4. 4
Asthma is the most common chronic disease of childhood
& the leading cause of childhood morbidity from chronic
disease as measured by school absences, emergency
department visits and hospitalizations.
Asthma Typically begins in early childhood, with earlier
onset in males than females .
Burden of Asthma in Children
5. 5
a chronic inflammatory disorder of the airways …… in
susceptible individuals, inflammatory symptoms are
usually associated with widespread but variable airflow
obstruction and an increase in airway response to a
variety of stimuli.
o Obstruction is often reversible, either spontaneously
or with treatment.
Asthma definition
6. 6
o Diagnosis of asthma is a clinical one….there is no
standardised definition of the type, severity or frequency
of symptoms, nor of the findings on investigation.
o Presence of symptoms…wheeze, cough, breathlessness,
chest tightness… airway hyperresponsiveness…airway
inflammation…
9. 9
o Inflammation in asthma patients can be present
during symptom-free periods:
o Symptoms resolve quickly. Inflammation, however, as
measured by airway hyperresponsiveness, takes far longer
o As chronic inflammation causes an increase in airway
hyperresponsiveness, if the inflammation is not
controlled, symptoms are likely to reoccur.
10. 10
Unfortunately…asthma is a major cause of
chronic morbidity and mortality throughout the
world and there is evidence that its prevalence has
increased considerably over the past 20 years,
especially in children.
Fortunately…asthma can be effectively treated
and most patients can achieve good control of
their disease.
11. 11
InflammationDamaged airway passage wall
Normal airway Airway inflammation
and bronchoconstriction
Inflammation and bronchoconstriction:
a two-part problem
12. 12
o Many young children, approximately 30% of all children,
have airway symptoms like cough and wheeze. However,
only 1/3 of these children with symptoms will develop
asthma later in life.
o Wheezing in preschool children is a heterogeneous
condition with multiple phenotypes.
13. Prevalenceo
Age Years
Martine z Pe diatrics 20 0 2; 1 0 9 : 36 2
Transient wheeze
Non-atopic viral
induced wheeze
Atopic asthma
0 3 6 11
Pre-school “Asthma phenotypes”
Wheezing is common in young children but is it asthma?
15. 15
o The medical literature commonly cites epidemiologic
criteria such as wheezing in the first 3 years of life,
transient versus persistent wheeze, or atopic versus
nonatopic, but these categories can be determined
only retrospectively and give no guide to treatment,
so are not useful for the clinician .
16. 16
o The European Respiratory Society Task Force
recommends differentiating wheezing phenotypes that
provide the pediatrician with some evidence that can assist
with treatment into:
1)Episodic viral wheezing
2)Multiple-trigger wheezing.
19. 19
o Young children who present with symptoms of cough,
wheeze, and shortness of breath may have either viral-
associated respiratory problems that may not persist
into later childhood or may have an asthmatic pattern
of airway inflammation that may subsequently develop
into asthma
25. 25
• It may be difficult to make a confident diagnosis of
asthma in children 5 years and younger, because
episodic respiratory symptoms such as wheezing and
cough are also common in children without asthma,
particularly in those 0–2 years old.
• Furthermore, it is not possible to routinely assess
airflow limitation in this age group.
Clinical Diagnosis of Asthma
26. 26
The diagnosis of asthma in preschool children is based
on recognising a characteristic pattern of episodic
respiratory symptoms and signs in the absence of
an alternative explanation, the diagnosis is
usually purely clinical.
27. 27
o Spirometric lung function are difficult to perform in
young children, because active cooperation is a
prerequisite for successful measurements.
o In preschool children, therefore, the diagnosis is
usually purely clinical.
29. 29
Probability of asthma
diagnosis
A probability-based approach to diagnosis
and treatment for wheezing children
replaces previous classifications by
wheezing phenotype
30. 30
o A probability-based approach, based on the pattern of
symptoms during and between viral respiratory
infections, may be helpful for discussion with
parents/carers .
o This approach allows individual decisions to be made
about whether to give a trial of controller treatment.
o It is important to make decisions for each child
individually, to avoid either over- or under-treatment.
33. Children’s Healthcare of Atlanta
Diagnosis
*BTS/SIGN (May 2008). British Guideline on the Management of Asthma
• Clinical features that increase the
probability of asthma:
– More than one of the following
symptoms especially if frequent,
worse at night/early morning/after
exercise/exposure to triggers etc.
