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Asthma in Children Asma in Kinders

Asthma in Children Asma in Kinders. P rof Sharon Kling Stellenbosch University & Tygerberg Children’s Hospital. Outcomes / Uitkomste. Clinical definition How common is asthma? How do we diagnose asthma in children? Other causes of wheezing in children

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Asthma in Children Asma in Kinders

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  1. Asthma in ChildrenAsma in Kinders Prof Sharon Kling Stellenbosch University & Tygerberg Children’s Hospital

  2. Outcomes / Uitkomste • Clinical definition • How common is asthma? • How do we diagnose asthma in children? • Other causes of wheezing in children • Management of asthma in children • Kliniesedefinisie • Hoe algemeen is asma? • Hoe diagnoseeronsasma in kinders? • Ander oorsake van fluitbors in kinders • Hantering van asma in kinders

  3. Children are NOT small adults! • Different anatomy • Congenital abnormalities: causes of wheezing • Different physiology • Growth • Drug handling • Anatomieverskil • Kongenitaleafwykings: oorsake van fluitbors • Fisiologieverskil • Groei • Hantering van middels

  4. The Global Burden of AsthmaDie Globale Las van Asma • Very common • 300 million people worldwide • More prevalent in western lifestyles and urban areas • Asthma mortality is also increasing and is alarmingly high • Baiealgemeen • 300 miljoenmensewêreldwyd • Meer algemeenwaarwesterseleefstyl en stedelike areas • Asmamortaliteitvermeerder en is baiehoog

  5. Angelo’s story • Presented to allergy clinic at age 10 years: asthma • Brother Julio had died 6 months previously after an acute asthma attack • Julio had been using up a full Ventolin® asthma pump every week – obtained from GP and pharmacy Names changed to preserve confidentiality

  6. Angelo 2 • How would you feel if you were Angelo? • What problems do you identify in this short scenario?

  7. Definition / definisie • Asthma is a lung disease with: • Airway obstruction that is reversible(spontan-eouslyor with treatment); • Airway inflammation; and • Increased airway responsiveness to a variety of stimuli • Asma is ‘n long-siekte met: • Lugwegobstruksiewatomkeerbaar is (spon-taan of nabehandeling); • Lugweginflammasie; en • Verhoogdelugwegresponsiwiteittot ‘n verskeidenheid van stimuli

  8. Risk factors / Risikofaktore • Genetic / Geneties • Allergen exposureAllergeenblootstelling • Environmental exposuresOmgewingsblootstellings

  9. Clinical Definition of AsthmaKlinieseDefinisie van Asma • Recurrent wheezing with or without a cough Herhaalde fluitbors met of sonder hoes • That respondsto a bronchodilatorRespondeer op ‘n brongodilator

  10. Diagnosis / Diagnose • History / Geskiedenis • Examination / Ondersoek • Special investigations / Spesialeondersoeke • Lung functions / longfunksies • Allergy tests / allergietoetse • Exclude other causes of wheezingSkakelanderoorsake van fluituit

  11. History / Geskiedenis

  12. History / Geskiedenis 1 • Repeated episodes of wheezing or tight chest • Cough, espat night • Early morning waking • Wheeze or cough after physical activity • Symptoms relieved when bronchodilator is used • Herhaalde episodes fluit- of toebors • Hoes, veral snags • Word vroegoggendwakker • Fluit of hoes naoefening • Simptomeverbeternabrongodilator

  13. History / Geskiedenis 2 • Symptoms worse during certain seasons • Triggers that worsen asthma • Allergens • Irritants • Simptomeergertydenssekereseisoene • Snellerfaktorewatasmavererger • Allergene • Prikkelendemiddels

  14. Allergens / AllergeneInhaled / inhalasie

  15. Irritants / Prikkelendemiddels

  16. History / Geskiedenis 3 • History of other allergic diseases • Allergic rhinitis • Eczema • Allergic conjunctivitis • Family history of asthma or allergy • Geskiedenis van anderallergiesetoestande • Allergieserinitis • Ekseem • Allergiesekonjunktivitis • Familiegeskiedenis van asma of allergie

  17. Examination Ondersoek

  18. ExaminationOndersoek • Growth / groei • Allergic appearance / allergiesevoorkoms • Chest deformities / Borskasdeformiteite • Hyperinflation, wheezesHiperinflasie, fluite • Other allergic conditionsAnder allergiesetoestande

  19. Special InvestigationsSpesialeOndersoeke • Lung function testing (> 6 years)Longfunksietoetse (> 6 jaar) • Identify specific allergens Identifiseerspesifiekeallergene • Skin prick tests / Velpriktoetse • Radioallergosorbent tests (RAST) • Exclude other causes of wheezingSkakelanderoorsake van fluituit

