• 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 leads to recurrent episodes of wheezing, breathlessness,
chest tightness and coughing (particularly at night or early morning).

Clinical symptoms in children 5 years and younger are variable and

non-specific.
• Widespread, variable, and often reversible airflow limitation.
Asthma Inflammation – Cells and Mediators
Mechanism – Asthma Inflammation

Source: Peter J. Barnes, MD

Asthma Inflammation
 Factors Influencing the Development
and Expression of Asthma

Host factors –

• Genetic

1. Genes predisposing to atopy

2. Genes predisposing to airway hyper responsiveness

• Obesity

• Sex
Environmental factors –
• Allergens –

1. Indoor – Domestic mites, furred animals (dogs, cats, mice),

cockroach allergens, fungi, molds, yeasts.

2. Outdoor – Pollens, fungi, molds, yeasts.

• Infections (predominantly viral)

• Occupational sensitizers

• Tobacco smoke

1. Passive smoking

2. Active smoking
• Indoor/Outdoor air pollution

• Diet
 Risk factors of Asthma in younger children
• Sensitization to allergen.

• Maternal diet during pregnancy and/ or lactation.

• Pollutants (particularly environmental tobacco smoke).

• Microbes and their products.

• Respiratory (viral) infections.

• Psychosocial factors.
Prevalence of Childhood asthma
The prevalence of childhood asthma has continued to
increase on the Indian subcontinent over the past 10 yrs
ISAAC Phase 3 Thorax 2007;62:758
 Underdiagnosed/
Misdiagnosed Acceptance of
Fear of steroids Asthma
diagnosis/label

Heterogenous
Heavy
Disease/varying
nebulisation
phenotypes
Issues in
Pediatric Asthma

Choice of right Cough or

device Wheeze

Poor patient/
Oral vs. Inhaled Lack of parent
knowledge & education
time vs.
more patients
 Other Challenges
• Most of the children are below 5 years of age, who cannot tell
their problems

• Parents are proxy story teller, who may mislead the doctor

• PEF cannot be performed in children below 5 years of age

• Fear of addiction to inhalation therapy

• Physicians lack of knowledge and time

 Clinical Features
• Recurrent Wheeze

• Recurrent Cough

• Recurrent Breathlessness

• Activity Induced Cough/Wheeze

• Nocturnal Cough/Breathlessness

• Tightness Of Chest

Asthma by Consensus, IAP 2003

 Symptomatology
• Cough – 90%
• Wheezing – 74%
• Exercise induced wheeze or cough – 55%

Ind J Ped 2002;69:309-12

 Typical features of Asthma
• Afebrile episodes

• Personal atopy

• Family history of atopy or asthma

• Exercise /Activity induced symptoms

• History of triggers

• Seasonal exacerbations

• Relief with bronchodilators Asthma by Consensus, IAP 2003

 When does Asthma begin?
• By 1 year – 26%
• 1-5 years – 51.4%
• > 5 years – 22.3%

77% Of Asthma Begins

In Children Less Than 5
Years

Ind J Ped 2002;69:309-12

 Tools to Diagnosis
• Good History Taking (ASK)

• Careful Physical Examination (LOOK)

• Investigations (PERFORM) – above 5 years only

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

 History taking (Ask)
• Has the child had an attack or recurrent episode of wheezing
(high-pitched whistling sounds when breathing out)?

• Does the child have a troublesome cough which is particularly

worse at night or on waking?

• Is the child awakened by coughing or difficult breathing?

• Does the child cough or wheeze after physical activity (like

games and exercise) or excessive crying?

• Does the child experience breathing problems during a

particular season?
CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
 History taking (Ask)
• Does the child cough, wheeze, or develop chest tightness
after exposure to airborne allergens or irritants e.g. smoke,
perfumes, animal fur?

• Does the child’s cold frequently ‘go to the chest’ or take more
If than
the10answer is ‘yes’ to any of the questions,
days to resolve?
a• diagnosis
Does the child of
use asthma should
any medication be considered
when symptoms occur?
How often?

• Are symptoms relieved when medication is used?

