A Presentation on Bronchial

Asthma

Presented by :
Pritam Pandey
Intern , Department Of Pediatrics
Chitwan Medical College Teaching Hospital
 Asthma
The Chronic inflammatory condition of airways

Resulting in episode of dynamic airways

obstruction

caused by airways hyperresponsiveness to

provocative triggers

characteried by paroxysmal dyspnoea , wheeze

and cough.
 Asthma triggers
• Indoor allergens (Animal danders, dust mites
molds )
• Seasonal aero allergen (pollens , seasonal
molds )
• Air pollutants (Environmental tobacco smoke
dust , ozone , mycotoxin )
• Strong noxious odor
• Occupational exposure (fomaldehyde , cedar,
cold dry air ,exercise, crying )
• Co morbid conditions ( Rhinitis , sinusitis
,Gerd)

• Drugs (aspirin ,b blockers , tartrazine )

 Etiopathogenesis
Type 1 hypersensitivity reaction :
Provocative stimuli
in genetically
susceptible
Individual

TH2 response and

release of
cytokines
 Etiopathogenesis ( contd)
IL 13 : stimulate mucus production

IL4 :stimulate and promote IgE production

IL5 : activate eosinophils

 Etiopathogenesis ( contd)
• IgE binds with the Fc receptor of mast cell
• Degranualation of mast cell ( histamine , ECF ,
NCF)
• Immediate ( 5 – 30 min) response
vasoconstriction vascular leakage and smooth
muscle spasm
• Late phase reaction(2 -8 hours) : activation of
eosinophills, neutrophills and t cell and thus
amplication of the inflammation
 Etiopathogenesis ( contd)
• Aiways remodeling (hypertrophy smooth
muscles , mucus gland,

• Increased vascularity and deposition of

subepithelial collagen
 Epidemiology
In USA, Prevalence of Asthma in 2015,

9.1 % female Vs 6.1 %male

8.4 % children and 7.6 % adults

Source :https://www.cdc.gov/asthma/asthmadata.htm
• 100 and 150 million people around the globe -
- roughly the equivalent of the population of
the Russian Federation -- suffer from asthma
.
• World-wide, deaths over 180,000 annually

• In Australia, one child in six under the age of

16 is affected
• Source :http://www.who.int/mediacentre/factsheets/fs206/en/
 Risk Factor
• Parental asthma
• Allergy (atopic dermatitis , allergic rhinitis ,food
allergy )
• Severe Lower respiratory tract infection
(Pneumonia , Bronchiolitis requiring
hospitalization )
• Male gender
• Low birth weight
• Environment tobacco smoke exposure
 Clinical features
• Intermittent dry cough
• Expiratory wheeze
• Symptom worst at night
• Symptoms triggered on exertion, cold, dry air
, laughing
• Tachypnea
• Audible wheeze worsening on crying
• Pulsus parodoxus (drop in systolic BP by10
mm Hg during inspiration)

• Decreased breathe sound in some lung field

(right lower posterior lobe common)

• crackles and rhonchi

• Child appears normal in between the episode
• Acute asthma :
1. Hyperinflammation
2. Tachypnea (air Hunger)
3. Use of assesory muscles
4. Indrawing of chest ,flaring of alae
5. Prolonged expiration
6. cyanosis
• Absence of previously present wheeze in a
cyanosed child is a sigh of omen
 Differential Diagnosis
• Upper respiratory tract infection
1. Allergic rhinitis
2. Chronic rhinitis
3. Sinusitis
4. Tonsillar hypertrophy
5. Nasal foreign body
 Middle respiratory tract infection

1. Laryngotracheobronchomalacia
2. Larygotracheobronchitis
3. Laryngeal web
4. Vocal cord paralysis
5. Foreign body aspiration
 Lower respiratory tract infection

1. Viral bronchiolitis
2. GERD
3. Tuberculosis
4. Pneumonia
5. Bronchiolitis obliterans
6. CCF
Ruling out Differential Diagnosis
 Asthma vs bronchiolitis

1. recurrent wheezing in a child >2 years old

• personal and/or family history of atopy or a
family history of asthma.
• Bronchiolitis : < 2 years of age and the
leading cause of hospital admission under 6
months of age
• Environmental or allergic precipitants are
often present in older children.
 Asthma vs Vocal cord dysfunction

1. Intermittent day time wheeze

2. Stridor
3. Improvement with bronchodilator in asthma
4. Flexible rhinolaryngoscopy : Parodoxical
vocal cord movement with anatomically
normal vocal cords
 Asthma vs foreign body aspiration

1. Unilateral wheeze after an episode of

choking and coughing
2. No previous h/o respiratory episode
3. Localized area of reduced air entry in patient
with chronic respiratory illness is suggestive
 Asthma vs Laryngotracheobronchitis