  20. Differences: Children and AdultsVerskille: Kinders en Volwassenes • Mimics of asthma • Diagnosis in young child difficult • More allergy • Lung functions difficult in young child • Drug delivery systems • Safety of medications • Toestandewatasmanaboots • Diagnose moeilik in jong kind • Verhoogdeallergie • Longfunksiesmoeilik • Lewering van middels • Veiligheid van middels

  21. Causes of recurrent wheezing in childrenOorsake van herhaalde fluitbors in kinders • Asthma • Post-viral wheezing (bronchiolitis) • Congenital lung abnormalities • TB (lymph nodes obstructing airways) • Gastro-oesophageal reflux • Cystic fibrosis • Immune deficiency • Asma • Postvirale fluitbors (brongiolitis) • Kongenitale long afwykings • TB (limfnodeswatlugweëobstrukteer) • Gastroesofagealerefluks • Sistiesefibrose • Immuungebrek

  22. Wheezing in the first 6 years of lifeFluit in die eerste 6 jaar van lewe Post viral/ viraal Asthma/ asma Martinez 1995

  23. Wheezing studies in children • Many children (about half) will wheeze when young • Some of them will outgrow wheezing • Some will continue to wheeze • Difficult to distinguish these groups • Baiejongkinders (omtrent die helfde) salfluitborshê • Sommigesal die fluitontgroei • Sommigesalvoortgaan met fluitbors • Moeilikomteonderskei

  24. Exclude other causes of wheezingSkakelanderoorsake van fluituit • Chest X-ray: congenital abnormalities, TB • Sweat test: cystic fibrosis • Barium swallow, pH study: gastro-oesophagealreflux • Tests of immunity • Borskasplaat: kongenitaleafwykings, TB • Sweettoets: sistiesefibrose • Bariumsluk, pH studie: gastroesofagealerefluks • Immuuntoetse

  25. Management / Hantering • Education • Avoid allergens • Environmental control (cigarette smoke) • Avoid triggers • Controlasthma symptoms • Relieve acute attacks of asthma • Opvoeding • Vermyallergene • Omgewingsbeheer (sigaretrook) • Vermysnellers • Beheerasmaaanvalle • Verligakuteasmaaanvalle

  26. Management Environmental control Asthma Education Medication

  27. Preventative / Avoidance Measures

  28. Management of Asthma in Children Classify Severity Institute treatment Follow-up, assess control Step therapy up or down

  29. ASTHMA SEVERITY CLASSIFICATION

  30. Types of Medications • Long-term “controller” medicationLangtermyn “kontrolleerder” medikasie • Anti-inflammatory, inhaled corticosteroids, e.g. budesonide • Quick-relief rescue “reliever” medicationVinnigwerkende “verligter” medikasie • Bronchodilator, beta-2 agonists, e.g. salbutamol

  31. Short acting ß2 agonist (bronchodilator) as necessary (reliever only) Step-wise management 1 • Step 1: mild intermittent Modified from BTS SIGN guidelines 2005

  32. Step 2: Persistent Sx: introduce regular controller Rx Inhaled steroids – start at dose appropriate to severity of disease (200 – 400 mcg/day, in two divided doses) Safe ICS dose in children 400 mcg/day Step-wise management 2 + Short acting ß2 agonist as necessary Modified from BTS SIGN guidelines 2005

  33. ICS dose 400 mcg/day

  34. How to Use a Metered-dose Inhaler (MDI) Evaluate inhaler technique at each visit. Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI

  35. Delivery systems: Spacers

  36. Home-made spacer: 500 ml cold drink bottle with mask

  37. Home-made spacer: 500 ml cold drink bottle without mask

  38. Assess controlEvalueerbeheer

  39. Asthma control Pharmacological management. Thorax 2003; 58 (Suppl I): i1-i92

  40. If asthma control poor, assess:As asmabeheerswak is, evalueer: • Is the diagnosis correct? • Is the child using the medication? -“adherence” • Technique • Delivery system ok? • Triggers and allergen avoidance? • Is diagnose korrek? • Gebruik die kind die medikasie? • Tegniek • Leweringstelsel ok? • Snellers en allergeenvermyding?

  41. Options for achieving asthma controlBehandelingsmoontlikhede • Increase inhaled steroid dose • Add on other asthma drugs • Long-acting ß2 agonist or • Leukotriene receptor antagonist or • Theophylline sustained release • Oral corticosteroids (prednisone) • Vermeerderinhalasiesteroïededosering • Voeganderasmamiddels by • Langwerkendeß2 agonisof • Leukotrienreseptorantagonisof • Teofillien • Oralekortikosteroïede (prednisoon)

  42. Important considerations - RxBelangrikedingeomteoorweeg - Rx • Severity of asthma • Safety of drugs • Cost of drugs • Availability of drugs • Patient’s preference • Erns van asma • Middelveiligheid • Koste van middels • Beskikbaarheid van middels • Pasiënt se voorkeur

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