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ASTHMA ON PEDIATRIC

By:
Camelia Farahdila Musaad
1102013061

Supervisor:
Dr. Pulung M. Silalahi, Sp.A

Departemen of Pediatric
Raden Said Sukanto Polic Centre Hospital
Faculty of Medicine Yarsi University
19 November 2018 - 26 Januari 2019
INTRODUCTION

ASTHMA • Can occur at any age


•Estimated at 7.2% (6% in adults; 10% in children)
a chronic inflammatory
•Can be mild and does not interfere with
airway disorder that
activities, but can be sedentary and disrupt
involves many cells and
activities and even daily activities
elements
HEALTH
PROBLEM

MANAGEMENT OF ASTHMA
DEFINITION
• Asthma :
a chronic inflammatory airway disorder that involves many cells
and elements, characterized by obstruction of air flow are
reversible with or without treatment
EPIDEMIOLOGY
• Asthma is a health problem worldwide à estimated at 7.2%
(6% in adults and 10% in children)

• Prevalence of asthma on children under the age of 5 years in dr.


Soetomo Hospital, Indonesia
• In 1997, there were 239 children from 8994 children (2.6%)

• In 2002, there were 472 children from 14,926 children (3.1%)


RISK FACTORS

HOST ENVIRONMENT

• Type of allergen
• Genetics
• Sensitization of the work environment
• History of atopy • Cigarette smoke

• Air pollution
• Gender
• Respiratory infections
• Ras • Diet

• Hyperreactivity of bronchus • Economic status


PATHOGENESIS

Figure 1. Pathogenesis of Asthma


PATHOGENESIS

Figure 2. Airway remodeling process


PATHOPHYSIOLOGY
DIAGNOSIS

ANAMNESIS

History of disease : Etc


1. Episodic, often reversible with or without treatment 1. History of atopy in family
2. Symptoms include coughing, shortness of breath, 2. History of atopy
heaviness in the chest and phlegm 3. Other burdensome diseases
3. Symptoms arise or worsen especially night or early 4. Disease development and
morning treatment
4. Begins with trigger factors that are individual
5. Response to bronchodilator administration
DIAGNOSIS
SUPPORTING EXAMINATION

1. Variability in PFR or FEVI >15%


2. Reversibility in PFR or FEVI >15%
3. Decreasing >20% in FEVI (PD20 or PC20) after bronchial provocation with
methacholine or histamine
4. Thorax X-ray, lung function test, and provocation test
5. Other examination : paranasal sinus X-ray, sweat test, immunological test, immune
deficiency test, reflux examination, mucosilliary test, bronchoscopy

*) The use of peak flow meters is an important and necessary thing to do, because in addition to
supporting the diagnosis also to determine the success of the management of asthma
DIFFERENTIAL DIAGNOSIS:
TUBERCULOSIS
• In Indonesia, Tuberculosis (TB) is still a common disease and one of the
symptoms is recurrent chronic cough

• There is overdiagnosis of TB and under diagnosis of asthma, because in paediatric


patients with recurrent chronic cough it is often the first time thought is TB, not
asthma

• Tuberculin test needs to be carried out both in groups that should be


suspected of asthma or non-asthma (see flow of diagnosis of asthma)
DIFFERENTIAL DIAGNOSIS
MILD PERSISTENT MODERATE PERSISTENT SEVERE PERSISTENT
CLINICAL PARAMETERS
ASTHMA ASTHMA ASTHMA

CLASSIFICATION
Frequency of attacks Once per month More than 1 time per month Often

Duration of attacks < 1 weeks ≥ 1 weeks Almost all year, there is no


remission

Intensity of attacks Usually mild Usually moderate Usually severe

Between attacks No symptoms There are often symptoms Symptoms of the day and
night
Sleep and Activity Not disturbed Often disturbed Always disturbed

Physical Examination (normal Normal May be disturbed Abnormal


condition) (abnormalities found)

Controlling medication (anti- No Need Need Need


inflammatory)

Lung function test (normal PEF/FEV1 > 80% PEF/FEV1 60- 80% PEF/FEV1 < 60%
condition)
Variability 20- 30%

Variability (if there is an attack) >15% >30% >50%


MANAGEMENT
• GENERAL PRINCIPLES :
1. Patients can undergo normal activities, including playing and
exercising
2. As few school absentee numbers as possible
3. Symptoms do not arise day or night
4. Lung function tests are as normal as possible, there are no striking
diurnal variations
5. Minimum drug requirements and no attacks
6. Drug side effects can be prevented so that no or as little as possible
arises, especially those that affect child development
ASTHMA EXACERBATIONS

