In Practice Asthma In Childhood - University Of Malta

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In PracticeAsthma in childhoodMarie Claire FormosaCase scenarioIntroductionA 4 year old girl, has been brought to the clinic by her parentsdue to three episodes of coughing and wheezing, with the firstepisode occurring approximately 6 months previously. The childhas a history of eczema and her mother suffered from asthma.The father is a smoker. This is a case of asthma in childhood.What is the cause of asthma and how is such a case managedin general practice?Asthma is the commonest chronic lung disease in childrencharacterized by chronic inflammation of the airways leadingto obstruction of airflow.1,2 This may be completely or partiallyreversed with or without specific therapy. Asthma exacerbationsare episodic but airway inflammation is chronically present.3Estimates of prevalence of asthma range from 7% in Franceand Germany to 11% in the USA and 15 to 18% in the UnitedKingdom. Approximately 20% of these patients have severeasthma, of which 20% is inadequately controlled.4 Peak age ofonset is 5 years, where it is more common in boys than girls, at aratio of 3:2.5 During adolescence, the prevalence is equal amongmales and females. Globally, morbidity and mortality associatedwith asthma have increased over the last 2 decades.2Predisposing and triggering factorsKey wordsAsthma, paediatricsMarie-Claire Formosa MDDepartment of Primary Health CareEmail: marieclaire formosa@yahoo.co.ukMalta Medical Journal Volume 20 Issue 01 March 2008The development of asthma in childhood is due to an interactionbetween environmental and genetic factors. There is nosingle gene for asthma.6,7 Asthma is associated with a geneticpredisposition to atopy, with an atopic component present in40% of patients, in the form of a personal or familial history ofeczema, hay fever and urticaria.5 Approximately 79% to 90% ofchildren with asthma have allergy.8Common environmental triggers for asthma includeexposure to allergens such as those from house dust mites,animals with fur, cockraoches, pollen, molds and tobacco smoke.3However the “hygiene hypothesis” claims that living in a cleanenvironment predisposes the immune system towards allergicreactivity. In fact a large number of studies have consistentlyshown that growing up on a farm in various rural areas in Europeconfers protection from the development of hay fever, atopicsensitization and asthma from childhood into young adulthood.9The early exposure to other children, domestic animals and lessfrequent use of antibiotics also has a protective effect.8 Exposureto environmental tobacco smoke worsens asthma control.Reduced smoking in the home and for young adults smokingrestriction on the work place may lower the prevalence ofasthma, improve asthma control, and reduce the use of medicalservices.10 A bidirectional relationship might also be presentbetween asthma and smoking in adolescents. Non-smokingadolescents with current diagnosed asthma and with moresevere asthma have an increased risk to become regular smokers.Among girls and adolescents with a smoking mother, havingasthma symptoms can be protective for experimental smoking.With regards to the effect of smoking on asthma, adolescent35

