History

Fact Explanation
Wheezing Asthma is a chronic inflammatory condition of the lung airways resulting in episodic reversible airflow obstruction. Wheezing is likely a result of turbulent air flow through large narrowed, central airways that causes oscillation of bronchial walls which result in musical, high-pitched, whistling sound. [1],[2],[3],[4]
Cough In cases of exercise-induced or nocturnal asthma cough may be the only symptom. Usually, the cough is nonparoxysmal and nonproductive. In addition, wheezing may be the presentation of cough. Children with nocturnal asthma tend to experience cough during the early hours of morning and after midnight. [1],[2],[3],[4]
Shortness of breath The airways are narrowed with increased resistance to exhaling air from the lung, resulting in air entrapment in the lung. Shortness of breath may be accompanied by wheezing. [1],[2],[3],[4]
Pattern of symptoms Children with chronic asthma may have one of several distinct patterns of symptoms, and the asthma pattern may change over time. Presence of daytime/nocturnal symptoms, limitation of activity due to the disease and need for rescue treatment is assessed to identify the pattern. [1],[2],[3],[4]
Triggering factors The airways of children with symptoms occur periodically, usually related to specific triggering events. asthma react to a variety of stimuli, which may include viral illnesses (eg, the common cold), exercise, pollen, foods to which the child is allergic, or environmental conditions. [1],[2],[3],[4]
Home enviorenment Ventilation and lightening inside the house; parental smoking habits; pets; gardening have to be noted as the triggering factor. [1],[2],[3],[4]
History of atopy Children with atopy (allergic rhinitis, dermatitis, food or drug allergy) are more prone to get asthma.[1],[2],[3],[4]
Family history Family history of asthma is a predictor of asthma risk. This poses potential risks as well as benefits. A focus on family history as a risk factor could decrease motivation to address environmental risk factors for asthma when a family history of asthma is absent. other-than that this could lead to stigmatization, overprotection, or increased use of healthcare resources without compensatory health outcome benefits. [1],[2],[3],[4]
References
  1. HERZOG R, CUNNINGHAM-RUNDLES S. PEDIATRIC ASTHMA: NATURAL HISTORY, ASSESSMENT AND TREATMENT Mt Sinai J Med [online] 2011 Sep, 78(5):645-660 [viewed 01 September 2014] Available from: doi:10.1002/msj.20285
  2. VAN AALDEREN WM. Childhood Asthma: Diagnosis and Treatment Scientifica (Cairo) [online] 2012:674204 [viewed 02 September 2014] Available from: doi:10.6064/2012/674204
  3. BOZKURT B.. Shortness of Breath. Circulation [online] 2003 June, 108(2):11e-13 [viewed 02 September 2014] Available from: doi:10.1161/01.CIR.0000075956.36340.78
  4. MARTINEZ FERNANDO D., WRIGHT ANNE L., TAUSSIG LYNN M., HOLBERG CATHARINE J., HALONEN MARILYN, MORGAN WAYNE J.. Asthma and Wheezing in the First Six Years of Life. N Engl J Med [online] 1995 January, 332(3):133-138 [viewed 02 September 2014] Available from: doi:10.1056/NEJM199501193320301
  5. YOUNG SALLY, LE SOUëF PETER N., GEELHOED GARY C., STICK STEPHEN M., TURNER KEVEN J., LANDAU LOUIS I.. The Influence of a Family History of Asthma and Parental Smoking on Airway Responsiveness in Early Infancy. N Engl J Med [online] 1991 April, 324(17):1168-1173 [viewed 02 September 2014] Available from: doi:10.1056/NEJM199104253241704
  6. BURKE WYLIE, FESINMEYER MEGAN, REED KATE, HAMPSON LINDSAY, CARLSTEN CHRIS. Family history as a predictor of asthma risk. American Journal of Preventive Medicine [online] 2003 February, 24(2):160-169 [viewed 02 September 2014] Available from: doi:10.1016/S0749-3797(02)00589-5