• Wheeze
• Cough
• difficulty breathing,
• chest tightness
• Atopic disorder
• FH of atopic disorder/asthma
• Improvement in symptoms or lung
function with adequate therapy
• Clinical features that lowerthe
probability of asthma:
– Symptoms with URTI only
– no interval symptoms
– isolated cough in the absence of
wheeze or difficulty breathing
– history of moist cough
– prominent dizziness, light-
headedness, peripheral tingling
– repeatedly normal physical
examination of chest when
symptomatic
– normal PEFR/spirometry when
symptomatic
– no response to a trial of asthma
therapy
– clinical features pointing to
alternative diagnosis
39. 39
Watchful waiting with review.
o In children with mild, intermittent wheeze and other
respiratory symptoms which occur only with viral upper
respiratory infections (colds), it is often reasonable to
give no maintenance treatment and to plan a review of
the child after an interval agreed with the parents/carers.
40. 40
Trial of treatment with review..
o Most children under five years of age and some older
children cannot perform spirometry.
o In these children, offer a trial of treatment for a specific
period. The choice of treatment (for example, inhaled
corticosteroids) depends on the severity and frequency
of symptoms.
41. 41
Trial of treatment with review..
o Monitor treatment for 6–8 weeks and if there is clear
evidence of clinical improvement, the treatment should
be continued and they should be regarded as having
asthma (it may be appropriate to consider a trial of
withdrawal of treatment at a later stage).
o If the treatment trial is not beneficial, then consider tests
for alternative conditions and referral for specialist
assessment.
46. 46
Aim of management
Aim of asthma management is to control the disease
Complete Control is defined as
1. No daytime symptoms
2. No night-time awakening due to asthma
3. No need for rescue medication
4. No asthma attacks
5. No limitations on activity including exercise
6. Normal lung function (in practical terms FEV1 and/or
PEF>80% predicted or best)
7. Minimal side effects from medication.
47. 47
Underlying principles of management
•Before initiating drug
treatment check
– Compliance with
existing treatment
– Inhaler technique
– Eliminate trigger factors
56. 56
• Patients should start treatment at the step most
appropriate to the initial severity of their asthma.
• The aim is to Achieve early control
• Maintain control
– Step up when necessary
– Step down when control is good
58. How do we apply the
stepwise approach?
• Start treatment at the step most
appropriate to initial severity
• Achieve early control
Maintain control
by stepping up
treatment as
necessary.
59. Stepping down
Ensure regular review of
patients as treatment is
stepped down
Decide which drug to step
down first and at what rate
When control is
good,
step down
63. 63
• For those with mild-intermittent asthma or
exercise-induced asthma, occasional use of
reliever therapy may be the only treatment
required.
64. 64
• The following medicines act as short-acting
bronchodilators:
Inhaled short-acting β 2
agonists
Inhaled ipratropium bromide
β 2
agonist tablets or syrup
Theophyllines.
• Inhaled SABA works more quickly and/or with
fewer side effects than the alternatives
66. 66
• Prescribe an inhaled short-acting β2
agonist as
short term reliever therapy for all patients
with symptomatic asthma.
67. 67
Salbutamol is the commonly used inhaled bronchodilator
therapy in children.
It is a short- acting ß-2 agonist, has a rapid onset of action
(within five minutes) and usually provides 4–6 hours of
bronchodilation.
It should be used as a reliever therapy and is in the first
step of all guidelines on asthma management.
68. 68
The use of short-acting inhaled beta2-agonists
on a daily basis, or increasing use, indicates
the need for additional long term control
therapy.
69. 69
Oral preparations of beta2 agonists have been used
extensively in the past with children but are less
effective than inhaled preparations and have more
side-effects
70. 70
The use of albuterol syrup has fallen out of favor over
the past decade with the advent of better modalities of
targeted, inhaled delivery systems (e.g., MDI with
spacer/holding chamber, nebulizer solution).
• AAAAI Guidelines (2004, p88) prefer inhaled
beta2-agonists to oral because higher
concentrations are delivered more effectively to
the airways, the onset of action is substantially
shorter, and systemic side effects can be
avoided or minimized.
• Authors concluded lack of updated information was a possible reason that
community-based PCPs continued to prescribe syrup.
Special Consideration – Albuterol
Syrup
71. 71
It is important that while reviewing a patient with asthma,
the practitioner establishes how often the child needs the
reliever therapy.
Need for frequent bronchodilator therapy, especially for
interval symptoms such as exercise intolerance or night
coughs, may indicate escalation of therapy – i.e. initiation
of step 2 of asthma management.
