Overview/Definition
Definition:
• Asthma is a heterogeneous chronic inflammatory airway disease characterized by variable airway obstruction, bronchial hyperresponsiveness, and airway inflammation
Most common chronic disease of childhood affecting 5-15% of children globally
Requires step-wise management approach based on severity assessment and control levels.
Epidemiology:
• Global prevalence ranges from 5-15% in children with increasing incidence in developing countries including India
Affects approximately 15-20 million children in India with urban prevalence higher than rural areas
Male predominance in childhood (2:1) that reverses after puberty
Leading cause of school absenteeism and pediatric hospitalizations.
Age Distribution:
• Can present at any age but often begins in early childhood with 80% developing symptoms before age 6 years
Wheezing in infants <3 years may represent transient wheeze rather than true asthma
School-age children commonly develop allergic asthma
Adolescent-onset asthma may persist into adulthood.
Clinical Significance:
• High-yield topic for DNB Pediatrics and NEET SS examinations focusing on GINA guidelines, step-wise management, inhaler device selection, and peak flow monitoring
Essential for understanding chronic disease management, medication adherence, and quality of life optimization in pediatric practice.
Age-Specific Considerations
Newborn:
• Asthma diagnosis rarely made in neonatal period as symptoms usually represent other conditions like bronchopulmonary dysplasia, congenital anomalies, or viral infections
Family history of asthma increases risk
Maternal asthma during pregnancy may affect neonatal respiratory outcomes
Early exposure to allergens and pollutants increases future asthma risk.
Infant:
• Recurrent wheezing in infants often labeled as "wheezy bronchitis" or "reactive airway disease" rather than asthma
True asthma diagnosis challenging as symptoms overlap with viral bronchiolitis
Inhaler technique requires spacer devices with face masks
Growth monitoring important as systemic steroids may affect development.
Child:
• Peak age for asthma diagnosis and management complexity
School-age children can cooperate with peak flow monitoring and inhaler technique instruction
Allergic sensitization common with environmental trigger identification important
Physical activity limitations may affect social development and self-esteem requiring careful balance.
Adolescent:
• Transition period with increased responsibility for self-management and medication compliance challenges
Peer pressure and body image concerns may affect treatment adherence
Sports participation important consideration
Pregnancy planning discussions needed for females
Preparation for transition to adult care.
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Clinical Presentation
Symptoms:
• Classic triad: wheeze, cough (often nocturnal or early morning), shortness of breath with variable severity and frequency
Exercise-induced symptoms, trigger-related symptoms (allergens, irritants, emotions)
Chest tightness, fatigue, sleep disturbance
Infants may present with feeding difficulties and irritability.
Physical Signs:
• During acute episodes: wheezing (may be absent in severe asthma), prolonged expiration, use of accessory muscles, nasal flaring, cyanosis
Between episodes: often normal examination or mild expiratory wheeze
Growth parameters usually normal unless poorly controlled
Allergic signs: eczema, allergic rhinitis.
Severity Assessment:
• Intermittent asthma: symptoms <2 days/week, nighttime awakening <2 nights/month, SABA use <2 days/week, normal activity
Mild persistent: symptoms >2 days/week but not daily, nighttime awakening 3-4 nights/month
Moderate persistent: daily symptoms, nighttime awakening >1 night/week but not nightly
Severe persistent: symptoms throughout day, frequent nighttime awakening, extremely limited activity.
Differential Diagnosis:
• Viral bronchiolitis (age <2 years, seasonal pattern), pneumonia (fever, consolidation), foreign body aspiration (sudden onset, unilateral wheeze), gastroesophageal reflux, vocal cord dysfunction, exercise-induced bronchospasm without asthma, cystic fibrosis, primary ciliary dyskinesia, cardiac causes of wheeze.
Diagnostic Approach
History Taking:
• Detailed symptom history: frequency, severity, triggers, timing, response to bronchodilators
Family history of asthma, allergies, eczema
Environmental exposures: pets, smoking, pollution, occupational hazards
Previous hospitalizations, ICU admissions, emergency visits
Current medications and adherence patterns
Quality of life impact assessment.
