1

B ro n ch ia l A s th m a
JERALDINE P. VERDE
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Bronchial Asthma

 Heteregenous diseased characterized by

chronic airway inflammation.
 Most common chronic disease of childhood
and leading cause of childhood morbidity.
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It is defined by history of

Asthma
respiratory symptoms such as
wheeze, shortness of breath,
chest tightness, and cough
together with variable
expiratory airflow limitation
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Risk
Factors
• allergens • occupational irritants •
• t o b a c c o smoke • respiratory infections •
• exercise • strong emotions •
• chemical irritants • drugs •
 ASTHMA PHENOTYPES
► Allergic Asthma- begins at childhood with past or family history of allergic diseases.
(+) good response to ICS

► Non-allergic Asthma- not associated with allergy. Less response to ICS

► Late-onset Asthma- women; diagnosed with asthma at adult life, non-allergic.

Require higher doses or relatively refractory to ICS.

► Asthma with fixed airflow limitation- long-standing asthma, due to airway wall
remodelling

► Asthma with Obesity- prominent airway inflammation and little eosinophilic airway
inflammation.
DIAGNOSIS
Patterns of Respi ratory Symptoms that are 7
characteristic of asthma
►More than one symptom (wheeze, cough, chest tightness, SOB (breathlessness and gurgly
chest(halak))
►Symptoms often worse at night (awakening the patient) or in the early morning
►symptoms vary over time and in intensity
►symptoms are triggered by viral infections (colds), exercise allergen exposure, changes in the
weather, laughter or irritants such as car exhaust fumes, smoke or strong smells
►Relief with bronchodilators
SABA
(inhaled/nebulized) 5 mins and peaks in 60 mins
Oral 30 mins and peaks in 2-3 hours
 Confirmation of the diagnosis, as well as the course and
the effect of therapy of asthma is made with repeated
measurements of airway obstruction with the use of :

1. SPIROMETRY
2. PEAK FLOW (by portable peak flow meter)
3. AIRWAY CHALLENGE TESTS

Phil consensus for the mgt of childhood asthma

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Spirometry
 Recommended in the initial assessment of patients suspected to have
asthma (PPS).
 Feasible in children from age 5 and training of both technician and subjects
improve reliability
 FEV1 measurements <80% of predictive value is evidence of airway
obstruction and reversibility with the use of bronchodilator by an increase
in FEV1 of ≥15% make a defi ni ti ve di agnosis of asthma (PPS)
 Reduced FEV-1 may be found in other lung diseases (or poor
spirometric technique) but reduced FEV1/FVC ratio indicates airflow
limitation. (> 0.90 in children)
 More reliable than PEF (GINA,2017)
 In mild asthmatic whose baseline FEV is normal or <80% but FEV1
increase is <15% after inhaled B2-Agonist the ff may help establish
the diagnosis:
1. metacholine/ histamine bronchoprovocation test
2. Exercise challenge test
3. Twice daily recording of peak flow to determine diurnal variation
4. Therapeutic trial of five days steroid and bronchodilator course

PPS
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Peak Expiratory Flow

 measurements are compared to the patient’s own previous best
measurements using his/her own peak flow meter
 an improvement of 60L/min or more than 20% of the pre-
bronchodilator PEF after inhalation of a bronchodilator or diurnal
variation in PEF of more than 20%variability
 correlates well with airway hyperresponsiveness
Predicted normal values (6-17 y/o
ht at least 100cm)
 Males: (Ht in cm - 100)5 + 175
 Females: ((Ht in cm - 100)5 + 170
OTHER TESTS

 Bronchial Provocation Tests

 Allergy Tests
 Exhaled Nitric Oxide Test (Removed in the 2017 GINA guidelines)
< 5 Years old

 Difficult to make a confident diagnosis of asthma,

because episodic respiratory symptoms such as
wheezing and cough are also common in children
without asthma, esp those 0-2 y/o.

 Not possible to routinely assess airflow limitation

Control- based ASTHMA
Management Cycle
HOW TO ASSESS ASTHMA
HOW TO ASSESS ASTHMA CONTROL

 Asthma CONTROL
- Extent to which the manifestations of asthma are controlled with or
without treatment
- 2 DOMAINS:
1. Symptom control
2. Future Risk for asthma outcome

POOR symptom control is a burden to patients and a risk factor for future
flare-ups
RISK FACTORS increase risk of having exacerbations, medication side
effects or loss of lung function
What is the role of lung function in
monitoring Asthma?
 Most useful indicator of future risk
 Recorded at diagnosis, 3-6 months after treatment and periodically
thereafter (atleast every 1-2 years).
How is asthma severity assessed? 31

