Asthma Basics
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The document discusses asthma triggers and diagnosing asthma. It provides information on the most common indoor asthma triggers like dust mites, pet dander, cockroaches, mold, and tobacco smoke. It notes that diagnosing asthma requires identifying recurrent symptoms like coughing, wheezing, and shortness of breath that are at least partially reversible with treatment. The diagnosis can be challenging for young children as lung function tests are difficult.
Asthma Basics
- 2. Dr. Ashraf El Adawy Consultant Chest Physician TB TEAM EXPERT – WHO Egypt
- 4. ©2004 Children’s Hospital and Health System / FAM Allies. are things that make asthma worse. Remember, everyone is different! Triggers …
- 5. 3 kinds of asthma triggers Allergens Infections Irritants
- 6. Common Asthma Triggers Allergens Molds Dust Mites Animals Pollen Food Pests (cockroaches) Irritants Secondhand smoke Strong odors Ozone Chemicals/cleaning compounds
- 7. Other asthma triggers Viral respiratory infections o Colds o Flu Exercise Changes in weather o Cold air o Wind o Humidity
- 8. Indoor Air Pollution A Major Health Concern Most people spend 90% of their time indoors Toxin levels indoors may be higher than outdoors because of energy tight buildings Most of the common asthma triggers are found indoors
- 9. 5 Most Common Indoor Environmental Triggers Secondhand Smoke Dust Mites Mold Pets/Animals Cockroaches
- 10. Animal allergens Dust mites Cockroach allergens Indoor fungi Tobacco smoke 5 Most Common Indoor Environmental Triggers
- 11. • Too small to be seen • Found almost everywhere! • Live in soft bedding • Feed on dead skin cells • Mites and mite droppings can be asthma triggers • Live in warm, humid places Dust Mites
- 16. Pet Dander
- 18. This trigger’s dander and saliva make asthma worse. Dogs and cats
- 24. Secondhand Smoke
- 25. Evidence suggests an association between environmental tobacco smoke exposure (ETS) and exacerbations of asthma among school-aged, older children, and adults. Evidence shows an association between environmental tobacco smoke exposure and asthma development among pre-school aged children.
- 28. Other Indoor Triggers Household Products Vapors from cleaning solvents (non-water based), paint, liquid bleach, mothballs, glue Spray deodorants, perfume bleach, pesticides, oven cleaners, drain openers, aerosol spray products
- 36. This pollutant can make allergic responses more severe. Diesel air pollution
- 43. Combustion Appliances Nitrogen dioxide is an odorless gas that can irritate your eyes, nose, and throat and may cause shortness of breath. This gas can come from the use of appliances that burn fuels, such as gas, wood, and kerosene
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- 54. Dust of book depo- sitories
- 65. What Can Make Asthma Worse? • Changes in weather and temperature • Infections in the upper airways, such as colds • Physical expressions of strong feelings (crying or laughing hard, yelling) Not all factors affect all people. It’s important to identify what affects a particular student’s asthma.