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

 Physical Examination (Look)
• General Attitude And Well Being

• Deformity Of The Chest

• Character Of Breathing

• Thorough Auscultation Of Breath Sounds

• Signs Of Any Other Allergic Disorders On The Body

• Growth And Development Status

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
What all features one should look for specifically?

 Dyspnea
• Expiratory wheeze
• Accessory muscle movement
• Difficulty in feeding, talking, getting to sleep
• Irritability

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

What all features one should look for specifically?

 Cough
• Persistent/ recurrent / nocturnal/ exercise-induced

Associated conditions
• Eczema
• Allergic Rhinitis

 Weight/Height

CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al

 What all investigations can be performed in
asthmatic children? (PERFORM)
Peak expiratory flow rate: It is highly suggestive of
asthma when:

• >15% increase in PEFR after inhaled short acting β2

agonist

• >15% decrease in PEFR after exercise

• Diurnal variation > 10% in children not on

bronchodilator OR
>20% In children on bronchodilator

1. Asthma by Consensus, IAP 2003

2. CHILDHOOD ASTHMA by KHUBCHANDANI R.P. et al
How to rule out the mimics?
 The Early Wheezer (< 3Years)
WALRI (wheeze associated Early onset asthma
lower respiratory tract infections)
or Viral Associated wheeze

• Febrile episodes • Afebrile episodes

• Personal atopy absent • Personal atopy present
• Family history of asthma / atopy
absent • Family history of asthma /
• Variable response to atopy present
bronchodilators • Predictable good response to
bronchodilators

Asthma by Consensus, IAP 2003

 Bronchiolitis in children

• Commonest cause of wheezing in children between 6

months to 3 years

• Resembles asthma

• Diagnosis essentially clinical

• Common viruses causing bronchiolitis in children:

– Respiratory syncytial virus (RSV)
 Clinical manifestations of RSV disease
• Rhinorrhoea

• Pharyngitis

• Cough

• Low grade fever

• Wheezing

• Increased respiratory rate

 Differential diagnosis
Age Common Uncommon Rare
Less than Bronchiolitis Aspiration pneumonia Asthma
6 months Gastro- Bronchopulmonary dysplasia Foreign body aspiration
esophageal Congestive heart failure
reflux Cystic fibrosis
6 months - Bronchiolitis Aspiration pneumonia Congestive heart failure
2 years Foreign body Asthma
aspiration Bronchopulmonary dysplasia
Cystic fibrosis
Gastro-esophageal reflux
2 - 5 years Asthma Cystic fibrosis Aspiration pneumonia
Foreign body Gastro-esophageal reflux Bronchiolitis
aspiration Viral pneumonia Congestive heart failure
Gastro-esophageal reflux

IPAG 2007
 Co morbid conditions
• Allergic Rhinitis
 Colds, ear infections
 Sneezing in the morning
 Blocked nose, snoring, mouth breathing
• Gastro esophageal reflux (GER)
 Nocturnal cough followed by vomiting
• Eczema
 Guidelines for confirming
Childhood Asthma diagnosis
 IPAG Diagnosis
• Characterize the problem
• Establish chronicity
• Exclude non-respiratory or other causes
• Exclude infectious diseases
• Consider patient’s age
• Use diagnostic aids

International Primary Care Airways Group 2007

 Early Childhood Asthma Diagnosis
(below 6 years)
Diagnostic Tool Findings that Support Diagnosis

Differential The diagnosis of asthma in children under age 6 is primarily

diagnosis one of exclusion.
Physical If the child does not appear acutely ill and is growing, and
examination there is no evidence specifically indicating another cause of
symptoms, a trial of therapy is warranted.
Trial of therapy Improvement with treatment supports a diagnosis of
(bronchodilators) asthma.
Frequent Health care professionals should always be prepared to
reassessment reconsider the diagnosis if management is ineffective or if
the clinical situation changes.

IPAG 2007
Childhood Asthma Diagnosis (6-14 years)

IPAG 2007
Childhood Asthma Diagnosis (6-14 years)

IPAG 2007
 NORDIC CONSENSUS
Confirm Asthma if,

If the child is having 3 attacks of airway obstruction in

last 1 yr.

