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G lobal INitiative for A sthma

Objectives

To discuss: Overview

Manifestations
Risk factors

Diagnosis
Classification Treatment

Objectives

To discuss: Overview

Overview

300 M individuals are affected worldwide

most common chronic disease of childhood


leading cause of childhood morbidity from chronic disease Typically begins in early childhood, with earlier onset in males than females Atopy is present in the majority of children over 3 years of age with asthma

Objectives

To discuss: Overview

Manifestations

Manifestations

Symptoms Episodic breathlessness Wheezing

Cough
Chest tightness

Manifestations

Physical Examination

May be normal
Wheezing on auscultation

Cyanosis
Drowsiness Difficulty speaking Tachycardia Hyperinflated chest

Use of accessory and intercostal muscles

Objectives

To discuss: Overview

Manifestations
Risk factors

Risk Factors
HOST FACTORS Genetic Obesity Sex ENVIRONMENTAL FACTORS Allergens
House dust mites Companion animal allergens Cockroaches Fungi

Infections Occupational sensitizers Pollutants Tobacco smoking

Recommendations

Avoid maternal smoking during pregnancy Avoid exposing children to atmospheric pollution and particularly tobacco smoke Avoid unnecessary use of antibiotics in young children Provide a calm and nurturing environment

Objectives

To discuss: Overview

Manifestations
Risk factors

Diagnosis

Diagnosis

Asthma diagnosis in childhood is difficult

Respiratory symptoms (wheezing and cough) also common in children without asthma
Not possible to routinely assess airflow limitation (spirometry)

Diagnosis

can often be made based on symptom patterns and on a careful clinical assessment of family history and physical findings. Typical symptom pattern: recurrent, during sleep, or with triggers such as activity, laughing or crying The presence of atopy or allergic sensitization provides additional predictive support.

Diagnosis

No specific test for diagnosis The enhance diagnostic confidence:


Spirometry (FEV1 /FVC 80%) Peak Expiratory Flow (20% improvement afterbronchodilator or diurnal variation of 20%) Tests for atopy (skin test w/ allergen)

Objectives

To discuss: Overview

Manifestations
Risk factors

Diagnosis
Classification

Classification

Characteristic
Daytime symptoms:
wheezing, cough, difficult breathing

Controlled

Partly contolled
(any measure present in any week)

Uncontrolled
(>3 features of partly controlled present in any week)

>Twice a week None


( < 2x/week)

>Twice a week

Limitations of activities Nocturnal symptoms or awakening Need for reliever/rescue

None

Any
(cough, wheeze or difficulty breathing,during exercise, play or laughing)

Any

None
(including no nocturnal coughing during sleep)

Any
(coughs during sleep or wakes with cough, wheezing, and/or difficult breathing)

Any

< 2 days/week

> 2 days/week

> 2 days/week

Classification

Asthma is controlled (all of the following): No (or minimal)* daytime symptoms No limitations of activity (Child is fully active,

plays and runs without limitations of symptoms)


coughing during sleep)

No nocturnal symptoms (including no nocturnal

No (or minimal) need for rescue medication


_________
* Minimal = twice or less per week

Classification

Asthma is uncontrolled: Daytime symptoms >2 times/week (last minutes or

hours or recur)

Any limitations of activity (May cough, wheeze or

have difficulty breathing during exercise, vigorous play, or laughing)

Any nocturnal symptoms (typically coughs during

sleep or wakes with cough, wheezing, and/or difficult breathing)

Need for rescue medication > 2 days/week

Objectives

To discuss: Overview

Manifestations
Risk factors

Diagnosis
Classification Treatment

Treatment Choosing an Inhaler Device


Age group Younger than 4 years Preferred device
Pressurized metereddose inhaler plus dedicated spacer with face mask

Alternative device
Nebulized with face mask

4-6 years

Pressurized metereddose inhaler plus dedicated spacer with mouth piece

Nebulizer with mouthpiece or face mask

Older than 6years

Dry powder inhaler or breath-actuated pressurized MDI or pressurized MDI w/ spacer and moutpiece

Nebulizer with mouthpiece or face mask

Treatment
Environmental control As needed rapid-acting 2-agonists
Controlled on as needed rapid-acting 2agonists Partly controlled on as needed rapid-acting 2agonists Uncontrolled on 2-agonists prn. or partly controlled on a low-dose inhaled glucocorticosteroid

Controller options
Continue as needed rapid-acting 2-agonists

Low-dose inhaled glucocorticosteroid


Leukotriene modifier

Double low-dose inhaled glucocorticosteroid


Low-dose inhaled glucocorticosteroid plus leukotriene modifier

Oral glucocorticosteroids should be used only for treatment of acute severe exacerbations of asthma. Green shaded boxes represent the preferred treatment options.

Treatment
Low daily doses of inhaled glucocorticosteroids* Daily dose
100 g

Drug

Beclomethasone dipropionate

Budesonide pMDI+spacer Budesonide nebulized


Ciclesonide Fluticasone propionate

200 g 500 g
NS 100 g

Mometasone furoate
Triamcinolone acetonide
*

NS
NS

Doses found to be without adverse systemic effects in clinical trials

Key Messages: Pharmacologic Therapy


A pressurized metered dose inhaler with a valved spacer (with or without a face mask depending on the childs age) is the preferred delivery system (Evidence A).
A low-dose inhaled glucocorticosteroid is recommended as the preferred initial treatment to control asthma (Evidence A). If low-dose inhaled glucocorticosteroid does not control symptoms, and the child is using optimal technique and is adherent to therapy, doubling the initial dose of glucocorticosteroid may be the best option (Evidence C).
(.continued)

Key Messages: Pharmacologic Therapy


When doubling the initial dose of inhaled glucocorticosteroid fails to achieve and maintain asthma control, the childs inhalation technique and compliance with the medication regimen should be carefully assessed and monitored. Use of oral glucocorticosteroids should be restricted to the treatment of acute severe exacerbations, whether viral-induced or otherwise. To avoid under and over-treatment continued need for asthma treatment should be regularly assessed (e.g., every three to six months).

Key Messages: Pharmacologic Therapy


Several trials have found little or no effect of intermittent treatment of wheezing episodes with:

Oral glucocorticosteroids Montelukast Inhaled glucocorticosteroids

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