Hassan Baroud Family Medicine - Board eligible 10.03.2022 • This powerpoint was prepared using Global Initiative for Asthma (GINA),2021 report.
• The section (children 5 years and younger)
was targeted as, I saw appropriate for the targeted topic in the available time. Why we are addressing this topic in antibiotic stewardship training ? It is a core pulmonology topic! • Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity from chronic disease as measured by school absences, emergency department visits and hospitalizations. • Asthma often begins in early childhood; in up to half of people with asthma, symptoms commence during childhood. • Onset of asthma is earlier in males than females. • Atopy is present in the majority of children with asthma who are over 3 years old, What is the definition of bronchial asthma? • Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. • It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, • together with variable expiratory airflow limitation. These variations are often triggered by factors such as exercise, allergen or irritant exposure, change in weather, or viral respiratory infections. Bronchial Asthma in children
Hassan Baroud Family Medicine - Board eligible 10.03.2022 • This powerpoint was prepared using Global Initiative for Asthma (GINA),2021 report.
• The section (children 5 years and younger)
was targeted as, I saw appropriate for the targeted topic in the available time. Why we are addressing this topic in antibiotic stewardship training ? It is a core pulmonology topic! • Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity from chronic disease as measured by school absences, emergency department visits and hospitalizations. • Asthma often begins in early childhood; in up to half of people with asthma, symptoms commence during childhood. • Onset of asthma is earlier in males than females. • Atopy is present in the majority of children with asthma who are over 3 years old, What is the definition of bronchial asthma? • Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. • It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, • together with variable expiratory airflow limitation. These variations are often triggered by factors such as exercise, allergen or irritant exposure, change in weather, or viral respiratory infections. Wheezing in child=child asthma? Viral-induced wheezing
• Recurrent wheezing occurs in a large proportion of
children aged 5 years or younger. It is typically associated with upper respiratory tract infections (URTI), which occur in this age group around 6–8 times per year. • Some viral infections (respiratory syncytial virus and rhinovirus) are associated with recurrent wheeze throughout childhood. • Wheezing in this age group is a highly heterogeneous condition, and not all wheezing indicates asthma. • . Viral-induced wheezing
• A large proportion of wheezing episodes in
young children is virally induced whether the child has asthma or not. Therefore, deciding when wheezing with a respiratory infection is truly an isolated event or represents a recurrent clinical presentation of childhood asthma may be difficult CLINICAL DIAGNOSIS OF ASTHMA
• It may be challenging 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, • and it is not possible to routinely assess airflow limitation or bronchodilator responsiveness in this age group. • A probability-based approach, based on the pattern of symptoms during and between viral respiratory infections, may be helpful for discussion with parents/carers DIFFERENTIAL DIAGNOSIS MEDICATIONS FOR SYMPTOM CONTROL AND RISK REDUCTION • Good control of asthma can be achieved in the overwhelming majority of young children with a pharmacological intervention strategy. • This should be developed in a partnership between the family/carer and the health care provider. • As with older children and adults, medications comprise only one component of asthma management in young children; other key components include education, skills training for inhaler devices and adherence, • non-pharmacological strategies including environmental control where appropriate, regular monitoring, and clinical review REVIEWING RESPONSE AND ADJUSTING TREATMENT • Assessment at every visit should include asthma symptom control and risk factors , and side-effects. • The child’s height should be measured every year, or more often. • Asthma-like symptoms remit in a substantial proportion of children of 5 years or younger, so the need for continued controller treatment should be regularly assessed (e.g. every 3–6 months) (Evidence D). • If therapy is stepped-down or discontinued, schedule a follow-up visit 3–6 weeks later to check whether symptoms have recurred, as therapy may need to be stepped-up or reinstituted (Evidence D). • Marked seasonal variations may be seen in symptoms and exacerbations in this age-group. For children with seasonal symptoms whose daily long- term controller treatment is to be discontinued (e.g. 4 weeks after their season ends), the parent/carer should be provided with a written asthma action plan detailing specific signs of worsening asthma, the medications that should be initiated to treat it, and when and how to contact medical care. flare-up or exacerbation • A flare-up or exacerbation of asthma in children 5 years and younger is defined as: • an acute or sub-acute deterioration in symptom control that is sufficient to cause distress or risk to health, and necessitates a visit to a health care provider or requires treatment with systemic corticosteroids. When to suspect an exacerbation? • Early symptoms of an exacerbation may include any of the following: • An acute or sub-acute increase in wheeze and shortness of breath • An increase in coughing, especially while the child is asleep • Lethargy or reduced exercise tolerance • Impairment of daily activities, including feeding • A poor response to reliever medication. • Upper respiratory symptoms frequently precede the onset of an asthma exacerbation, indicating the important role of viral URTI in precipitating exacerbations in many, although not all, children with asthma. • In a randomized controlled trial of acetaminophen versus ibuprofen, given for pain or fever in children with mild persistent asthma, there was no evidence of a difference in the subsequent risk of flare-ups or poor symptom control. INITIAL HOME MANAGEMENT OF ASTHMA EXACERBATIONS • Initial management includes an action plan to: • enable the child’s family members and carers to recognize worsening asthma • recognize when it is severe, • initiate treatment,:Inhaled SABA via a mask or spacer, and review response • identify when urgent hospital treatment is necessary, Need for urgent medical attention • The child is acutely distressed • The child’s symptoms are not relieved promptly by inhaled bronchodilator • The period of relief after doses of SABA becomes progressively shorter • A child younger than 1 year requires repeated inhaled SABA over several hours. Discharge and follow up after an exacerbation • Before discharge, the condition of the child should be stable (e.g. he/she should be out of bed and able to eat and drink without problems). • Prior to discharge from the emergency department or hospital, family/carers should receive the following advice and information • Instruction on recognition of signs of recurrence and worsening of asthma. • The factors that precipitated the exacerbation should be identified, and strategies for future avoidance of these factors implemented. • A written, individualized action plan, including details of accessible emergency services • Further treatment advice explaining that: o SABAs should be used on an as-needed basis, but the daily requirement should be recorded to ensure it is being decreased over time to pre-exacerbation levels. o ICS has been initiated where appropriate (at twice the low initial dose for the first month after discharge, then adjusted as needed) or continued, for those previously prescribed controller medication. • A supply of SABA and, where applicable, the remainder of the course of oral corticosteroid, ICS or LTRA • A follow-up appointment within 1–2 days and another within 1–2 months, depending on the clinical, social and practical context of the exacerbation Any role for routine prescribing of antibiotic in bronchial asthma management? Surely, NO