Investigations:
• Peak flow monitoring (age >5 years): personal best establishment, daily monitoring during exacerbations
Spirometry with bronchodilator response (age >6 years): FEV1 improvement >12% and >200mL suggests reversibility
Fractional exhaled nitric oxide (FeNO) when available
Allergy testing (skin prick tests, specific IgE) for trigger identification.
Normal Values:
• Peak flow varies by height, age, and gender using predicted values or personal best (typically 400-600 L/min in adolescents)
Normal FEV1 >80% predicted, FEV1/FVC ratio >0.8 in children
Bronchodilator response <12% improvement in normal individuals
Normal FeNO <25 ppb in children, <50 ppb in adults.
Interpretation:
• Asthma diagnosis requires: reversible airway obstruction (spirometry showing >12% FEV1 improvement post-bronchodilator), airway hyperresponsiveness, or typical clinical presentation with response to asthma therapy
Peak flow variability >20% suggests poor control
FeNO elevation >35 ppb in children suggests eosinophilic inflammation.
Management/Treatment
Acute Management:
• Mild exacerbation: SABA (salbutamol) 2-10 puffs via MDI+spacer every 20 minutes up to 1 hour, prednisolone 1-2 mg/kg (max 40mg) daily for 3-5 days
Moderate exacerbation: continuous nebulized salbutamol 0.15 mg/kg/hr, systemic steroids, oxygen if needed
Severe: IV magnesium sulfate 25-50 mg/kg over 20 minutes, consider aminophylline.
Chronic Management:
• Step 1: SABA PRN
Step 2: Low-dose ICS daily + SABA PRN
Step 3: Low-dose ICS + LABA or medium-dose ICS
Step 4: Medium-dose ICS + LABA + LTRA or high-dose ICS + LABA
Step 5: Add-on therapy (anti-IgE, anti-IL5, oral steroids)
Step down when controlled >3 months.
Lifestyle Modifications:
• Trigger avoidance: allergen identification and environmental control measures
House dust mite reduction, pet allergen control, smoking cessation
Physical activity encouraged with pre-exercise SABA if needed
Weight management for overweight children
Influenza vaccination annually
Proper nutrition and adequate sleep.
Follow Up:
• Newly diagnosed: 2-6 weeks after treatment initiation, then every 3-6 months when stable
Medication adjustments based on control assessment using validated tools (ACT, GINA assessment)
Annual spirometry in children >6 years
Step down therapy when well-controlled >3 months
Emergency action plan provided to all families.
Age-Specific Dosing
Medications:
• Salbutamol MDI: 2-10 puffs (100 mcg/puff) via spacer PRN, nebulized 0.1-0.15 mg/kg (min 2.5mg, max 5mg)
Prednisolone: 1-2 mg/kg/day (max 40mg) for 3-5 days
Fluticasone low-dose: 2-11 years 50-100 mcg BID, >12 years 100-250 mcg BID
Montelukast: 2-5 years 4mg daily, 6-14 years 5mg daily, >15 years 10mg daily.
Formulations:
• Salbutamol: MDI 100 mcg/puff (preferred with spacer), nebulizer solution 0.5%
Prednisolone tablets 5mg, oral solution 3mg/5mL
Fluticasone: MDI 25, 125, 250 mcg/puff, DPI 50, 100, 250 mcg/dose
Budesonide: nebulizer suspension 0.25, 0.5mg/2mL
Montelukast chewable tablets 4, 5mg, tablets 10mg.
Safety Considerations:
• ICS monitoring for growth velocity (annual height measurement), oral thrush (rinse mouth after use), hoarse voice
Systemic steroid short courses generally safe but avoid prolonged use
LABA never used without ICS due to increased mortality risk
Monitor heart rate with high-dose SABA use
Proper inhaler technique essential for drug delivery.
Monitoring:
• Asthma control assessment using standardized questionnaires (ACT score >20 indicates good control)
Peak flow monitoring twice daily during exacerbations
Growth velocity monitoring annually in children on ICS
Side effect monitoring: oral examination for thrush, voice assessment
Medication adherence assessment and inhaler technique review.