If the child gets 1 attack of asthmatic symptoms after

the age of 2 yrs.

Irrespective of age in an attack in children with

allergy (eczema, food allergy etc.) or history of atopy.

If the child does not become free of symptoms when

infection has ceased or has persistent symptoms for
more than a month.

Respir Med. 2000;94(4):299-327

 IAP GUIDELINES
3 Or More Episodes Of Airflow Obstruction With Several Of The
Following:
• Afebrile Episodes
• Personal Atopy Or Family H/O Atopy / Asthma
• Nocturnal Exacerbations
• Exercise/Activity Induced Symptoms
• Trigger Induced Symptoms
• Seasonal Exacerbations
• Relief With Bronchodilators ± Oral Steroid

Asthma by Consensus, The Indian Academy of Pediatrics 2003

 GINA
• The following symptoms are highly suggestive of a diagnosis of
asthma:
– frequent episodes of wheeze (more than once a month)
– activity-induced cough or wheeze
– nocturnal cough in periods without viral infections
– absence of seasonal variation in wheeze
– symptoms that persist after age 3

• A simple clinical index based on:

– presence of a wheeze before the age of 3
– presence of one major risk factor (parental history of asthma
or eczema) or two of three minor risk factors (eosinophilia,
wheezing without colds, and allergic rhinitis) has been
shown to predict the presence of asthma in later childhood

Global Initiative for Asthma 2008

 GINA
• A useful method for confirming the diagnosis of asthma in
children 5 years and younger is a trial of treatment with short-
acting bronchodilators and inhaled glucocorticosteroids

• Children 4 to 5 years old can be taught to use a PEF meter, but

to ensure reliability parental supervision is required

• Use of spirometry and other measures recommended for older

children such as airway responsiveness and markers of airway
inflammation is difficult and several require complex
equipment making them unsuitable for routine use

GINA 2008
 BTS

• Initial assessment of children suspected of having asthma

should be based on:
– presence of key features in the history and clinical examination
– careful consideration of alternative diagnoses

• Using a structured questionnaire may produce a more

standardised approach to the recording of presenting clinical
features and the basis for a diagnosis of asthma

British Thoracic Society 2008

 Clinical features that increase the probability of asthma
• More than one of the following symptoms: wheeze, cough, difficulty
breathing, chest tightness, particularly if these symptoms:
◊ are frequent and recurrent
◊ are worse at night and in the early morning
◊ occur in response to, or are worse after, exercise or other triggers, such
as exposure to pets, cold or damp air, or with emotions or laughter
◊ occur apart from colds

• Personal history of atopic disorder

• Family history of atopic disorder and/or asthma

• Widespread wheeze heard on auscultation

• History of improvement in symptoms or lung function in response to

adequate therapy

BTS 2008
 Clinical features that lower the probability of asthma
• Symptoms with colds only, with 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 peak expiratory flow (PEF) or spirometry when symptomatic

• No response to a trial of asthma therapy

• Clinical features pointing to alternative diagnosis

BTS 2008
Asthma Phenotypes
 What do you understand by
phenotypes?

• Phenotypes
“the visible properties of an organism that are
produced by the interaction of genotype and
the environment”
-Webster’s New Collegiate Dictionary
 Pre-school “Asthma phenotypes”
Wheezing is common in young children but is it asthma?

Atopic asthma
Prevalence of wheeze

Non-atopic viral
induced wheeze

Transient wheeze
0 3 6 11
Age Years
Martinez Pediatrics 2002;109:362
 Asthma phenotypes in childhood
Transient
• linked with smoking during pregnancy
• viral RTIs
• not associated with atopy
• remits by school age
• Impaired lung function at birth
 Asthma phenotypes in childhood
Persistent
• not associated with atopy:
- associated with viral RTIs (RSV),
- may remit during school age
- LTRAs have been found to be beneficial

• associated with atopy:

- bronchial responsiveness, impaired lung function
- parental history of asthma
- most ongoing during school age
 Classification of Asthma
• The goal of the treatment is to achieve and maintain control for
prolonged periods with due regard to the safety of treatment, potential for
adverse effects, and the cost of treatment required to achieve this goal.

