ABDELRAZZAQ ABU-MAYALEH MD

1. WHEEZY CHEST IN PEDIATRICS ABDELRAZZAQ ABU-MAYALEH MD

2. Differential Diagnosis of Wheezing in Infancy Infection(Bronchiolitis) Asthma: Three Phenotypes in Children ≤ 5 yr • Transient wheezer (onset ≤ 3 yr of age, then resolving) • Persistent wheezers (onset ≤ 3 yr of age and then persisting)  • Late-onset wheezer (onset of wheeze between 3 and 6 yr of age) • ASPIRATION SYNDROMES(GER……etc) • ANATOMIC ABNORMALITIES(malcia…..ect) • GENETIC DISEASES(CF……ect) • BPD • CHF • FBA

3. Bronchiolitis Age < 1y ( peak 6 month ) Family History Negative Recurrence can happened but not frequent . Usually the episode with preceding URTI. No eosinophylia No significan respons to albuterol . RAWD Age >1 y of (peak: 4-6 year ) Family History Positive Repeated episodes in same infant Sudden onset without preceding infection Eosinophylia Immediat response to aerosolized albuterol Differentiation between acute episod of Bronchiolitis ond RAWD

4. Treatment of asthma in ped. • Rescue releaver therapy(SABA) • Controller medications: need decision making which medication is best ? • Several guidelines.....give more than one option . • other factors affect the decision as well

5. Factors to consider • Age • Severity / level of control • Patient & family preference • Cost • Availability • Co-morbidity

6. Controller Medications • Inhaled glucocorticosteroids: Budesonide, Fluticasone, Beclomethasone, Mometasone • Leukotriene modifiers: Montelukast, Zafirlukast • Long-acting β2-agonists: Salmeterol, Formoterol • Cromones: cromolyn, Nedocromil • Methylxanthines: Theophylline • Systemic glucocorticosteroids • Anti-IgE: omalizumab • Immunotherapy

7. Levels of Asthma Control

8. Asthma education Environmental control As needed rapid acting B2-agonist

9. PRACTALL EAACI / AAAAI Consensus Report Pharmacotherapy Recommendations for Children 0 to 2 Years Asthma diagnosis: >3 episodes of reversible bronchial obstruction within 6 months aEspecially if severe or requiring frequent oral corticosteroid therapy; beg, 1 to 2 mg/kg/day prednisone for 3 to 5 days during acute and frequently recurrent obstructive episodes. Adapted from Bacharier LB, et al. Allergy. 2008;63(1):5–34.

10. PRACTALL EAACI / AAAAI Consensus Report Pharmacologic Treatment (Children >2 Years) ICS (200 µg BDP equivalent) LTRAa (Dose depends on age) OR Step down if appropriate INSUFFICIENT CONTROLb Increase ICS dose (400 µg BDP equivalent) OR Add ICS to LTRA Step Up Therapy to Gain Control INSUFFICIENT CONTROLc Step down if appropriate Increase ICS dose (800 µg BDP equivalent) OR Add LTRA to ICS OR Add LABA INSUFFICIENT CONTROLc • Consider other options • Theophylline • Oral corticosteroids aLTRA may be particularly useful if the patient has concomitant rhinitis; bCheck compliance, allergy avoidance, and reevaluate diagnosis;cCheck compliance and consider referring to specialist. ICS=inhaled corticosteroids; LTRA=leukotriene receptor antagonist; BDP=beclomethasone dipropionate; LABA=long-acting β2-agonist. Adapted from Bacharier LB, et al. Allergy. 2008;63(1):5–34.

11. Before choosing a controller • Start with salbutamol PRN (inhaler or nebulizer same efficacy),but not oral. • Does the patient need a controller? Recurrent wheeze or severe episodes usually needs a controller • Always treat co-existing allergic rhinitis,GER,and sinusitis.

12. Individualized approach • An infant or pre-school child with mild-moderate infrequent attacks is likely to do well with leukotriene modifier, which may also help mild allergic rhinitis. • Considering cost and family preference, may choose a low-dose inhaled steroid (flixotide MDI vsBudesonide Nebulizer) • May go with the family choice, provided close follow-up to see response and adjust accordingly.

13. Individualized approach • More severe symptoms or poorly controlled Asthma usually requires medium dose inhaled steroids or Flixotide/Salmeterol MDI low-medium dose. • Older children (> 7-8 years) may use dry powder inhalers: Budesonide +/- Formeterol Turbuhaler or Flixotide +/- Salmeterol Discus.

14. Re-assessment • Very important to follow-up and assess response to initial therapy, if not well-controlled consider: • Check compliance, if not compliant find out why; try simpler regimen (e.g. once daily instead of twice daily, MDI instead of nebulizer- especially toddlers) • Check technique for inhalers • Consider changing to a different controller • Consider adding a different controller • Consider a higher dose

15. Summary • There are many choices for treating Asthma, it is not “one size fits all”, find out what’s best for your patient • Every asthmatic needs education, inhaled Salbutamol and triggers avoidance • Decision is affected by age, severity, family and patient’s choice • Follow-up and re-assessment are vital in reaching the desired result

16. Thank you