Asthma

Presented by:
Irfan Izzati Mohd Zubir
Rishi Kartini Padmanand
Ng Kai De
Tay Guan Kai
Muhammad Asri Bin Sudirman
INTRODUCTION
 Definition
Recurrent episodes of
WHEEZING,
Chronic airway Increase airway BREATHLESSNESS,
inflammation responsiveness CHEST TIGHTNESS and
COUGHING (at night /
early morning)

*Airflow obstruction – often reversible – spontaneously / treatment

 Pathophysiology
Bronchoconstriction

Eosinophils, lymphocytes,
Increase airway responsiveness
mast cells, neutrophils

Mucosal oedema Excessive mucus

due to inflammation production
 Types of Childhood Asthma
v Recurrent wheezing
- primarily triggered by common respiratory viral infections
- usually resolves during preschool and lower school years, without increased risk of asthma in later life

v Chronic asthma
- associated with allergy that persists into later childhood and adulthood
CLINICAL FEATURES
 Clinical features (Symptom)
• Symptoms:
o Dry coughing
§ recurrent/intermittent, but some may exhibit persistent dry cough
o Expiratory wheezing
o Shortness of breath
o Chest tightness
These symptoms worse especially at night.
Triggers: laughing, crying or exposure to tobacco smoke or air pollution.

• Other subtle & non-specific symptoms

o Limitation of physical activities
o General fatigue
o Difficulty keeping up with peers in physical activities
 Clinical features (Sign)
Signs in Acute Exacerbation Signs of chronic illness
• Drowsiness • Harrison’s sulci
• Cyanosis • Hyperinflated chest
• Wheezing • Eczema
• Tachypnoea
• Use of accessory muscles
• Tachycardia
• Hyperinflated chest
v Barrel chest
v Hyperresonance on percussion
v Loss of cardiac and liver dullness
• Rhonchi
Definition of tachypnoea (breaths/min)

Age Breaths/min

< 2months > 60

2 - 12 months > 50

12 months (1year) – 5 years > 40

> 5 years > 30

 Eczema

Harrison’s sulci Eczema

Other signs
Inspection:
• Altered consciousness
• Respiratory distress
• Oral candidiasis
• Cushing features
• Other signs of atopic disease:
• Allergic shiners
• Adenoid type facies
• Allergic conjunctivitis
• Urticaria
• Angioedema
 Adenoid-type facies

Allergic shiners

Allergic
cobblestoning
(chronic allergic
conjunctivitis)

Allergic conjunctivitis
Urticaria
Angioedema of lip
HISTORY TAKING
 Presenting symptoms/compliant
• Chest tightness o Trigger:
• Wheezing § Dust mites
• Coughing § Pets
§ Perfume
o Nature of cough:
dry/productive/barking § Pollen
§ Smoke
o Onset: night/day
§ Cold weather/food
o Intermittent/continuous
§ Emotional expression
o Duration e.g., laughing, crying, excited, stress
o Sputum colour & smell: blood § Exercises
stained/greenish; foul smelling § Carpet
(can rule out TB/ bronchiectasis/
cystic fibrosis)
o Relieving factor:
§ Does the patient take inhaler? How many times? How many puff?
o Does symptoms affect child’s daily activities?
§ Feeding, playing, sleeping, absent to school?
o Did parents bring child for nebulization?
§ If so, how many times patient was nebulized?
§ Any medication given?
o Any associated symptoms?
§ Fever
§ Running nose, nasal congestion
§ Stridor
§ Hoarseness of voice
§ Inspiratory whoop
§ Post-tussive vomiting
§ Chest pain
 Known case of asthma
• When was the patient diagnosed with asthma?
• What clinical presentation of the patient at that time?
• What are the usual triggering factors for the patient?
• What treatment did the patient received since the diagnosis?
• Current medication:
o What medication? What colour is the inhaler?
o How many times per day?
o How many puff?
o Compliant or not?
o Any follow up?
o Any change in medication before?
• When was the latest admission (AEBA)/latest nebulization?
 Assessment of asthma control (GINA)
• In the past 4 weeks:
o Daytime asthma symptoms?
§ > 1x/week?
§ > 2x/week?
o Any night waking due to asthma? (nocturnal symptoms)
o Any reliever needed for symptoms? How frequent in a week?
§ > 1x/week?
§ > 2x/week?
o Any activity limitation due to asthma? (does the patient always skip school?)
Evaluation of the background of the patient’s condition
• Intermittent
• Mild persistent
• Moderate persistent
• Severe persistent

By asking:
v Daytime symptoms (daily, <1x/week, >1x/week)
v Nocturnal symptoms (daily, >1x/week, >2x month, <1x/month)
v Exercised induced symptoms (daily, yes/no)
v Sleep & activity disturbance (>2x/month, >1x/month, not affecting)