Examination

Fact Explanation
respiratory rate Respiratory rate increase as a compensatory mechanism. In asthma there is airway narrowing. Increased respiratory rate compensate that by increasing amount of air volume that inspired within a minute. In severe asthma respiratory rate can get increased >50 breaths/min in children 2-5 years, >30 breaths/min in children 5 or over. [1],[2],[3]
use of accessory muscles of respiration Increase respiration is also done by increasing the volume of the chest cavity. To increase the volume of the chest cavity use of accessory is necessary. Seen in severe asthma attacks [1],[2],[3]
Loud expiratory wheezing wheezing occur due to turbulent air flow through constricted bronchioles which occur in asthma. Seen in severe asthma attacks but absent in life threatening asthma. [1],[2],[3]
Pulsus paradoxus presence of marked pulsus paradoxus (the difference between systolic pressure on inspiration and expiration) indicates moderate to severe in children but is difficult to measure accurately and is therefore unreliable. [1],[2],[3]
Pulse In severe asthma pulse rate increased >130 beats/min in children aged 2-5 years, >120 beats/min in children 5 or over. [1],[2],[3]
Talking used to assessed the severity of the acute attack if the child is old enough to talk. in acute severe asthma they are unable to feed or complete a sentence in one breath. [1],[2],[3]
References
  1. ORTIZ-ALVAREZ O, MIKROGIANAKIS A, CANADIAN PAEDIATRIC SOCIETY, ACUTE CARE COMMITTEE. Managing the paediatric patient with an acute asthma exacerbation Paediatr Child Health [online] 2012 May, 17(5):251-256 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3381918
  2. VAN AALDEREN WM. Childhood Asthma: Diagnosis and Treatment Scientifica (Cairo) [online] 2012:674204 [viewed 02 September 2014] Available from: doi:10.6064/2012/674204
  3. BUSH A, SAGLANI S. Management of severe asthma in children Lancet [online] 2010 Sep 4, 376(9743):814-825 [viewed 02 September 2014] Available from: doi:10.1016/S0140-6736(10)61054-9

Differential Diagnoses

Fact Explanation
Upper respiratory tract infection These patient can present with cough and wheezing. But with the history of similar illness in neighbor children and no history of previous asthma attack makes the diagnosis more towards infection. But as infection can trigger asthma attack, infection in a asthma patient need more attention.[4]
Foreign Body aspiration Coughing, choking, acute dyspnoea, and sudden onset of wheezing are the most common symptoms. History of aspiration and choking help to differentiate from asthma.[5]
Allergic Rhinitis It is a symptomatic disorder of the nose induced after exposure to allergens via IgE-mediated hypersensitivity reactions. there are 4 cardinal symptoms watery rhinorrhea, nasal obstruction, nasal itching and sneezing. [6]
Tracheobronchomalacia Tracheomalacia is a rare condition where the trachea is weak due to soft cartilage in a certain area or throughout the trachea. If the mainstem bronchi are involved as well, the term tracheobronchomalacia is used. Breathing becomes difficult as a result of the soft tracheal cartilage. Other signs and symptoms include wheezing, frequent upper respiratory infections and a bluish color to the skin surrounding the mucous membranes of the nose and mouth. [1]
Hyperventilation syndrome Hyperventilation syndrome (HVS) is characterized by functional hyperventilation attacks with no underlying organic abnormality. HVS patients show various clinical symptoms such as anxiety, dyspnea, hypocapnia, tetany, and unconsciousness. [2]
Pulmonary edema usually present immediately but can occur several hours later. Signs and symptoms of respiratory distress are often present but frothy, pink sputum is the hallmark sign [3]
References
  1. MALONE PS, KIELY EM. Role of aortopexy in the management of primary tracheomalacia and tracheobronchomalacia. Arch Dis Child [online] 1990 Apr, 65(4):438-440 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1792197
  2. MUNEMOTO T, MASUDA A, NAGAI N, TANAKA M, YUJI S. Prolonged post-hyperventilation apnea in two young adults with hyperventilation syndrome Biopsychosoc Med [online] :9 [viewed 02 September 2014] Available from: doi:10.1186/1751-0759-7-9
  3. FREMONT RD, KALLET RH, MATTHAY MA, WARE LB. Postobstructive Pulmonary Edema: A Case for Hydrostatic Mechanisms Chest [online] 2007 Jun, 131(6):1742-1746 [viewed 02 September 2014] Available from: doi:10.1378/chest.06-2934
  4. FRY J. Common Upper Respiratory Tract Infections Res Newsl [online] 1955 May:43-52 [viewed 06 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2239048
  5. PASSàLI D, LAURIELLO M, BELLUSSI L, PASSALI G, PASSALI F, GREGORI D. Foreign body inhalation in children: an update Acta Otorhinolaryngol Ital [online] 2010 Feb, 30(1):27-32 [viewed 06 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881610
  6. MIN YG. The Pathophysiology, Diagnosis and Treatment of Allergic Rhinitis Allergy Asthma Immunol Res [online] 2010 Apr, 2(2):65-76 [viewed 06 September 2014] Available from: doi:10.4168/aair.2010.2.2.65