Table 1: Consider asthma if any of the following signs orsymptoms are present3: Frequent episodes of wheezing – more than once amonthActivity-induced cough or wheezeCough particularly at night during periods withoutviral infectionsAbsence of seasonal variation in wheezeSymptoms persist after three years of ageSymptoms occur or worsen in the presence oftriggering factorsThe child’s colds repeatedly “go to the chest” or takemore than 10 days to clear up.Symptoms improve when asthma medication is givensmoking predicts a higher incidence of asthma symptoms. Inaddition, smoking leads to an increased symptom severity score,and this effect seems to be stronger in girls. 11 There is alsoevidence for an association between asthma and air pollutants,including ozone, NO2 and particulate matter. Air pollutionresearch is evolving rapidly and in the near future, cliniciansand public health agencies may provide recommendations forasthmatics that go beyond paying attention to the air-pollutionforecast.12 Viral infections are important triggers of asthma.Infants hospitalized with bronchiolitis are at significantlyincreased risk for both recurrent wheezing and childhoodasthma. It is not known whether viral bronchiolitis directlycontributes to asthma causation or simply identifies infants atrisk for subsequent wheezing. Alternatively the properties ofthe infecting virus may be important. A genetic susceptibilityto asthma after viral bronchiolitis might be present.13 Bacterialinfections may also be responsible. In fact neonates colonized inthe hypopharyngeal region with S. pneumoniae, H. influenzaeor M. catarrhalis, or with a combination of these organisms, areat increased risk for recurrent wheeze and asthma early in life.14Asthma and excessive body weight frequently coexist. Excessivebody weight is associated with an additional decrease in qualityof life in children with asthma.15 Other triggers include exercise,cold air, strong emotional expressions, (e.g. laughing and crying)chemical irritants, drugs such as aspirin and beta blockers andaggravating conditions not appropriately treated (e.g. rhinitis,sinusitis, gastroesophageal reflux).3,8Clinical featuresAsthma is characterized by recurring episodes of wheezing,breathlessness, chest tightness and coughing. Between attacksthe child may be asymptomatic with no abnormal physicalsigns.5 A history of persistent cough (cough-variant asthma),night coughs, exercise induced cough, post-tussive emesis fromcopious amounts of mucus and cough following cold air exposureare all suggestive of asthma. Abdominal pain is common owingto the use of accessory muscles.1 The child may also complain of36Table 2: Differential diagnosis of wheezing 1Respiratory causes(Common) Infection Foreign body Cystic fibrosis Laryngotracheomalacia(Uncommon) Bronchopulmonary dysplasia a1-antitrypsin deficiency Allergic bronchopulmonary aspergillosis Ciliary dyskinesia syndrome Hypersensitivity pneumonitis Bronchiectasis Pulmonary hemosiderosis Visceral larva migrans – hypereosinophilic disordersCardiovascular causes Congenital heart disease Vascular rings/slingsGastrointestinal Gastroesophageal reflux H-type tracheo-esophageal fistula Foreign bodyMiscellaneous Immunodeficiency disorder Vasculitis, collagen vascular disease Psychogenic coughConsider alternate diagnosis if 8 Failure to thrive Cyanosis at feeding Vomiting at feeding Failure to respond to appropriate treatment Clubbingfatigue and becomes easily irritated. Infants may have difficultyfeeding or may grunt during sucking. Older children may avoidcertain activities such as sports and sleep-overs.8 Most childrenwho develop wheezing after 5 years of age have asthma.3 Thenature of wheezing changes with the severity of the asthma. Inthe mildest form, wheezing is only end-expiratory. As severityincreases, the wheeze lasts throughout expiration, and may evenbe present during inspiration. In most severe cases, air flow maybe so limited that wheezing may be absent.2Any child with asthma can experience a life-threateningepisode.8 During acute episodes, the physical examinationmay reveal a hyper-inflated chest that is hyper-resonantMalta Medical Journal Volume 20 Issue 1 March 2008