(based on Paeds protocol)

Past medical history Sick contact
• Any underlying illness (heart or lung • Any contact history with:
problems)? o Person with prolonged cough?
• Any previous admission for lung o Person with TB?
infection? Due to asthma? o Person with URTI?
o Person with COVID-19 +ve?
Atopy history Drug history
• Allergic rhinitis • Aspirin
• Allergic conjunctivitis • Beta blocker
• Urticarial
• Eczema
• Food & drug allergy?
Family history
• Childhood-onset asthma
• Allergic rhinitis
• Eczema
• Allergic conjunctivitis
• Food/drug allergies
• Anyone with TB, chronic cough etc.
DIFFERENTIAL DIAGNOSIS
• Gastroesophageal reflux disease
• Viral bronchiolitis
• Rhinosinusitis
• Laryngotracheobronchomalacia
• Laryngotracheobronchitis
• Vocal cord dysfunction
• Foreign body aspiration
• Chronic bronchitis (environmental tobacco smoke exposure)
• Cystic fibrosis
• Congenital anatomic abnormality of airways
• Bronchopulmonary dysplasia
• Hypersensitivity pneumonitis
• Pulmonary parasitic infections
• Tuberculosis
Gastroesophageal reflux
• Often co-morbid with childhood asthma (may make asthma difficult to manage)
• May lead to microaspiration OR aspiration pneumonia
• Clinical features: frequent vomiting, choking, poor weight gain
Viral bronchiolitis
• Respiratory syncytial virus (RSV) is responsible for >50% of cases
• More common in boys, age at onset is < 24 months, peak incidence 1-6 months
• Especially those who live in crowded conditions and have not been breast-fed
• Usually presented with low grade fever and coryzal symptoms (nasal congestion & discharges, cough)
Rhinosinusitis
• Usually presented with pain, swelling and tenderness over cheek, nasal congestion
• May associated with fever and cough

Foreign body aspiration

• History of sudden onset of symptoms such as cough, wheeze, or choking is suggestive
• Persistent wheezing unresponsive to bronchodilator
Vocal cord dysfunction (VCD)
• Usually in older children and adolescents
• Vocal cord involuntarily close inappropriately during inspiration and sometimes exhalation
• Can manifest as intermittent daytime wheezing
• Presented as SOB, coughing, throat tightness, and often audible wheezing
• Spirometric LFT reveals ‘truncated’ and inconsistent inspiratory and expiratory flow-volume loops
• May co-exist with asthma
• Can be diagnosed by flexible rhinolaryngoscopy
 Hints from the History Taking (in this case)
Features Descriptions
Fever Suggestive for respiratory tract infection
Nasal discharge May indicate rhinosinusitis
Vomiting May be suggestive of gastroesophageal reflux (recurrent aspiration)
Pleuritic pain Pneumonia must be considered
Inspiratory ‘whoop’ Pertussis (whooping cough), caused by Bordetella pertussis
Productive cough Bronchiectasis (may secondary to cystic fibrosis)
Chocking Suggesting foreign body aspiration

Family history of atopy, pet at home, nocturnal cough, exercise-induced cough are highly suggestive for asthma
INVESTIGATION
1. Full blood count (FBC)
Investigation
Increase numbers of eosinophils.

2. Spirometry:

To monitor response to treatment, assess degree of reversibility to therapeutic intervention, and measure the severity of asthma
exacerbation.

3. Peak expiratory flow (PEF)

Monitoring devices to measure airflow.

4. Allergy skin testing.

To evaluate children with persistent asthma (NOT during exacerbation of symptoms).

Positive results = correlate strongly with bronchial allergen provocative challenges.

5. Exhaled Nitric Oxide (FeNO).

Non-invasive measure of allergic airways inflammation used in clinical settings. Nitric oxide is a marker of allergic/eosinophilic
inflammation easily and quickly measured in exhaled breath.

6. Chest X-Ray:

To rule out other condition.

***Not routinely done. Diagnosis usually acquired by full history taking and physical examination only.
 A 4-year-old boy with asthma

Frontal (A) and lateral (B) radiograph show pulmonary hyperinflation, flattening of the
diaphragms, and minimal peribronchial thickening. No asthmatic complication is apparent.