Investigations - for Diagnosis

Fact Explanation
Spirometry gold standard for measure of airflow in asthma is to the measures airflow and lung volumes during a forced expiratory maneuver. Normative values for FEV1 (forced expiratory volume in 1 sec) have been standardized for children, based on height, gender, and ethnicity. But these measures alone, are not diagnostic of asthma, because so many other conditions can cause airflow reduction. Response to inhaled β-agonist medication is greater in asthmatics vs. nonasthmatics-an improvement in FEV1 greater than 12% is consistent with asthma. But valid spirometric measures are also dependent on a patient's ability to properly execute a expiratory maneuver. Reproducible spirometric efforts are an indicator of test validity. If, on three consecutive attempts, the FEV1 is within 5%, then the best FEV1 effort of the three is used. [1],[2],[3],[4]
Chest X ray Most of times Chest radiographs (posteroanterior and lateral views) in children with asthma appear to be normal. There can be subtle and nonspecific findings of hyperinflation as flattening of the diaphragms and peribronchial thickening. Chest radiographs are helpful to exclude other conditions that mimic asthma as aspiration pneumonitis, hyperlucent lung fields in bronchiolitis obliterans.[1],[2],[3],[4]
Allergic testing Done to assess sensitization to inhalant allergens. When the allergens are identified, environmental factors and outdoor factors may be modified to reduce asthmatic symptoms.[1],[2],[3],[4]
Bronchoprovocation challenges Asthmatic airways are more sensitive to inhaled methacholine, histamine, and cold or dry air. The degree of airways hyperresponsiveness to these exposures correlates with asthma severity and airways inflammation. Because bronchoprovocation challenges have to be carefully dosed and monitored in an investigational setting, their use is rarely practical in a general practice setting[1],[2],[3],[4]
CT With better resolution some lung abnormalities can be seen clearly. For example, bronchiectasis is sometimes difficult to appreciate on chest radiograph but is clearly seen on CT scan and it help to differentiate asthma from other diseases such as cystic fibrosis, allergic bronchopulmonary mycoses (e.g., aspergillosis), ciliary dyskinesias, or immune deficiencies. [1],[2],[3],[4]
References
  1. VAN AALDEREN WM. Childhood Asthma: Diagnosis and Treatment Scientifica (Cairo) [online] 2012:674204 [viewed 02 September 2014] Available from: doi:10.6064/2012/674204
  2. National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2007 Aug. Section 3, Component 1: Measures of Asthma Assessment and Monitoring. Available from: http://www.ncbi.nlm.nih.gov/books/NBK7230/
  3. BURR M L, BUTLAND B K, KING S, VAUGHAN-WILLIAMS E. Changes in asthma prevalence: two surveys 15 years apart.. Archives of Disease in Childhood [online] 1989 October, 64(10):1452-1456 [viewed 02 September 2014] Available from: doi:10.1136/adc.64.10.1452
  4. MAGNUS P., JAAKKOLA J. J K. Secular trend in the occurrence of asthma among children and young adults: critical appraisal of repeated cross sectional surveys. BMJ [online] 1997 June, 314(7097):1795-1795 [viewed 02 September 2014] Available from: doi:10.1136/bmj.314.7097.1795