• Assessment of asthma control should include control of the clinical

manifestations, control of the expected future risk to the patient such as
exacerbations, accelerated decline in the lung function, and side-effects
of the treatment.

• The achievement of good clinical control of asthma leads to reduced risk

of exacerbations.
 Controlled Partly controlled
Characteristic Uncontrolled
(All of the following) (Any present in any week)

More than
Daytime symptoms None (2 or less / week)
twice / week

Limitations of activities None Any

3 or more features of
Nocturnal symptoms /
None Any partly controlled
awakening
asthma present in any
Need for rescue / More than
None (2 or less / week) week*
“reliever” treatment twice / week

< 80% predicted or

Lung function#
Normal personal best (if known)
(PEF or FEV1)
on any day

* Exacerbation
Any exacerbation should be prompt review ofNone Onethat
maintenance treatment to ensure oritmore / year
is adequate. 1 in any week
#
Lung function is not a reliable test for children 5 years and younger . GINA 2009
 Levels of Asthma Control in Children 5 years and younger
Characteristic Controlled (All of the following) Partly Controlled (Any Uncontrolled
measure present in any (Three or more of features of
week) partly controlled asthma in any
week)
Daytime symptoms None More than twice/week More than twice/week
– wheezing, cough, (less than twice/week, typically (typically for short periods (typically last minutes of hour or
difficult breathing for short periods of on the order on the order minutes and recur, but partially or fully
minutes and rapidly relieved by rapidly relieved by use of a relieved with rapid-acting
use of a rapid-acting rapid-acting bronchodilator) bronchodilators)
bronchodilator)

Limitation of None Any Any

activities (child is fully active, plays and (may cough, wheeze, or (may cough, wheeze, or have
runs without limitation or have difficulty breathing difficulty breathing during
symptoms) during exercise, vigorous exercise, vigorous play or
play or laughing) laughing)

Nocturnal None Any Any

symptoms/ (no nocturnal coughing during (typically coughs during (typically coughs during
awakening sleep) sleep/wakes with cough, sleep/wakes with cough,
wheezing and/or difficult wheezing and/or difficult
breathing) breathing)

Need for Less than/equal to 2 days/week > 2 days/week > 2 days/week

reliever/rescue
treatment
• Examples of validated measures for assessing clinical control of asthma
include –
• Asthma Control Test (ACT) – www.asthmacontrol.com

• Childhood Asthma Control test (C - Act)

• Asthma Control Questionnaire (ACQ) – www.qoltech.co.uk/asthma1.htm

• Asthma Therapy Assessment Questionnaire (ATAQ) –

www.ataqinstrument.com

• Asthma Control Scoring System

 Asthma Treatments

• Classified into Controllers and Relievers

• Controllers – medications to be taken on daily long term basis.

• Relievers – medications to be used on as-needed basis to

relieve symptoms quickly.
• Asthma treatment can be administered in different ways – inhaled,
oral, or by injection.
• Advantage of inhaled therapy - drugs are delivered directly into the
airways, producing higher local concentrations with significantly less
risk of systemic side effects.
• Inhaled medications for asthma are available as pressurized MDIs,
DPIs, soft mist inhalers and nebulized or ‘wet’ aerosols.
• CFC inhaler devices are being phased out due to the impact of CFCs
upon the atmospheric ozone layer, and are being replaced by HFA
devices.
• Choosing an inhaler device for children with asthma *-

Age group Preferred device Alternative device

Pressurized metered-dose inhaler

Younger than 4 years plus dedicated spacer with face Nebulizer with face mask
mask

Pressurized metered-dose inhaler

4-5 years plus dedicated spacer with Nebulizer with mouthpiece
mouthpiece

Dry powder inhaler or breath

actuated pressurized metered-
dose inhaler or pressurized Nebulizer with mouthpiece
Older than 6 years
metered-dose inhaler with spacer
with mouthpiece

*
Based on efficacy of drug delivery, cost effectiveness, safety, ease of use, and convenience . GINA 2009
 Asthma management and prevention
• The goals for successful management of asthma are
1. Achieve and maintain control of symptoms

2. Maintain normal activity levels, including exercise

3. Maintain pulmonary function as close to normal as possible

4. Prevent asthma exacerbations

5. Avoid adverse effects from asthma medications

6. Prevent asthma mortality

Five interrelated components of therapy are required to achieve
and maintain control of asthma-

1. Develop Patient/Doctor partnership

2. Identify and reduce exposure to risk factors

3. Assess, treat, and monitor asthma

4. Manage asthma exacerbations

5. Special considerations
 Develop Patient/Doctor partnership -
• Effective management of asthma requires the development of a

partnership between the person with asthma and the health care

team.