1. Give oxygen

2. Nebulizer with β-agonists ± anticholinergics with oxygen (4-6 times


administration)

3. Correction of acidosis, dehydration and electrolyte disorders if present

4. Give intravenous Steroids on a bolus, every 6-8 hours

5. Give intravenous Aminophylline*


ASTHMA EXACERBATIONS

6. If clinical improvement occurs, nebulizer continued every 6 hours to 24


hours, and administration of Steroids and Aminophylline can be taken
orally

7. If in 24 hours the patient remains stable, patients can be discharged with


β-agonist drugs (inhalers or oral) given every 4-6 hours for 24-48 hours, oral
steroids**
MILD PERSISTENT ASTHMA

1. Mild persistent asthma is adequately treated with a reliever in the form of a


short-acting bronchodilator β-agonist inhaler (SABA) or a group of canteens
that work quickly if necessary or if there are symptoms / attacks (evidence
level A)

2. The use of single oral β-agonists with large doses often causes side effects such
as palpitations, and this can be reduced by reducing the dose and combined
with theophylline (evidence level C)

3. If the inhaler is not available or cannot be used, then β-agonist is given orally
(evidence level D)
MODERATE PERSISTENT ASTHMA

1. If the use of β-agonist inhalers is more than 3 times a week (without


calculating the use of physical pre-activity), or moderate / severe attacks
occur more than once a month, then the use of anti-inflammation as a
controller is indicated (evidence level A)
SEVERE PERSISTENT ASTHMA

1. In the administration of anti-leukotriene (Zafirlukas) there has been an


increase in liver enzymes, therefore liver abnormalities are contraindicated
as a controller in children asthma is no longer used because it has no
meaningful benefits (evidence level A)

2. The use of oral corticosteroids as a controller is the last choice after the use
of steroid inhalers or the alternatives above have been carried out
(evidence level B)
SEVERE PERSISTENT ASTHMA

3. If with a 2nd line treatment for 6-8 weeks there are still asthma symptoms,
then a 3rd line can be given, which can increase the dose of corticosteroids
to high doses, or keep the medium dose added with PROFIT, or TSR, or ALTR
(evidence level D)
SEVERE PERSISTENT ASTHMA

How to administer steroid inhaler ? Low to High vs High to Low

• Children with severe persistent asthma à High dose inhaler steroid + short-

term oral steroid – then the steroid inhaler dose is reduced until the smallest

dose is still optimal

• The steroid dose of inhalers which is still considered safe is the equivalent of

400 µg / day (Budesonide)

• Dose of 800 µg / day à it seems to have an effect on the HPA axis


HOW TO ADMINISTER DRUGS?

AGE INHALATION TOOL

< 2 years old Nebulizer, Aero chamber, Baby haler

2 – 4 years old Nebulizer, Aero chamber, Baby haler, Metered-Dose Inhaler

(MDI) with spacer

5 – 8 years old MDI Nebulizer with spacer, Powder inhaler (Spin haler, Disk

haler, Rota haler, Turbu haler)

> 8 years old MDI Nebulizer, Powder inhaler, Auto haler


*) Lenfant C, Khaltaev N. Global Initiative for Asthma. NHLBI/WHO Workshop Report 2002
PREVENTION
1. Environmental control

2. Exclusive breastfeeding, at least 4 months

3. Avoidance of potentially allergenic foods

4. Reduced exposure to house dust mites and animal hair loss

5. Improvement of ventilation of the room, and avoidance of humidity


of the room is necessary for children who are sensitive to house dust
and drought (Evidence Level A)
PROGNOSIS
• COHORT STUDIES :

1. Many babies with wheezing do not continue to develop asthma


in their childhood and adolescence

2. History of asthma in family and atopic dermatitis in children with


wheezing is a one important indicator of future asthma

3. Two of the following three conditions : eosinophilia, allergic

rhinitis, and wheezing which persist in non-flu conditions


CONCLUSION
• Asthma is a chronic inflammatory airway disorder that involves many
cells and their elements

• The purpose of managing childhood asthma in general is to ensure the


achievement of the potential for child development optimally

• Asthma drugs can be divided into 2 major groups : reliever (reliever)


and controlling drugs (controller)

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