Investigations - Fitness for Management

Fact Explanation
Oxygen saturation Done to assess the severity of asthma attack and circulation. it is <92% in severe life threatening attacks. Then as immediate management O2 is given via face mask/nasal prongs to achieve normal saturation [1],[2]
References
  1. National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2007 Aug. Section 3, Component 1: Measures of Asthma Assessment and Monitoring. Available from: http://www.ncbi.nlm.nih.gov/books/NBK7230/
  2. VAN AALDEREN WM. Childhood Asthma: Diagnosis and Treatment Scientifica (Cairo) [online] 2012:674204 [viewed 02 September 2014] Available from: doi:10.6064/2012/674204

Investigations - Followup

Fact Explanation
Spirometry The reductions in FEV1 as a percentage of predicted is one of four criteria used to determine asthma severity. It is helpful as an objective measure in the management of asthmatics. [1],[2]
Plethysmography That it is the optimum technique for assessing pharmacological effects in asthmatics. Three readings are adequate to detect changes above variability in asthmatics. [1],[2],[3]
References
  1. National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2007 Aug. Section 3, Component 1: Measures of Asthma Assessment and Monitoring. Available from: http://www.ncbi.nlm.nih.gov/books/NBK7230/
  2. VAN AALDEREN WM. Childhood Asthma: Diagnosis and Treatment Scientifica (Cairo) [online] 2012:674204 [viewed 02 September 2014] Available from: doi:10.6064/2012/674204
  3. HOUGHTON CM, WOODCOCK AA, SINGH D. A comparison of plethysmography, spirometry and oscillometry for assessing the pulmonary effects of inhaled ipratropium bromide in healthy subjects and patients with asthma Br J Clin Pharmacol [online] 2005 Feb, 59(2):152-159 [viewed 02 September 2014] Available from: doi:10.1111/j.1365-2125.2004.02262.x

Investigations - Screening/Staging

Fact Explanation
Spirometry The reductions in FEV1 as a percentage of predicted is one of four criteria used to determine asthma severity.[1]
References
  1. VAN AALDEREN WM. Childhood Asthma: Diagnosis and Treatment Scientifica (Cairo) [online] 2012:674204 [viewed 02 September 2014] Available from: doi:10.6064/2012/674204

Management - General Measures

Fact Explanation
Patient education Education makes the child and family, partners in the asthma management process. First, a basic understanding of the pathogenesis of asthma can help asthmatic children and their parents to understand the importance of recommendations aimed at reducing airways inflammation. All asthmatic children and their families can benefit from a written asthma management plan with a daily management plan describing regular asthma medication use and other measures to keep asthma under good control and an action plan for asthma exacerbations, describing actions to take when asthma worsens, including what medications to take and when to contact the regular physician and/or obtain emergent or urgent medical care. [1],[2],[3]
Assessment and monitoring Regular follow-up visits can help to maintain optimal asthma control. In addition to the assessment and monitoring of disease severity, follow-up visits should evaluate adherence and concerns with asthma management recommendations, and especially the daily administration of controller medications when prescribed. Reassessment during each visit of the role of different medications in asthma management and the technique used with inhaled medication use can be insightful and lead to important teaching opportunities. [1],[2],[3]
Control of environmental factors and comorbid conditions The majority of children with asthma consist of an allergic component to their disease. Because of this, steps should be taken to investigate and minimize allergen exposures in sensitized asthmatics. Rhinitis, sinusitis, and gastroesophageal reflux commonly accompany asthma and can worsen disease severity. Indeed, these conditions are also common causes of chronic coughing. Effective management of these co-morbid conditions can often improve asthma symptoms and disease severity, so that less medication is needed to achieve good asthma control. [1],[2],[3]
References
  1. PARTRIDGE MR. Educating patients with asthma. Postgrad Med J [online] 1994 Sep, 70(827):599-603 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2397738
  2. TOWNSHEND J, HAILS S, MCKEAN M. Management of asthma in children BMJ [online] 2007 Aug 4, 335(7613):253-257 [viewed 02 September 2014] Available from: doi:10.1136/bmj.39255.692222.AE
  3. ROORDA R J. Prognostic factors for the outcome of childhood asthma in adolescence.. Thorax [online] 1996 January, 51(Suppl 1):S7-12 [viewed 02 September 2014] Available from: doi:10.1136/thx.51.Suppl_1.S7