• Assessed retrospectively from the level of treatment required to

control of symptoms and exacerbations.
• Can be assessed when patient is on regular controller treatment
for several months.
 Components of Severity Classification of Asthma Severity
(Children 0-4 Years)
Intermittent Persistent
Mild Moderate Severe
Impairment Symptoms ≤2 days/week ˃2 days/week daily throughout the
but not daily day
Nighttime 0 1-2x/month 3-4x/month ˃1x/week
Awakenings
SABA Use for ≤2 days/week ˃2 days/week daily several times
Symptom but not daily per day
Control
Interference none minor limitation some limitation extremely
with Normal limited
Activity
Risk Exacerbations 0-1/year ≥2 exacerbations in 6 months requiring oral CS or
Requiring Oral ≥4 wheezing episodes per year lasting ˃1 day
Systemic CS and
risk factors for persistent asthma
15
 Components of Severity Classification of Asthma Severity
(Children 5-11 Years)
Intermittent Persistent
Mild Moderate Severe
Impairment Symptoms ≤2 days/week ˃2 days/week but daily throughout the
not daily day
Nighttime 0 1-2x/month 3-4x/month ˃1x/week
Awakenings
SABA Use for ≤2 days/week ˃2 days/week but daily several times per
Symptom not daily day
Control
Interference none minor limitation some limitation extremely limited
with Normal
Activity
Lung Function normal FEV1; FEV1≥80% FEV1 60-80% FEV1<60%
FEV1 ˃80% predicted; predicted; predicted;
predicted; FEV1/FVC ˃80% FEV1/FVC 75-80% FEV1/FVC <75%
FEV1/FVC ˃85%
Risk Exacerbations 0-1/year ≥2 exacerbations in 6 months requiring oral CS or
≥4 wheezing episodes per year lasting ˃1 day a n d
Requiring Oral 16
risk factors for persistent asthma
 Components of Severity Classification of Asthma Severity
(Adolescents ≥12Years)
Intermittent Persistent
Mild Moderate Severe
Impairment Symptoms ≤2days/week ˃2 days/week butnot daily throughout theday
daily
Nighttime ≤2x/month 3-4x/month ˃1x/week butnot often7x/week
Awakenings nightly

SABA Use for ≤2days/week ˃2 days/week butnot daily several times per day
Symptom ˃1x/day
Control
Interference none minorlimitation somelimitation extremelylimited
with Normal
Activity
Lung Function normal FEV1; FEV1≥80%predicted; FEV1˃60 but <80% FEV1<60%predicted;
FEV1˃80% predicted; FEV1/FVC˃85% predicted; FEV1/FVC reducedby
FEV1/FVC˃85% FEV1/FVC reducedby <5%
5%
Risk Exacerbations 0-1/year ≥2in 1y
Requiring Oral
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How to investigate asthma 35

control?
the degree to which the manifestations of asthma (symptoms, functional
impairments, and risks of untoward events) are minimized and the goals of therapy
are met
Once therapy is initiated, the emphasis thereafter for clinical management is
changed to the assessment of asthma control. The level of asthma control will
guide decisions either to maintain or adjust therapy.
 Components of Control Classification of Asthma Control
(Children 0-4 Years)

Controlled Partly Controlled Uncontrolled

Impairment Symptoms ≤2 days/week ˃2 days/week throughout the

day
Nighttime ≤1x/month ˃1x/month ˃1x/week
Awakenings
SABA Use for ≤2 days/week ˃2 days/week several times per
Symptom Control day

Interference with none some limitation extremely limited

Normal Activity

Risk Exacerbations 0-1/year 2-3/year ˃3/year

Requiring Oral
Systemic CS

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 Components of Control Classification of Asthma Control
(Children 5-11 Years)

Controlled Partly Controlled Uncontrolled

Impairment Symptoms ≤2 days/week but ˃2 days/week; throughout the

not more than multiple times on day
once on e a c h day ≤2 days/week
Nighttime ≤1x/month ˃2x/month ˃2x/week
Awakenings
SABA Use for ≤2 days/week ˃2 days/week several times per
Symptom Control day

Interference with none some limitation extremely limited

Normal Activity

Risk Exacerbations 0-1/year ˃2/year

Requiring Oral
Systemic CS
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 Components of Control Classification of Asthma Control
(Adolescents ≥12Years)

Controlled Partly Controlled Uncontrolled

Impairment Symptoms ≤2 days/week ˃2 days/week throughout the

day

Nighttime ≤2x/month 1-3x/month ˃4x/week

Awakenings
SABA Use for ≤2 days/week ˃2 days/week several times per
Symptom Control day

Interference with none some limitation extremely limited

Normal Activity

Risk Exacerbations 0-1/year ˃2/year

Requiring Oral
Systemic CS
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Management of ASTHMA
Goals of Asthma Management
(GINA,2017)

1. To achieve good control of symptoms and maintain

normal activity levels.