• Caused by parainfuenza virus I and II

• Croupy cough (barking seal like)
• Fever
• Inspiratory stridor
• Steeple sigh in radiograph
 Asthma vs Laryngeomalacia
• Inspiratry stridor
• Stridor increasing on crying and subside on
placing the patient prone
 Investigation
• Pulmonary function test
1. FEV1:FVC <0.8
2. BRONCODILATOR RESPONSE :improvement
in FEV1 more than or equal to 12 %
3. Exercise challenge :worsening of FEV1 of
more than or equal to 15 %
4. Daily PEFR/FEV1: diurnal variation of > or
equal to 20 %
• Chest Xray
1. Hyperinflatted lung
2. Peribronchial thickening
3. Hyperlucent lung field ( bonchiolitis
obliterans)
4. Complication of asthma ( atelectasis,
pneumothorax ,pneumomediastinum )
• Classification of Asthma Severity
 Day Time Night Time Short acting Predictibilit Therapy
Symptom Symptoms B agonist y ( FEV1)
s use

Intermitten <2/ week 0 -4 years : 0 <2/week >80% step 1

t ≥5 years : <2/month

Mild >2/week 0 -4 years :1-2/month >2/week >80 % Step 2

Persistent but not ≥5 : 2- 3 /month but not
daily more than 1
per day
Moderately daily 0 -4 years :3-4/month daily 60-80% Step 3
persistent ≥5 :>1/week but not
nightly

Severely Through 0 -4 years :>1/week Several <60%

persisent out the ≥5 : often 7 / week times in a STEP 4
day day
• Stepwise approach of managing
Asthma in Children
• Step 1 : SABA as needed for the symptoms
 step 2

• 0-4years :
low dose ICS /chromolyn /montelukast
5 -11 years :low dose ICS
alternate :Chromolyn/LTRA/Theophylline
≥12 years : low dose ICS
Alternative : LTRA or theophylline
 Step 3

0-4years : medium dose ICS

5 -11 years :medium dose ICS
Low dose ICS ±LABA/LTRA or theophylline
≥12 years : medium dose ICS
Low dose ICS+LABA
 Step 4

0-4years : medium dose ICS +LABA/LTRA

5 -11 years : medium dose ICS +LABA/LTRA or
theophylline
≥12 years : medium dose ICS+LABA
 STEP 5

0-4years : High dose ICS + LABA/LTRA or

theophylline
5 -11 years :high dose ICS +LABA/LTRA or
theophylline
≥12 years : high dose ICS+LABA
add omalizumab in allergic cases
 Step 6

0-4years : High dose ICS + LABA/LTRA or

theophylline + 0ral cortiosteroid
5 -11 years :high dose ICS +LABA/LTRA or
theophylline + oral corticosteroid
≥12 years : high dose ICS+LABA +oral
corticosteroid
add omalizumab in allergic cases
1. 0-4 years (budesonide/fluticasone)0.5 -1->1
nebulization
 Selection of appropriate inhalation
device
• A rough guide
< 4 years of age :MDI with spacer with face mask
4-12 years :MDI with spacer
>12 years :MDI
 Use of MDI
• Remove cap and shape well in vertical
direction
• Breathe out gently
• Put the mouth piece in mouth and start
inspiration slowly pressing the canister and
continue to inhale deeply
• Hold breathe for 10 sec or more
• Wait for few second before repeating the
inhalation again
 Assessing

Asthma control and

Adjusting therapy in
children
 Well controlled
components

symptoms ≤2 days / week but not more than

once on each day
Night awakening 0-11 years : ≤1 /month
≥12 years : ≤2/month
Short acting B agonist use ≤2days/week

Exacerbation requiring systemic 0-1/year

corticosteroid
Lung function FEV1 >80 %
FEV1/FVC >0.8
 Not well tolerate
components

symptoms >2 days / week or multiple times on

Night awakening
Short acting B agonist use
≤2days/week
0-4 years : >1 /month
5-11 year : >2 /month
≥12 years : 1-3/week
>2days/week

Exacerbation requiring systemic 2-3/year

corticosteroid

Lung function FEV1 : 60-80%

FEV1/FVC : 0.75 -0.8
 Very poorly controlled controlled

components

symptoms through out the day

Night awakening 0-4 years : >1 /week

5-11 year : ≥2/week
≥12 years : ≥4/week
Short acting B agonist use several times per day

Exacerbation requiring systemic 3+ /year

corticosteroid

Lung function FEV1 <60%

FEV1/FVC <0.75
• Step up and step down approach
Well controlled:
• maintain current step ,follow up 1 to 6 month
• Step down treatment if controlled for at least 3 months
Not Well controlled
• Step up (1step) and reevaluate in 2-4 weeks
• If no improvement consider in 2-4 weeks
alternative diagnosis or adjusting therapy
• For side effect , consider alternative option
 Very poorly controlled
• Consider a short course of oral steroid
• Step up 1-2 steps and re evaluate in 2 weeks
• If no improvement consider in 2-4 weeks
alternative diagnosis or adjusting therapy
• For side effect , consider alternative option
• Risk Assesment for corticosteroid
Adverse effect
 Low risk
• low or medium dose
 Medium risk