72. 72
Increasing use of SABA treatment or the use of SABA >
2 days a week for symptom relief (not prevention of EIB)
generally indicates inadequate asthma control and the
need for initiating or intensifying anti-inflammatory
therapy.
Regularly scheduled, daily, chronic use of SABA is
not recommended.
73. 73
Good asthma control is associated with little or no need for
short-acting β2
agonist.
Anyone prescribed more than one short acting bronchodilator
inhaler device a month should be identified and have their
asthma assessed urgently and measures taken to improve
asthma control if this is poor.
76. 76
• Inhaled corticosteroids are the recommended
& most effective preventer drug for adults
and children with asthma , for achieving overall
treatment goals.
77. 77
• There is an increasing body of evidence
demonstrating that, at recommended doses, ICS are
also safe and effective in children under five with
asthma.
78. 78
o ICS Should be considered for adults, children aged
5–12 &children under the age of five with any of
the following features :
– Using inhaled SABA three times a week or more
– Symptomatic three times a week or more
– Waking one night a week
In addition, ICS should be considered in adults & children
aged 5–12 who have had an asthma attack requiring oral
corticosteroids in the last two years
79. 79
In mild to moderate asthma, starting at very high doses
of ICS and stepping down confers no benefit.
Start patients at a dose of inhaled corticosteroids
appropriate to the severity of disease.
A reasonable starting dose of inhaled corticosteroids will
usually be low dose for adults and very low does for
children .
Starting dose of inhaled steroid
80. 80
The doses of ICS are expressed as very low (generally
paediatric doses), low (generally starting dose for
adults), medium and high .
Adjustments to doses will have to be made for other
inhaler devices and other corticosteroid molecules
84. 84
In adults, a reasonable starting dose of inhaled
corticosteroids will usually be 400 micrograms BDP
per day and in children 200 micrograms BDP per day.
Titrate the dose of inhaled corticosteroid to the
lowest dose at which effective control of asthma is
maintained
85. 85
Is important that while considering a change of the type of
steroids or inhaler device used (e.g. Turbohaler),
equivalent doses of inhaled steroids relative to
beclometasone are given before the change is initiated to
avoid any inadvertent risk of overdosing with steroids.
86. 86
BDP and budesonide are approximately equivalent in clinical
practice, although there may be variations with different delivery
devices.
At present a 1:1 ratio should be assumed when changing between
BDP and budesonide.
Fluticasone provides equal clinical activity to BDP& budesonide
at half the dosage
Mometasone appears to provide equal clinical activity to BDP
and budesonide at half the dosage.
COMPARISON OF INHALED
CORTICOSTEROIDS
87. 87
Most current ICS are slightly more effective when taken
twice rather than once daily, but may be used once daily
in some patients with milder disease and good or
complete control of their asthma.
There is little evidence of benefit for dosage frequency
more than twice daily.
Give inhaled corticosteroids initially twice daily (except
ciclesonide which is given once daily).
Frequency of dosing of inhaled corticosteroids
88. 88
ICS usage as a preventer therapy should be
explained to the parents in simple, plain
terms.
90. Children’s Healthcare of Atlanta
Dose, drug, &Dose, drug, &
route dependentroute dependent
Corticosteroids for Asthma: Benefits and
Risks
ReducesReduces
inflammationinflammation
Most effectiveMost effective
long-term controllong-term control
medication formedication for
asthma*asthma*
DecreasesDecreases
morbidity / mortalitymorbidity / mortality
Generally knownGenerally known
and can beand can be
monitoredmonitored
BenefitsBenefits
RisksRisks
91. 91
The safety of ICS is of crucial importance and a balance
between benefits and risks for each individual needs to
be assessed.
Account should be taken of other topical steroid
therapy (e.g. for eczema)when assessing systemic risk
Steroid warning cards should be issued to patients on
higher dose inhaled steroids, and at every review,signs of
systemic steroid toxicity should be actively looked for
92. 92
Administration of medium or high dose ICS (at or
above 400 micrograms BDP a day or equivalent) may be
associated with systemic side effects(e.g growth failure
and adrenal suppression) .
Isolated growth failure is not a reliable indicator of
adrenal suppression and monitoring growth cannot be
used as a screening test of adrenal function
93. 93
Monitor growth (height and weight centile) of
children with asthma on an annual basis.
The lowest dose of inhaled corticosteroids
compatible with maintaining disease control should be
used.
Many patients will benefit more from add-on therapy
than from increasing ICS above doses as low as 200
micrograms BDP/day.
