and that severity is not an unvarying feature of an individual patient's asthma but may change over months or years.

5.Asthma control in the guidelines is defined as:

• No (twice or less/week) daytime symptoms
• No limitations of daily activities, including exercise
• No nocturnal symptoms or awakening because of asthma
• No (twice or less/week) need for reliever treatment
• Normal or near-normal lung function results
• No exacerbations

6.Emphasis is given to the concept that increased use, especially daily use, of reliever medication is a warning of deterioration of asthma control and indicates the need to

reassess treatment.

7.The roles in therapy of several medications have evolved since previous versions of the report: Recent data indicating a possible increased risk of asthma-related death associated with the use of long acting β2-agonists in a small group of individuals has resulted in increased emphasis on the message that long-acting β2-agonists should not be used as monotherapy in asthma, and must only be used in combination with an appropriate dose of inhaled glucocorticoids.

8.Long-acting oral β2-agonists alone are no longer presented as an option for add-on treatment at any step of therapy, unless accompanied by inhaled glucocorticoids.

9.Leukotriene modifiers: Clinical benefits of monotherapy with leukotriene modifiers have been shown more prominent role as controller treatment in asthma. Leukotriene modifiers reduce viral induced asthma exacerbations in children ages 2-5 with a history of intermittent asthma.

10.Theophylline: A few studies in children 5 years and younger suggest some clinical benefit of theophylline. However, the efficacy of theophylline is less than that of low-dose inhaled glucocorticoids and the side effects are more pronounced.

11.Monotherapy with cromones is no longer given as an alternative to monotherapy with a low dose of inhaled glucocorticoids.

12.Oral glucocorticoids in children with asthma should be restricted to the treatment of severe acute exacerbations, whether viral-induced or otherwise. There is no evidence to support the use of maintenance low-dose inhaled glucocorticoids for preventing transient early wheezing.

13.Oxygen saturation, which should be measured in infants by pulse oximetry, is normally greater than 95 percent. Arterial or arterialized capillary blood gas measurement should be considered in infants with oxygen saturation less than 90 percent on high-flow oxygen whose condition is deteriorating. Routine chest X-rays are not recommended unless there are physical signs suggestive of parenchymal disease.

14.Reliever Medications - Rapid-acting inhaled β₂-agonists are the most effective bronchodilators available and therefore the preferred treatment for acute asthma in children of all ages. Alternative relievers include anticholinergics and short-acting theophylline.

15.Increased / daily use of reliever medication is a warning of deterioration and indicates the need to reassess treatment.

16.Treatment options are organized into five steps reflecting increasing intensity of treatment (dosages and/or number of medications) required to achieve control. At all Steps, a reliever medication should be provided for as needed use. At Steps 2 through 5, a variety of controller medications are available. If asthma is not controlled on the current treatment regimen, treatment should be stepped up until control is achieved. When control is maintained, treatment can be stepped down in order to find the lowest step and dose of treatment that maintains control.

17.Spirometry is a preferred method of measuring airflow limitation and its reversibility to establish a diagnosis of asthma. An increase in FEV, of >=12% (or >=200ml) after administration of a bronchodilator indicates reversible airflow limitation consistent with asthma.

18.Peak Expiratory Flow (PEF) measurements can be an important aid in both diagnosis and monitoring of asthma. PEF measurements are ideally compared to the patient’s own previous measurements using his / her own peak flow meter. An improvement of 60 L/min (or >=20% of the pre-bronchodilator PEF) after inhalation of a bronchodilator, or diurnal variations in PEF of more than 20% (with twice-daily readings, more than 10%), suggests a diagnosis of asthma. PEF monitoring can be done at home.