• high dose
• <4 cases oral steroid burst treatment/year)
 High risk

• Chronic corticosteroid use >7.5mg daily or

equivalent for more than a month
• >7 cases oral corticosteroid burst
treatment/year
 Steroid adverse effect
• Osteoporosis (ALP, calcium phosphoros,DEXA
scan)
• Peptic ulcer
• Growth reduction (standiometry )
• Avascular necrosis of head of femur
• Cataract (opthalmic evaluation )
 Steroid adverse effect
• Oral ulcer, candidiasis
• Cushingoid feature
• Flaring of TB
• Immunosuppression
• Adrenal insufficiency
 theophylline
• Narrow therapeutic index (10-20mg/dl)
• Overdose : seizure, hypokalemia,cardiac
arrhythmia
• Ciprofloxacin , macrolides,oral anti fungal
agent,increases the plasma conc
SABA
• Salbutamol
• albuterol
• Tebutaline
LABA
• Salmeterol
• form0terol
Hypokalemia
Arrhythmia (tachycardia, fibrillation)
 Leucotriene receptor antagonist
• Zafirlukast (use in > 5yrs)and montelucast (use
in >1 yrs)

Omalizumab (>12 years) subcutenous ,

anaphyaxis can some time occur
Status asthmaticus
• Medical emergency

• A severity of exacerbation of asthma that

doesn’t improve with standard therapy
 Management of status asthmaticus

• At home
1. Immediate treatment with rescue medication

(inhaled SABA , up to 3 treatment with I hour, a short

couse of corticosteroid can be given for days not to
exceed 60mg/day )

Consult physician if bronchodilators are required

frequently in 24-48 hours
 At emergency department
• Oxygen supplementation

• inhaled B agonist (albuterol 0.15mg/kg) every 20 min

for 1 hour

• Systemic corticosterid oral/IV (hydrocortisone

5mg/kg)

Discharged if PEF 70 % of predicteded and saturation

of >92 %maintained at room air for 4 hours
At Hospital

Oxygen
supplementation
 At Hospital

SABA inhaled every 20 min /1 hours

or continous 5-15mg/hour

Monitor for tachycardia and

hypokalaemia, irritability and
tremor

VQ mismatch due to therapy can

occur ,so monitor saturation
 Oral /
injectable
corticosteroid
Add ipratropium bromide to SABA
every 6 hours if no improvement
(effective in patient with mucus
hypersecretion)
• Injectable theophylline followed by continous
infusion

• Mgso4 50mg/kg dissolved in dextose

• If no improvement prepare for mechanical

ventilation
Chest physiotherapy . Incentive
spirometry and mucolytic not
recommended as may trigger
bronchoconstriction in active
phase
 C/C
• Acute exacerbation
• Pneumothorax
• Peumomediastinim
• Atelectasis
• Secondary infection
• Respiratory failure
• Steroid toxicity
•Brain storming ?
• A 3 years Male child presented to the
pediatrics OPD with a chief complain of
sudden onset of shortness of breathe while
playing in garden .The child gives a history of
frequent running nose. He was admitted twice
for bronchilitis in the past What social history
would you ask ?
 Day Time Night Time Short acting Predictibilit Therapy
Symptom Symptoms B agonist y ( FEV1)
s use

Intermitten <2/ week 0 -4 years : 0 <2/week >80% step 1

t ≥5 years : <2/month

Mild >2/week 0 -4 years :1-2/month >2/week >80 % Step 2

Persistent but not ≥5 : 2- 3 /month but not
daily more than 1
per day
Moderately daily 0 -4 years :3-4/month daily 60-80% Step 3
persistent ≥5 :>1/week but not
nightly

Severely Through 0 -4 years :>1/week Several <60%

persisent out the ≥5 : often 7 / week times in a STEP 4
day day
• A 3 years male child with asthma presents to
you with the history of night symptom of 1
times in month and a day symptom of 2 times
in a week ?
• Where do you classify it in asthma severity ?
• What treatment will you give ?
• A 6 years male child with asthma presents to
you with the history of night symptom of 1
times in month and a day symptom of 2 times
in a week ?
• Where do you classify it in asthma severity ?
• What treatment will you give ?
• http://www.eaaci.org/attachments/878_PRAC
TALL%20Consensus%20Report%20PP.pdf
• http://www.asthma.ca/adults/control/pdf/Ast
hma_in_infants_and_young_children_tip_she
et.pdf
• http://journals.plos.org/plosone/article/file?i
d=10.1371/journal.pone.0136841&type=print
able