Hyperinflation in children
-More than 9 posterior ribs

Adapted from Nelson essential paediatrics

Techniques in Peak expiratory flow
• Move the marker to the bottom of the numbered scale.
• Stand up straight.
• Take a deep breath. Fill your lungs all the way.
• Hold your breath while you place the mouthpiece in your
mouth, between your teeth. Close your lips around it. Do not put
your tongue inside the hole.
• Blow out as hard and fast as you can in a single blow. Your first
burst of air is the most important, so blowing for a longer time
will not affect your result.
• Write down the number you get. If you coughed or did not do
the steps right, do not write down the number. Do it over again.
• Move the marker back to the bottom and repeat these steps 2
more times. The highest of the 3 numbers is your peak flow
number. Write it down in your results log.
• Consider doing it at the same time each day in order to
compare the results from day to day.
• Use the same peak flow meter for everyday readings

Adapted from Medline Plus

MANAGEMENT
 Assessment Of Severity
Initial (Acute Assessment)
§ Diagnosis
• Symptoms (cough, wheezing, breathlessness , pneumonia)
§ Triggering factors
• Food, weather, exercise, infection, emotion, drugs, aeroallergens
§ Severity
• RR, colour, respiratory effort, conscious level

üCXR - rarely helpful (unless suspected complications like pneumothorax, pneumonia or lung collapse)
üInitial ABG - acute severe asthma
 Assess
severity
 Severity and control assessment

§ GINA – asthma management from severity-based to control-based

§ GINA assessment - 3 levels of asthma control :
• Well-controlled
• Partly controlled
• Uncontrolled
§ Patients already on treatment – assessed at every clinic visit – control of asthma
GINA 2018
 Treatment Plan
Regular Assessment and Monitoring
+
Patient education
+
Control of Factors contributing to Asthma severity
+
Principle of Asthma pharmacotherapy

Attain Optimal Asthma Control !

Regular Assessment and Monitoring

• Asthma severity
• Asthma control
• Responsiveness to therapy
Asthma Diary
 To access how well the asthma is managed

Symptoms:
Coughing at night during sleep, until awaken at night

Coughing in the morning when waking up

Coughing in the day

Coughing after playing

Sudden onset of shortness of breath (SOB)/wheezing/fast breathing

Require MDI reliever/oral medications or Nebulization at clinic or hospital

Allergic rhinitis symptoms: sneezing or watery nose in the morning

 Patient education
Educate the child and family

Basic facts about asthma

Self-management skills

Daily management

Asthma action plan for asthma exacerbations

Follow-up
Control of Factors • Eliminate and reduce problematic environmental exposure
contributing to • Treating Comorbid Conditions
Asthma severity
 Management of Acute Asthma

Assessment of
Mild attacks: Severity
- Home treatment
- Personal asthma action plan
Moderate or Severe attacks:
- Require clinic/hospital
attendance
Management of
Special conditions:
- Previous ICU admission for Acute Asthma
asthma, or a patient with Exacerbations
parents that are either
uncomfortable or judged Criteria for admission:
unable to care for the child - Failure to responds to standard
with AEBA home treatment
- Should be admitted to hospital - Failure to responds to nebulised 2-
Admission agonists
- Relapse within 4 hours of nebulised
2-agonists
- Severe acute asthma
 Algorithm for
Treatment of Acute Asthma
Asthma Action Plan
Pharmacotherapy of Asthma
 Goals of therapy

Achieve well-controlled state by reducing impairment and risk

v NIH Asthma Guidelines (2007) provides treatment recommendations that vary by level of
asthma severity and age groups

v Recommendations for initial treatment are based on assessment of the severity of asthma
and any modifications of treatment are determined by the level of control
 Reliever

v Relieve respiratory symptoms

i. Intermittent short acting 2-agonist

is the drug of choice
ii. Oral bronchodilator is discouraged

Adapted from: MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL

Training Module For Health Care Providers
 Preventer

v Reduce airway inflammation

i. Inhaled corticosteroid is the

treatment of choice
ii. Leukotrienes antagonist
iii. Age of child
iv. Asthma wheeze phenotypes
v. Frequency and severity of
symptoms

Adapted from: MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL

Training Module For Health Care Providers
 Controller medication

v Shown to have better control with no

night symptoms, no increase in short
acting -agonist use

i. Seretide (Flixotide + Salmeterol)

ii. Symbicort (Pulmicort)

Adapted from: MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL

Training Module For Health Care Providers
Short Term Controller Medications
• Short-acting Inhaled -Agonists
• Anticholinergic agents
1. Short-acting Inhaled -agonists (SABA)

§ SABAs are the first-line medications for acute treatment in asthma symptoms and preventing exercise
induced bronchospasm.
§ E.g., Albuterol, Levalbuterol, Terbutaline, Pirbuterol
• They are also commonly used in together with LABAs, inhaled corticosteroids, or long-acting
muscarinic agonists in treatment for COPD.
• 4-6 hours duration of action

§ Mode of administration
• Inhalation via metered dosing or dry powder inhalation: inhalation has an increase in therapeutic
value and a decrease in systemic side effects
• Oral administration

§ Side Effect
• Overuse of B-agonists is associated with an increased risk of death or near-death episodes of
from asthma
• Use of 1 MDI/mo or at least 3MDIs/year (200 inhalations/MDI) indicates inadequate asthma
control
2. Anticholinergic Agents