2. To minimize future risk; that is to reduce the risk of flare -

ups, maintain lung function and lung development as
close to normal as possible and minimize medication
side-effects.
General Principles

1. Population-level recommendation about preferred

asthma treatments represent the best treatment for most
patients in a population.

2. Patient-level Treatment Decisions – individual

characteristics, risk factors, comorbidities or phenotype
that predict the pt’s likely response to treatment, pt’s own
preferences, and practical issues like inhaler technique,
adherence and affordability.
Partnership between the patient and their health care provider is
important for effective asthma mgt.

Health Literacy or patient’s ability to obtain, process and

understand basic health information to make appropriate health
decisions-should be taken into account in asthma mgt and
education
Treating to control Symptoms and
Minimize Risk

1. Medications

2. Treating modifiable risk factors and

comorbidities

3. Nonpharmacologic therapies and strategies

Control-Based Management
Initial Controller Treatment
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 53

Stepwise Approach for adjusting

treatment
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01
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02
03
03
04
05
REVIEWING RESPONSE AND
ADJUSTING TREATMENT
 HOW OFTEN PATIENTS ARE REVIEWED?
 1-3 months after staring treatment and 3-12 months after
that.
 After an exacerbation, review visit within 1 week
Stepping UP
Stepping DOWN
Essential skills and Guided Asthma-
Self Management

1. Asthma Information
2. Inhaler Skills
3. Adherence
4. Written asthma action plan
5. Self-monitoring
6. Regular medical review
Inhaler skills
Adherence
Treating modifiable risk factors
Non-Pharmacologic 66

Interventions
 ►Cessation of smoking
 ►Physical activity
 ►Avoidance of occupational exposures
 ►Avoidance of medications that may make asthma worse
 ►Diet rich in fruits and vegetables
 ►Avoidance of indoor and outdoor allergens
 ►Weight reduction
 ►Allergen immunotherapy
 ►Breathing exercises
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Non-Pharmacologic
Interventions
►Avoidance of indoor air pollution
►Vaccinations
►Bronchial thermoplasty
►Relaxation strategy
►Staying indoors during unfavourable environmental conditions
►Avoidance of foods allergens
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Acute
Exacerbation
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acute or subacute increase in wheeze
01 and shortness of breath

increase in coughing, especially while

02 the child isasleep

Recognizing
Exacerbation 03 lethargy or reduced exercise tolerance

impairment of daily activities, including

04 feeding

05 poor response to reliever medication

Written Asthma Action Plan
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Mild or M o d e r a t e
►talks in phrases
►prefers sitting to lying
►not agitated
►RR increased
►accessory muscles not used
►PR 100-120 b p m
►O2 saturation on room air 90-95%
►PEF ˃50%
Severe 75

►unable to speak or drink

►central cyanosis
►confusion or drowsiness
►marked subcostal a n d subglottic retractions
►O2 sat <92%
►silent chest
►PR ˃200 bpm(0-3 y) ˃180 (4-5 y)
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Life-Threatening
►drowsy
►confused
►silent chest
Acute 77
Exacerbation
Acute 78
Exacerbation
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Acute Exacerbation
Management Plans
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Need for Urgent Medical
Attention
child is acutely distressed

child’s symptoms are not relieved promptly by inhaled bronchodilator

period of relief after doses of SABA becomes progressively shorter

a child younger than 1 year requires repeated inhaled SABA over several hours
 82

Inhaled SABA 2 puffs given 1

Initial Treatment puff at a time via spacer; may
at Home be repeated twice at 20-min
intervals prn

oral LTRA for 7-20 days indicated for

intermittent viral wheezing
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Indications for Immediate Transfer to a
Hospital

severe exacerbation that fail to resolve within 1-2h despite repeated dosing of
inhaled SABA

respiratory arrest

lack of supervision in the home or doctor’s office

recurrence of signs of severe exacerbation within 48h particularly when
treatment with OCS has already been given

children ≤2 years
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Conduct brief history and PE while initiating

therapy
Administer O2 at 1Lpm by face mask to
Hospital achieve and maintain O2 saturation of 94-

Manageme nt 98%
Salbutamol 2.5mg via nebulizer every
20min for the firsthour
 ipratropium bromide 250mcg via nebulizer
every 20min for 1hour
IV methylprednisolone 1mg/kg q6h on day
1 or oral prednisolone 1-2mg/kg
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Conduct brief history and PE while initiating

Hospital therapy.
Administer O2 as needed by face mask to

Manageme nt achieve and maintain O2 saturation of 94-

98%.
Salbutamol 2.5mg diluted in 3mL of NSS via
nebulizer.
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Primary Prevention
 Children should not b e exposed to environmental t o b a c c o smoke
during pregnancy or after birth.

 Vaginal delivery should b e encouraged where possible.

 Breastfeeding is advised.
 The use of broad-spectrum antibiotics during the first year of life
should b e discouraged.
Thank
you!