94. 94
In general,while the use of ICS may be associated with
adverse effects (including the potential to reduced bone
mineral density) with careful ICS dose adjustment this
risk is likely to be outweighed by their ability to reduce
the need for multiple bursts of oral corticosteroids .
95. 95
1. Oropharyngeal candidiasis
2. Hoarseness
3. Coughing
To reduce the potential for adverse affects:
Use the lowest dose necessary to maintain control.
Administer with spacers/holding chambers.
Advise patients to (Rinse with water , gargle and
spit out) after inhalation.
Local side effects
98. 98
In children, pMDI and spacer are the preferred method of
delivery of β2 agonists or inhaled corticosteroids.
A face mask is required until the child can breathe
reproducibly using the spacer mouthpiece.
Where this is ineffective a nebuliser may be required
104. Choosing an inhaler device for children with asthma *
-
Age group Preferred device Alternative device
Younger than 4 years
Pressurized metered-dose
inhaler plus dedicated spacer
with face mask
Nebulizer with face mask
4-5 years
Pressurized metered-dose
inhaler plus dedicated spacer
with mouthpiece
Nebulizer with mouthpiece
Older than 6 years
Dry powder inhaler or
breath actuated pressurized
metered-dose inhaler or
pressurized metered-dose
inhaler with spacer with
Nebulizer with mouthpiece
105. 105
Inhaled medications is a waste of money if not used
properly
Poor technique is a barrier to good control
Check at each visit
Don’t rely on patient’s knowledge – ask them to
demonstrate
106. 106
Fate of inhaled drugs – Good Technique
Swallowed
GI tract
Deposited in lung
Lungs
Metabolism or absorption
from the lung
Liver
Oral
bioavailability
Absorption
from gut
First-pass
metabolism
Systemic
Circulation
Mouth
pharynx
mucociliary
clearance
80%
20%
Schematic representation of potential dose distribution
A Guide to Aerosol Delivery Devices for Respiratory Therapists. American Association for
Respiratory Care. 1st Edition. Page 1.
Webpage: http://www.aarc.org/education/aerosol_devices/
Adapted from Barnes et al. AJRCCM 1998;157:S1-S53
107. 107
Fate of inhaled drugs – Good Technique
Swallowed
GI tract
Deposited in lung
Lungs
Metabolism or absorption
from the lung
Liver
Oral
bioavailability
Absorption
from gut
First-pass
metabolism
Systemic
Circulation
Mouth
pharynx
mucociliary
clearance
80%
20%
Schematic representation of potential dose distribution
A Guide to Aerosol Delivery Devices for Respiratory Therapists. American Association for
Respiratory Care. 1st Edition. Page 1.
Webpage: http://www.aarc.org/education/aerosol_devices/
Adapted from Barnes et al. AJRCCM 1998;157:S1-S53
Swallowed
GI tract
Deposited in lung
Lungs
Metabolism or absorption
from the lung
Liver
Oral
bioavailability
Absorption
from gut
First-pass
metabolism
Systemic
Circulation
Mouth
pharynx
mucociliary
clearance
95%
5%
Schematic representation of potential dose distributionAdapted from Barnes et al. AJRCCM 1998;157:S1-S53
A Guide to Aerosol Delivery Devices for Respiratory Therapists. American Association for
Respiratory Care. 1st Edition. Page 1.
Webpage: http://www.aarc.org/education/aerosol_devices/
Fate of inhaled drugs – Poor Technique
108. 108
Stepping down therapy once asthma is controlled is
recommended , but often not implemented leaving some
patients overtreated.
Patients should be maintained at the lowest possible
dose of inhaled corticosteroid.
Reduction in inhaled corticosteroid dose should be slow
as patients deteriorate at different rates.
109. 109
Stepping down therapy
Reductions should be considered every three months,
decreasing the dose by approximately 25–50% each time.
Regular review of patients as treatment is stepped down
is important
110. 110
Practitioners need to balance the benefits and risks for
each individual child while on steroid therapy, and if
the child remains symptom-free for more than a
year, it may be appropriate to decrease and then
stop the steroids and monitor the child regularly
111. 111
• Inhaled steroids are the first choice preventer drug.