- 66. § ß-Blockers Exposure to sensitizing drugs § Aspirin and NSAIDS § ACE inhibitors
- 68. What is Asthma? A disease that: Is chronic Produces recurring episodes of breathing problems – Coughing – Wheezing – Chest tightness – Shortness of breath
- 69. Make the asthma diagnosis Episodic airflow obstruction Airflow obstruction is at least partially reversible Alternative diagnoses are excluded Inflammation causes recurrent episodes of coughing, wheezing, breathlessness, and chest tightness. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. -- NAEPP EPR3 2007 Definition of asthma
- 70. The prevalence or rate of asthma is …… On the rise or increasing
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- 75. Allergic Disease is Epidemic H O W C O M M O N A R E A L L E R G I E S ? One in five Americans – 55 million people – have allergies to airborne triggers such as pollen, mold, dust mites or animal dander. VERY
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- 77. Changes in the prevalence of allergic diseases combinations in 6-7 yrs old children Kudzyte et al. Pediatric Pulmonology and Allergology 2004 A+ADAR+AD 0 0.5 % 1994-95 y 2001-02 y A+AR+AD A+AR * * * *p<0.05 ISAAC (International Study of Asthma and Allergy in Childhood)
- 78. Changes in the prevalence of allergic diseases combinations in 13-14 yrs old children Kudzyte et al. Pediatric Pulmonology and Allergology 2004 A+ADAR+AD 0 0.5 % 1994-95 y 2001-02 y A+AR+AD A+AR * * *p<0.05 1.0 ISAAC (International Study of Asthma and Allergy in Childhood)
- 80. We need to be proactive and not just reactive
- 81. Diagnosis of Asthma History of Recurrent Symptoms *Wheeze Cough Shortness of breath Rule Out Other Causes of Symptoms Document Presence of Airflow Obstruction ● Spirometry ● PEFR Demonstrate Reversibility of Obstruction/Symptoms
- 83. A correct diagnosis of asthma is essential if appropriate drug therapy is to be given. Asthma symptoms may be intermittent and their significance may be overlooked by patients and physicians Asthma symptoms may be non-specific, result in misdiagnosis , This is particularly true among children, and lead to inappropriate treatment.
- 84. Asthma Diagnosis By history, the patient must meet three criteria: ─ Symptoms of asthma occur in response to an allergen , trigger or airway irritant (airway hyperreactivity) ─ Repeated episodes of symptoms (recurrence) ─ Response to treatment (reversibility) measured objectively by spirometry with a significant increase postbronchodilator or relief of symptoms
- 85. Symptoms of Bronchial Asthma Bronchial asthma is episodic •In-between attacks patients especially young ones may be asymptomatic The common symptoms are: Cough Wheezing Tightness Dyspnea 85
- 87. Diagnosis of Asthma Detailed medical history – Cough Nocturnal Seasonal Related to workplace Related to specific activity – Recurrent wheeze – Recurrent dyspnea – Recurrent chest tightness – Triggers (allergic and non-allergic)
- 88. o Symptoms that suggest asthma include wheezing, dyspnea, chest tightness, or cough in the following circumstances (1) with exposure to cold air (2) after exercise (3) during respiratory infections (4) following inhalant exposures in the workplace (5) after exposure to allergens and other asthma triggers.
- 89. Not All That Wheezes Is Asthma… -Foreign body - Upper airway diseases - Enlarged lymph nodes or tumor - Vocal cord dysfunction - Aspiration/GERD - COPD - CHF - PE - Drug reaction/side effect
- 90. Asthma Does Not Always Wheeze… √ Chronic or nocturnal cough with awakenings √ Exercise induced symptoms √ Chest tightness √ Viral induced symptoms
- 91. Wheezes are heard more commonly during expiration because the airways normally narrow during this phase of respiration. Wheezing during expiration alone is generally indicative of milder obstruction than if present during both inspiration and expiration, which suggests more severe airway narrowing.
- 92. In contrast, the absence of wheezing in an asthmatic may indicate either improvement of the bronchoconstriction or severe, widespread airflow obstruction. The latter suggests that the airflow rates are too low to generate wheezes or the viscous mucus is obstructing large regions of the peripheral airways. Increasing exhaustion and a "silent chest" are ominous signs of respiratory muscle fatigue and failure
- 93. Asthma – To Wheeze or Not To Wheeze Asthma does not always present with classic wheezing, chest tightness and cough. Sometimes, only the cough is present and we call this Cough Variant Asthma. Some people only get symptoms when they exercise and we call this Exercise Induced Asthma.
- 94. When cough is the only asthma symptom, this is known as cough variant asthma (CVA). People with cough-variant asthma often have no other "classic" asthma symptom, such as wheezing or shortness of breath
- 95. √ Wheezing does not always indiciate asthma and vice versa - you can have an asthma attack where wheezing is not the main symptom. √ Coughing can sometimes be the main symptom of an asthma attack (but again, a persistent cough does not necessarily mean he has asthma)
- 96. A chronic cough is defined as one that lasts longer than 8 weeks. There are many causes of chronic cough in nonsmoking adults. Asthma, gastroesophageal reflux disease, post- nasal drip and post-infectious cough are the most common causes. Asthma is believed to be responsible for 24% to 29% of these persistent coughs
- 97. Absence of symptoms at the time of the examination does not exclude the diagnosis of asthma
- 98. Is it Asthma? √ Recurrent episodes of wheezing √ Troublesome cough at night √ Cough or wheeze after exercise √ Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants √ Colds “go to the chest” or take more than 10 days to clear √ Symptoms improved by appropriate asthma treatment?