Prevention & Follow-up
Prevention Strategies:
• Primary prevention: avoid maternal smoking during pregnancy, breastfeeding promotion, reduce early antibiotic exposure, maintain healthy indoor air quality
Secondary prevention: allergen avoidance, trigger identification and control, proper medication adherence
Tertiary prevention: prevent exacerbations through optimal control and emergency preparedness.
Vaccination Considerations:
• Annual influenza vaccination recommended for all children with asthma
Standard childhood immunizations should continue as scheduled
COVID-19 vaccination recommended as asthma may increase risk of severe illness
Live vaccines generally safe unless on high-dose systemic steroids (>2mg/kg/day prednisolone equivalent for >2 weeks).
Follow Up Schedule:
• Initial management: 2-6 weeks after starting treatment
Stable controlled asthma: every 3-6 months for medication review and control assessment
Poorly controlled: monthly visits until improvement achieved
Exacerbations: follow-up within 1-7 days depending on severity
Annual comprehensive review with spirometry if appropriate.
Monitoring Parameters:
• Symptom control assessment using validated questionnaires (ACT, GINA control assessment)
Peak flow monitoring when indicated (personal best, daily during exacerbations)
Growth velocity annually in children on ICS therapy
Inhaler technique assessment at each visit
Emergency action plan review and updates
School performance and quality of life assessment.
Complications
Acute Complications:
• Life-threatening asthma attack with respiratory failure requiring mechanical ventilation
Status asthmaticus refractory to standard bronchodilator therapy
Pneumothorax or pneumomediastinum from severe coughing or barotrauma
Medication side effects: tremor and tachycardia from excessive SABA use, systemic effects from high-dose steroids.
Chronic Complications:
• Growth suppression from poorly controlled asthma or excessive steroid use
Airway remodeling leading to irreversible obstruction in severe chronic asthma
Psychosocial impacts including anxiety, depression, social isolation
School absenteeism affecting academic performance
Exercise limitation affecting physical development and peer relationships.
Warning Signs:
• Signs of poor control: increasing symptom frequency, nocturnal awakening, increased SABA use, decreased peak flow, exercise limitation
Emergency signs: inability to speak in sentences, accessory muscle use, cyanosis, altered mental status, peak flow <50% personal best
Medication-related: growth deceleration, persistent oral thrush, voice changes.
Emergency Referral:
• Immediate emergency referral for: severe respiratory distress, inability to speak, altered consciousness, cyanosis, peak flow <33% personal best
Urgent referral for: asthma poorly controlled despite step 4-5 treatment, frequent exacerbations requiring systemic steroids, suspected adverse drug reactions, significant psychosocial concerns affecting management.
Parent Education Points
Counseling Points:
• Explain asthma as chronic condition requiring daily management even when feeling well, like diabetes requiring insulin
Emphasize difference between controller medications (prevent symptoms) and rescue medications (treat symptoms)
Discuss realistic expectations: goal is normal activity and minimal symptoms, not cure
Address common myths and fears about medications.
Home Care:
• Environmental trigger control: dust mite reduction (covers, washing bedding weekly in hot water), pet allergen management, smoking cessation, mold control
Recognize early warning signs of exacerbations
Maintain written asthma action plan with clear instructions for medication adjustments
Ensure rescue medications available at home, school, and during travel.
Medication Administration:
• Proper MDI technique: shake inhaler, exhale fully, place mouthpiece in mouth and seal lips, actuate while inhaling slowly and deeply, hold breath 10 seconds
Spacer use improves drug delivery and reduces side effects
Rinse mouth after ICS use to prevent thrush
Store medications properly avoiding extreme temperatures.
When To Seek Help:
• Seek immediate medical attention for: difficulty breathing or speaking, lips or face turning blue, peak flow in red zone (<50% personal best), rescue medications not helping after 1 hour
Contact healthcare provider for: symptoms worsening over days, increased rescue medication use, nighttime awakening from asthma, concerns about medication side effects.