– Alternative initial preventer therapies are available but are
less effective than ICS in patients taking short-acting β2
agonists alone :
• LTRA
- In children under five years who are unable to take ICS,
leukotriene receptor antagonists may be used as an
alternative preventer
• Theophyllines have some beneficial effect
• Antihistamines and ketotifen are ineffective
118. Treatment Options for adult Patients
Not Controlled on Inhaled Steroids
Patients not controlled on inhaled steroidsPatients not controlled on inhaled steroidsPatients not controlled on inhaled steroidsPatients not controlled on inhaled steroids
Increase theIncrease the
dose of inhaleddose of inhaled
steroidsteroid
Add leukotrieneAdd leukotriene
receptorreceptor
antagonistsantagonists
Add long-acting
beta2-agonists
AddAdd
theophyllinetheophylline
119. 119
A proportion of patients with asthma may not be
adequately controlled at step 2 (with very low-dose
ICS alone).
Before initiating a new drug therapy practitioners
should recheck adherence , inhaler technique and
eliminate trigger factors.
Initial add on therapy
120. 120
The duration of a trial of add-on therapy will depend on
the desired outcome.
For instance, preventing nocturnal awakening may
require a relatively short trial of treatment (days or
weeks), whereas preventing asthma attacks or
decreasing steroid tablet use may require a longer trial
of therapy (weeks or months).
If there is no response to treatment the drug should be
discontinued.
121. 121
• Many patients will benefit more from add-on
therapy than from increasing ICS above
doses as low as 200 micrograms BDP/day.
123. 123
In children over five,, options for initial add-on
therapy are limited to LABA and LTRA, with evidence
to support both individually, but insufficient evidence
to support use of one over the other
LABA are not licensed for use in children under 5
years of age
124. 124
Add on therapy
• First choice in adults and children over 5
– LABA
• Consider before going above BDP 200mcg/day
• Improves lung function and exacerbations
• Reduces exacerbations
• (LABA) should not be used without ICS
• Children under 5
– LTRA
126. Children’s Healthcare of Atlanta
• Recent data indicating a possible increased risk of
asthma Related death associated with use of LABA in a
small group of individuals has resulted in increased
emphasis on the message that:
• LABA should not be used as monotherapy in asthma &
must only be used in combination with an appropriate
dose of ICS.
127. 127
Long-acting inhaled β2
agonists should only be started in
patients who are already on inhaled corticosteroids, and
the inhaled corticosteroid should be continued.
The benefits of these medicines used in conjunction with
ICS in the control of asthma symptoms outweigh any
apparent risks.
SAFETY OF LONG-ACTING Β2
AGONISTS
128. 128
In efficacy studies, where there is generally good adherence,
there is no difference in efficacy in giving ICS and a LABA
in combination or in separate inhalers.
In clinical practice, however, it is generally considered that
combination inhalers aid adherence and also have the
advantage of guaranteeing that the LABA is not taken
without the ICS
135. 135
If control remains poor on a low dose ICS plus
a LABA:
1)Re-check the diagnosis
2)Assess adherence to existing medication
3)check inhaler technique before stepping up
therapy.
136. 136
If there is no improvement when a LABA is
added, stop the LABA and try:
An increased dose of ICS to low dose (children) if
not already on this dose.
Add LTRA
137. 137
If there is an improvement when a LABA is
added but control remains inadequate:
Continue the LABA and increase the dose of ICS from
very low dose to low dose in children (5–12 years),
if not already on these doses.
Continue the LABA and the ICS and add an LTRA or a
theophylline
140. 140
If control remains inadequate on medium dose (adults) or
low dose (children) of an inhaled corticosteroid plus a
long-acting β2 agonist, the following interventions can
be considered:
§ increase the inhaled corticosteroids to high dose (adults)
or medium dose (children 5-12 years) or
§ add a leukotriene receptor antagonist or
§ add a theophylline
143. 143
Some patients with very severe asthma not controlled
at step 4 with high-dose ICS, and who have also been
tried on or are still taking long-acting -agonists,β
leukotriene antagonists or theophyllines, require
regular long-term steroid tablets.
For the small number of patients not controlled at step 4,
use daily steroid tablets in the lowest dose providing
adequate control.
To get the best results it is necessary to establish the optimal treatment for each patient on an individual basis.
It is important to control symptoms as quickly as possible, so starting treatment at a very low level and building up slowly is not appropriate.
Ask the audience if they have real case histories to demonstrate stepping up treatment to achieve optimal control.
It is equally important not to over-treat.
As with any treatment strategy, the benefits of the regimen must be balanced with the potential risks. The benefits of corticosteroids in asthma management have been well documented. The risks of corticosteroids, which are dependent on the specific agent, its dose, and route of administration, are generally known and can be monitored.