• Patients can learn to –

1. Avoid risk factors

2. Take medications correctly

3. Understand the difference between controller and reliever

medications

4. Monitor their status using symptoms and, if relevant, PEF

5. Recognize signs that asthma is worsening and take action

6. Seek medical help as appropriate

• Education should be integral part of all interactions between health care
professional and patients.

• Using variety of methods such as discussions, demonstrations, written

materials, group classes, video/audio tapes, dramas and patient support
groups helps reinforce educational messages.

• Health care professional and patients should prepare a written personal

asthma action plan that is medically appropriate and practical.

• Additional self-management plans can be found on –

1. www.asthma.org.uk
2. www.nhlbisupport.com/asthma/index.html
3. www.asthmaz.co.nz
Identify and reduce exposure to risk factors -
• Measures to prevent the development of asthma and asthma
exacerbations by avoiding or reducing exposure to risk factors
should be implemented wherever possible.

• Reducing patients exposure to some categories of risk factors

improves the control of asthma and reduces medication needs.
Assess, Treat and Monitor Asthma –

• The goal of asthma treatment can be reached in most patients

through a continuous cycle that involves – assessing, treating and
monitoring asthma.

• Each patient should be assessed to establish his/her current

treatment regimen, adherence to the current regimen, and level of
asthma control.

• Each patient is assigned to one of five treatment steps.

• At each treatment step, reliever medication should be provided for

quick relief of symptoms as needed.
• Inhaled medications are preferred because they deliver drugs
directly to the airways where they are needed, resulting in
potent therapeutic effects with fewer systemic side effects.

• Inhaled medications for asthma are available as pressurized

MDIs, breath actuated MDIs, DPIs and nebulizers.

• Spacer devices make inhalers easier to use and reduce

systemic absorption and side effects of ICS.

• Patients should be demonstrated about the use of devices.

• Monitoring is essential to maintain control and establish the lowest step and
dose of treatment to minimize cost and maximize safety.

• If asthma is not controlled, step up the treatment. Improvement is generally

seen within 1 month.

• If asthma is partly controlled, consider stepping up treatment, depending

more effective options available, safety and cost of possible treatment and
patient’s satisfaction with the level of control achieved.

• If controlled asthma is maintained for at least 3 months, step down with a

gradual, stepwise reduction in treatment. The goal is to decrease treatment
to the least medication necessary to maintain control.
 Asthma management approach based on control
for children 5 years and younger

Asthma education, Environmental approach, and as needed rapid acting beta -agonists

Uncontrolled or only partly

Controlled on as needed rapid Partly controlled on as needed
controlled on low - dose inhaled
acting beta2-agonists rapid acting beta2-agonists
glucocorticosteroid

Controller options

Continue as needed rapid acting Low – dose inhaled Double Low – dose inhaled
beta2-agonists glucocorticosteroid glucocorticosteroid

Low – dose inhaled

Leukotriene modifier glucocorticosteroid plus Leukotriene
modifier
 To summarize…

Diagnosis

• Asthma is an inflammatory illness

• Diagnosis of asthma is clinical, and relies on history

• All asthma does not wheeze

• In children < 3 yrs, WALRI is an important differential diagnosis

• 2 out of 3 children outgrow their asthma

• A family history of asthma / atopy increases risk of asthma

 To summarize…
Long term management
• Patient education is a very important part of asthma management
• Drugs control, but do not cure asthma
• Clinical grading over time, decides long term management plan
• Mild intermittent asthma does not merit controllers
• Inhaled steroids are mainstay of long term asthma management
• Treatment should be stepped up or stepped down depending upon patient
response
Thank You