Management - Specific Treatments

Fact Explanation
Management of acute episode The child should be given a β2-bronchodilator. For severe exacerbations, high-dose therapy should be given and repeated every 20-30 minutes ,may need to be given via nebuliser. The addition of nebulised ipratropium to the initial therapy in severe asthma is beneficial. For moderate to severe asthma, 10 puffs should be given via metered-dose inhaler (MDI) and large volume spacer. Oxygen is given when O2 saturation<92%. oral prednisolone given for 2-5 days. Intravenous therapy has a role children who fail to respond adequately to inhaled bronchodilator. iv aminophylline, a loading dose is given over 20 minutes, followed by continuous infusion. Seizures, severe vomiting and fatal cardiac arrhythmias may follow a rapid infusion. If the child is already on oral theophylline, the loading dose should be omitted. With both aminophylline and salbutamol, the ECG should be monitored and blood electrolytes checked. intravenous magnesium is helpful in life-threatening asthma. Antibiotics are only given if there are clinical features of bacterial infection. Ifthese measures are insufficient artificial ventilation is required. [1],[2],[3],[4],[5]
Reliever medication - Short-Acting β2-Agonists - albuterol, levalbuterol, terbutaline, pirbuterol Drugs of choice for acute episodes of bronchospasm and exercise-induced bronchospasm because they have rapid onset of action, and 4-6 hr duration of action. β-Agonists bronchodilate by inducing airway smooth muscle relaxation, reducing vascular permeability airways edema, and improving mucociliary clearance. It is helpful to monitor the frequency of inhaled β-agonist use, in that use of >1 canister/mo (200 inhalations/mo) indicates inadequate asthma control and necessitates initiating or intensifying controller therapy. [1],[2],[3],[4],[5]
Reliever medication - Anticholinergic Agents - ipratropium bromide Much less potent than the β-agonists. Inhaled ipratropium is mostly used in the treatment of acute severe asthma. When used in combination with albuterol, ipratropium significantly improve lung function and reduce the rate of hospitalization. Has few central nervous system side effects, and it is available in both MDI and nebulizable formulations.[1],[2],[3],[4],[5]
Reliever medication - Systemic Glucocorticoid Therapy- short course use in moderate- to-severe asthma. both to hasten recovery and prevent recurrence of symptoms. Eventhough oral glucocorticoid therapy can be used, in children in respiratory distress can use IV glucocorticoid therapy. For hospitalized children, administering methylprednisolone at 1 mg/kg/dose every 6 hr for 48 hr, with a taper to 1-2 mg/kg/24 hr (maximum 60 mg/24 hr) in two divided doses until the patient's PEFs reach 70% of predicted or personal best is recommended. For outpatient management of acute asthma, 1-2 mg/kg/24 hr (maximum 60 mg/24 hr) of prednisone or methylprednisolone in a single or two divided doses for 3-10 days is recommended. [1],[2],[3],[4],[5]
long term medication - Nonsteroidal Anti-inflammatory Agents. Indicated for mild to moderate asthma, must be administered frequently (two to four times/24 hr). Not nearly as effective as the other two major controllers (inhaled glucocorticoids and leukotriene-modifying agents). Therefore they are considered as alternative agents. Because they inhibit exercise-induced bronchospasm, they can be used in place of short-acting β-agonists, especially in children who develop unwanted adverse effects with β-agonist therapy (e.g., tremor and elevated heart rate). [1],[2],[3],[4],[5]