§ Ipratropium bromide – much less potent than -agonists: used primarily in acute severe asthma
§ It can be used with albuterol, ipratropium (improve lung function, reduce rate of hospitalization)

§ Mechanism of action:
Acetylcholine plays an important role in the pathophysiology of asthma via binding to airway
muscarinic receptors to trigger bronchoconstriction, mucus secretion and inflammation, while pre-
clinical data have highlighted the importance of cholinergic-mediated bronchoconstriction in airway
remodeling. Anticholinergics antagonize the parasympathetic effects of acetylcholine, thus
providing therapeutic benefit via a supplementary mechanism to ICS and LABA effects in asthma.

§ Mode of administration:
• Delivered directly to the airways by pressurized aerosol (MDI)
• Available in nebulizer forms
• Minimally absorbed (systemic effects are small)
Long Term Controller Medications
Corticosteroids
Long acting Inhaled B-Agonists
Leukotriene- Modifying Agents
Long acting Inhaled Anticholinergics
Nonsteroidal Anti-inflammatory Agents
1. Inhaled Corticosteroid: First line treatment for persistent asthma
§ Examples
• Beclomethasone dipropionate
• Budesonide
• Fluticasone propionate

§ Mode of administration
• Metered Dose Inhaler - Hydrofluoroalkane as propellant, less expensive than nebulizers, convenient,
faster to use, has a dose counter
• Dry Powder Inhaler- Portable, dose counter, less coordination needed compared to MDI but needs higher
inspiratory flow to use effectively
• Nebulizer- Coordination with the patient not required, high doses possible but more time required per
dose

§ Side effects
● Oral candidiasis (thrush): due to propellant-induced mucosal irritation and local immunosuppression
● Dysphonia (hoarse voice): due to vocal cord myopathy
● Corticosteroid adverse effect screening and osteoporosis prevention measures are recommended for
patients receiving higher doses of ICS
 Systemic Corticosteroid – Primarily used to treat asthma exacerbations

*Exclude comorbid conditions and keep the dose at < 20mg every day
§ Examples:
• Prednisone, prednisolone and methylprednisolone are completely and rapidly absorbed with peak
plasma concentrations occurring within 1-2 hour

§ Mode of administration
• Oral or IV route
• Parenteral route: indicated in children who are vomiting or unable to consume orally and patients
with moderate to severe or life-threatening acute exacerbations

§ Side Effect
• Metabolic effects occur immediately
• Effects such as growth suspension, osteoporosis and cataracts takes month to years to manifest
• Occur in duration dependant manner and cumulative dose dependant
2. Long acting Inhaled B-Agonists

§ Examples
• Salmeterol: prolonged onset of effect (60min)
• Formoterol: rapid onset of effect (5-10 min)

§ Mode of administration
• Metered dose inhaler
• Dry powder inhaler

§ Indications
• Patients with nocturnal asthma
• Patients who need frequent use of SABA inhalations during day to prevent exercise induced bronchospasms

§ Side effects
• Warning of an increase in severe asthma episodes

*Are not intended to be used at monotherapy for persistent asthma

*Ability to mask worsening asthma inflammation and severity
3. Leukotriene- Modifying Agents

§ Examples
• Leukotriene receptor antagonists (LTRAs)
• Montelukast (> 1 yrs old, administered once daily)
• Zafirlukast (>5 yrs old, administered twice daily)
• Inhibitors of Leukotriene synthesis
• Zilueton (children >12yrs old)

§ Mode of administration
• Oral (Montelukast)

§ Side effect: A precaution is taken by informing the family to observe any mood changes
4. Long acting Inhaled Anticholinergics (>12 year old)

§ Example
• Tiotropium (24 hour duration of action)

§ Mode of administration
• Dry powder inhalation

§ Side effect
• Commonly, dry mouth and blurred vision
The Science Guiding Selection of an Aerosol Delivery Device
Timothy R Myers
Respiratory Care Nov 2013, 58 (11) 1963-1973; DOI: 10.4187/respcare.02812
Prognosis of Childhood asthma
 • 35% preschool age children experience
recurrent coughing and wheezing
• 1/3 continue to have persistent asthma
in childhood
• Children with moderate to severe
asthma with lower lung function
measures ae likely to have persistent
asthma in adults
• Children with mild asthma and normal
lung function are likely to improve with
time
• Complete remission for 5 year in
childhood is uncommon

Murayama, Norihide & Murayama, Kikuno. (2018). Data on nasal eosinophil positive rates
in childhood asthma on each age. Data in Brief. 20. 10.1016/j.dib.2018.09.018.
Prevention
5.3 Prevention of
Childhood Asthma
 Supervised by:
Doctor Tan Sue Lyn