to percussion. Tachypnea, tachycardia, cough, inspiratoryand expiratory wheezing, and a prolonged expiratory phaseare common clinical signs. As the attack progresses there iscyanosis, use of accessory muscles of respiration, decreasedbreath sounds (tight silent chest) and diminished wheezing,agitation and inability to speak, tripod sitting position, andpulsus paradoxus.1If the child is in imminent respiratory arrest, in additionto the aforementioned symptoms, there is drowsiness andconfusion. However, adolescents may not have these symptomsuntil they are in frank respiratory failure.2DiagnosisAsthma can be diagnosed on the basis of the patient’ssymptoms and medical history (Table 1). This disease isfrequently under-diagnosed and many patients do not receiveadequate therapy. On the other hand, not all wheeze and coughare caused by asthma and caution is needed to avoid prescribingasthma therapy unnecessarily (Table 2).3Lung function measurement helps diagnosis and alsoassessment of asthma severity. Spirometry is the preferredmethod, but this may not be feasible in young children,particularly under the age of 4 years. Moreover some childrencannot conduct the manoeuvre adequately until after age 7.For these children, the diagnosis of asthma has to be basedlargely on clinical judgement and an assessment of symptomsand physical findings and usually on the response to a trail ofinhaled bronchodilator and/or corticosteroid therapy.3 Newertechniques, such as a measurement of airway resistance usingimpulse oscillormetry system are being evaluated for thispopulation of patients.2 In children who can perform spirometryan increase in FEV1 of more than or equal to 12% or 200mlafter administration of a bronchiodilator indicates reversibleairflow limitation consistent with asthma. However most asthmapatients will not exhibit reversibility at each assessment, andrepeated testing is advised.Peak expiratory flow (PEF) measurements can also beutilised in monitoring of asthma. PEF measurements are ideallyTable 3: The Peak Flow Zone System8 80% *GREEN ZONE: Good control No asthma symptoms Take medications as usual50-80%* YELLOW ZONE: Caution Use a short-acting inhaled b2-agonist Check about changing medications or increasing dose 50%* RED ZONE – Medical alert Use a short-acting inhaled b2-agonist Call doctor or emergency departmentMalta Medical Journal Volume 20 Issue 01 March 2008compared to the patient’s own previous best measurementsusing his/her own peak flow meter. A diary of symptoms andPEF readings should be kept. An improvement of 60L/min (or 30% of the prebronchodilator PEF) after the inhalation of abronchodilator, or diurnal variation of PEF of more than 20%(with twice daily readings, more than 10%) suggests uncontrolledasthma.3 Patients and parents can be advised on how to altertheir treatment according to the PEF values (Table 3).Chest radiographs in both posteroanterior and lateralviews should be obtained in all new wheezing patients toidentify anatomic abnormalities, atelactasis, foreign bodiesor neoplasms.1 If the child is a known asthmatic and thereis not suspicion of infection, radiology is not required forevery admission.5 If a full blood count is taken it may show aneosinophilia. Allergy testing is recommended for children withpersistent asthma who are exposed to perennial indoor allergensand is helpful for diagnosing relevant allergic factors that maycontribute to asthma severity.8TreatmentAsthma can be primarily treated in the community withmost patients achieving good control of their disease. 5 A holisticapproach is required.Patient, family and doctor partnershipand educationThe children and their families need to be actively involvedin managing asthma. Education should begin at the time of thediagnosis and continue at every step of clinical care. Knowledgeabout avoiding risk factors, how to take the medication correctlyand understanding the difference between controller andreliever medications is crucial for optimal control, togetherwith information on how to monitor the asthma control status,recognize signs of worsening asthma and take the appropriateaction.3 A written personal asthma action plan that is appropriateand practical should be prepared with the collaboration of thedoctor, child, and family members3 since a relationship betweenparental beliefs about asthma medications and medicationadherence exists.17 As children grow older they need educationabout what is happening especially adolescents who wouldbenefit from receiving all information themselves.8 Using knownpersonalities who themselves have asthma and using teensupport groups can be very affective. Parents should support theteenager’s efforts toward self-management, but still be involvedin their children’s care.Children with asthma require regular monitoring.Information about symptom patterns over the past 2 weeks(particularly night and early morning symptoms) and schoolabsenteeism and limitation of daily activities due to asthmashould be sought. For infants it is important to ask aboutdifficulty with feeding, changes in respiratory rate, retractions,irritability and weight loss.The older child spends a substantial amount of hours atschool. The school should be given an action plan including37

early warning signs of an asthma episode, what medicationsthe student uses and how they should be taken. The parentsshould be encouraged to meet with the teacher, school nurseand perhaps the principal at the beginning of the school year tomake them aware of the child’s needs regarding asthma.8Identifying and reducingexposure to risk factorsAllergen avoidance can produce changes in diseaseactivity and symptoms, before any medical intervention isimplemented.18,19 Smoking must be avoided around the child,therefore smoking cessation plans for parents and care giversneed to be implemented as part of asthma management.Dust mites can be limited by encasing the child’s mattress inan allergen-impermeable cover and cover the pillow in andallergen impermeable case, which need to be washed weekly at atemperature of 130oF (55oC). Desirable actions include removingcarpets from the bedroom and from rooms that are laid oncement. Stuffed toys should be minimized from the child’sbedroom and washed weekly in hot water. Pets should ideallybe removed from home but if this is not acceptable they shouldbe kept out of the child’s bedroom and washed weekly.8 Physicalactivity can cause asthma symptoms but patients should notavoid exercise. Symptoms can be prevented by taking a rapidacting inhaled b2-agonist before strenuous exercise (leukotreinereceptor antagonists or cromolyn are alternatives).27Pharmacological management– stepwise approachPharmacologic management includes the use of controlagents such as inhaled corticosteroids, inhaled, longacting bronchodilators, theophylline, leukotriene receptorantagonists, and recently introduced strategies such as the useof anti-IgE antibodies. Relief medications include short-actingbronchodilators, systemic corticosteroids and ipratropium.2 Astepwise approach to pharmacologic treatment to achieve andmaintain control of asthma should be used (Tables 4 and 5).A child should start treatment at the step appropriate to theinitial severity.Monitoring and maintaining controlTreatment should be reviewed every 1 to 3 months afterthe initial visit and every three months thereafter. After anexacerbation follow up should be offered within two weeks toone month.3 Before stepping up treatment, the appropriatenessof the inhaler and the technique being used should be assessed.If control is achieved step wise reduction to the lowest possiblecorticosteroid dose may be possible. The dose must be reducedslowly, with a reduction being considered every 3 months andbe decreased by up to 50% each time.20 Any exacerbation shouldprompt review of maintenance treatment. By definition anyexacerbation in any week indicates uncontrolled asthma.338Pharmacological management– drug informationb2-adrenergic agonist inhalation therapy is best reservedfor acute symptomatic episodes of wheezing rather than beingused for routine chronic therapy during asymptomatic periods.Commonly reported potential side effects include a fine tremor,headache and palpitations. 20Table 4: Stepwise approach to the management ofasthma in children aged 5 to 18 years 20Step 1Occasional use of inhaled short-acting b2-agonists (ISABA)Step 2(if above are used more than once a week, or exacerbationsrequiring systemic steroids or nebulised bronchodilators)ISABA as required Regular standard dose inhaled corticosteroidsStep 3ISABA as required Regular standard dose inhaled corticosteroids Inhaled long-acting b2-agonistIf no response:Discontinue long-acting b2-agonistIncrease dose of inhaled corticosteroids to upper end ofstandard doseIf still no response:Add one of leukotriene receptor antagonist, modifiedrelease theophylline, or modified release oral b2-agonistsStep 4Inhaled short-acting b2-agonist as required Regular high dose inhaled corticosteroids Inhaled long acting b2-agonist 6 week therapeutic trial of one or more of leukotrienreceptor antagonist, modified release theophylline ormodified release oral b2-agonistStep 5If persistent poor control refer to respiratory specialistMalta Medical Journal Volume 20 Issue 1 March 2008