long term medication - Inhaled glucocorticoid therapy These drugs reduce asthma symptoms, improve baseline pulmonary function, reduce bronchial hyperresponsiveness. These drugs cause the less need for short-acting β-agonists use and less need for prednisone. Can reduce, by up to 50%, urgent care visits and hospitalizations for acute asthma. low-dose inhaled glucocorticoid therapy is recommended for all patients with persistent asthma [1],[2],[3],[4],[5].
long term medication - Systemic Glucocorticoid Therapy oral glucocorticoid therapy is now used primarily to treat asthma exacerbations and in rare patients with severe disease who remain symptomatic despite optimal use of other asthma medications. Keep the oral glucocorticoid dose at ≤20 mg administered on alternate days. Doses exceeding this amount are associated with numerous adverse effects.[1],[2],[3],[4],[5]
long term medication - Theophylline because of its potential toxicity this is rarely used in pediatric asthma. Long term use can reduce asthma symptoms and need for supplemental β-agonist use. Used in individuals with oral glucocorticoid-dependent asthma as theophylline have some glucocorticoid-sparing effects. Theophylline has a narrow therapeutic window; therefore, serum theophylline levels need to be routinely monitored, especially if the patient has a viral illness associated with a fever or is placed on a medication known to delay theophylline clearance. [1],[2],[3],[4],[5]
long term medication - Long-Acting Inhaled β-Agonists.(LABAs) - Salmeterol and formoterol These medication do not use for acute episodes of bronchospasm or asthma exacerbations, nor recommended as monotherapy for persistent asthma. Salmeterol has a prolonged onset of action, whereas formoterol has an onset of action within 5-10 min. Both medications have a prolonged duration of effect of at least 12 hr. Because of that, used in patients with nocturnal asthma and for individuals who require frequent use of short-acting β-agonist inhalations. They good for patients who are suboptimally controlled on inhaled glucocorticoid therapy alone.[1],[2],[3],[4],[5]
long term medication - Leukotriene-Modifying Agents. Leukotrienes are potent proinflammatory mediators that can induce bronchospasm, mucus secretion, and airways edema. Leukotriene receptor antagonists (LTRAs) have bronchodilator and targeted anti-inflammatory properties and block exercise-, aspirin-, and allergen-induced bronchoconstriction. Two LTRAs are approved for use in children: zafirlukast and montelukast. Both medications improve asthma symptoms, decrease need for supplemental β-agonist use, and improve pulmonary function in patients with asthma. Montelukast is administered once daily (10 mg for children ≥ 15 yr; 5 mg for children 6-14 yr; 4 mg for children 2-5 yr). [1],[2],[3],[4],[5]
References
  1. TOWNSHEND J, HAILS S, MCKEAN M. Management of asthma in children BMJ [online] 2007 Aug 4, 335(7613):253-257 [viewed 02 September 2014] Available from: doi:10.1136/bmj.39255.692222.AE
  2. HERZOG R, CUNNINGHAM-RUNDLES S. PEDIATRIC ASTHMA: NATURAL HISTORY, ASSESSMENT AND TREATMENT Mt Sinai J Med [online] 2011 Sep, 78(5):645-660 [viewed 02 September 2014] Available from: doi:10.1002/msj.20285
  3. POTTER PC. Current guidelines for the management of asthma in young children Allergy Asthma Immunol Res [online] 2010 Jan, 2(1):1-13 [viewed 02 September 2014] Available from: doi:10.4168/aair.2010.2.1.1
  4. BUSH A, SAGLANI S. Management of severe asthma in children Lancet [online] 2010 Sep 4, 376(9743):814-825 [viewed 02 September 2014] Available from: doi:10.1016/S0140-6736(10)61054-9
  5. VAN AALDEREN WM. Childhood Asthma: Diagnosis and Treatment Scientifica (Cairo) [online] 2012:674204 [viewed 02 September 2014] Available from: doi:10.6064/2012/674204