Inhaled corticosteroids (ICS) can cause side effects. Thisdepends on the formulation, dosing and device used, andthe subject’s age, severity of asthma and inhaler technique.22Administration of inhaled steroids at or above 400µg per day ofbeclomethasone dipropionate or equivalent and administrationof long term oral steroids e.g. longer than 3 months or three tofour courses per year may be associated with systemic side effectssuch as growth suppression. However there is little evidence forreduction in long-term growth at normal doses.21 Neverthelessit is important to monitor child’s height on regular basis andscreen for development of cataracts if high doses are being used.5Growth deceleration of asthmatic children on maintenanceICS is compensated for after the first 12 months of treatment.This effect does not differ between budesonide or fluticasonepropionate, despite some variation in the pattern of lineargrowth.23 At above-licensed doses, biochemical adrencorticalsuppression can occur with some unusual but documented casesof clinical Addisonian crisis. Limited evidence in paediatric agegroups would suggest that ciclesonide may have some advantagealthough it is not as yet licensed in all countries.21 Hypertrichosismay be a useful clinical pointer to exogenous steroid excess.24Hoarseness and candidiasis of the mouth or throat have beenreported. This can be reduced by using a spacer device and byrinsing the mouth with water after inhalation.20Table 5: Stepwise approach in the management ofasthma in children younger than 5 years of age:Step 1Short acting b2-agonist as required – Preferably inhaled,since more effective and less side effects than oralStep 2(if above are used for more than twice a week or nighttime symptoms or exacerbations)Inhaled short acting b2-agonist Regular standard dose of inhaled corticosteroids (ICS),of leukotriene receptor antagonist or theophylline if ICScannot be used.Step 3Under 2 years: refer to respiratory specialist2 to 5 years:Inhaled short acting b2-agonists Regular standard dose inhaled corticosteroids Leukotriene receptor antagonistStep 4If persistent poor control refer to respiratory specialist.Malta Medical Journal Volume 20 Issue 01 March 2008There a strong scientific rationale for single inhaler therapyin asthma. The use of the single inhaler combining salmeterol/fluticasone propionate provided a statistically significantimprovement in lung function and in symptoms but providedno significantly increased protection against exacerbationswhen compared to increased doses of inhaled corticosteroidsin patients with asthma.25 In patients with mild asthma, thesymptom-driven use of inhaled beclomethasone (250µg)and salbutamol (100µg) in a single inhaler is as effective asregular use of inhaled beclomethasone (250µg twice daily)and is associated with a lower 6 month cumulative dose ofthe inhaled corticosterods.26 Using a budesonide/formoterolcombination inhaler as regular maintenance treatment twicedaily but also as a rescue therapy for breakthrough symptomscan provide more effective control of asthma, particularly inreducing exacerbations, than using a short-acting b2-agonist orformoterol as rescue therapy.27 There is insufficient evidenceat present to recommend the use of combi

with asthma have increased over the last 2 decades.2 Predisposing and triggering factors The development of asthma in childhood is due to an interaction between environmental and genetic factors. There is no single gene for asthma.6,7 Asthma is associated with a genetic predisposit

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