- 99. Several studies have demonstrated that patients’ symptom reports are unreliable indicators of airflow limitation Poor perception of the severity of asthma on the part of the patient and health care professional has been cited as a major factor causing delay in treatment and thus may contribute to increased severity and mortality from asthma exacerbations. However, this is not the case with all patients
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- 101. Asthma diagnosis in children Asthma is the Most Common Chronic Illness of Childhood Asthma is Underdiagnosed and therefore Undertreated in Infants and Children
- 102. There should be an identifiable trigger usually a viral infection Airways obstruction is reversible with bronchodilators Usually more than 3 episodes TO DIAGNOSE ASTHMA IN INFANTS THINK OF THE “3R” Reactivity Reversibility Recurrence Finder Curr. Probl. Pediatr. 1999
- 103. A diagnosis of asthma should be considered if more than 3 episodes of reversible bronchial obstruction have been documented within the previous 6 months.
- 104. Diagnosis of Asthma in Children 5 Years and Younger Asthma diagnosis in this age group is difficult Respiratory symptoms (wheezing and cough) also common in children without asthma Not possible to routinely assess airflow limitation (spirometry) Lung function testing is of limited use because of practical difficulties obtaining reliable results.
- 105. Diagnosis of Asthma in Children 5 Years and Younger No tests provide a diagnosis with certainty but the following may be useful adjuncts in a diagnostic decision: Therapeutic trial with inhaled glucocortiosteroid and rapid-acting β2-agonists for 8-12 weeks Tests for atopy
- 106. Asthma should be suspected in any infant with recurrent wheezing and coughing episodes. Diagnosis is often only possible through long- term follow-up, observations of the child´s response to bronchodilator and/or anti- inflammatory treatment and consideration of the extensive differential diagnoses.
- 108. In children 5 years and younger, the diagnosis of asthma has to be based largely on clinical judgment and an assessment of symptoms and physical findings. A useful method for confirming the diagnosis in this age group is a trial of treatment with SABA and ICS. Marked clinical improvement during the treatment and deterioration when treatment is stopped supports a diagnosis of asthma.
- 109. <5 years: clinical judgement and response to asthma treatment may be the only reliable means for diagnosing asthma Spirometry for children >5 years Asthma in children < 5 years
- 110. Natural History of Childhood Wheeze Age (Years) WheezingPrevalence Non-atopic wheezers Transient early wheezers IgE-associated wheeze/asthma 0 3 6 11 Martinez. J Allergy Clin Immunol 1999;104:S169-S174.
- 111. 1 1 1 Wheezing phenotypes in children 12 Longitudinal birth cohorts Original Tucson Group (Taussig L et al 1985)
- 113. Wheezing phenotypes Episodic wheezing and cough is very common even in children who do not have asthma and particularly in those under age 3. Three categories of wheezing have been described in children 5 years and younger: 1. Transient early wheezing 2. Persistent early-onset wheezing (before age 3). 3. Late-onset wheezing/asthma.
- 114. Transient early wheezing Commonest form of wheeze Decrease lung function at birth The pattern of respiratory symptoms starting in the first year of life. Generally, transient wheezing in infants is not associated with a family history of asthma or allergic sensitization - Non Atopic No airway hyper-responsiveness
- 115. Transient early wheezing Transient early wheezing, is often outgrown in the first 3 years - characteristically resolves around the age of 3 Transient early wheezing, is often associated with prematurity & male gender &,Teenage pregnancy and parental maternal smoking , as well as postnatal exposure to tobacco smoke..
- 116. OR for asthma in the first 5 years of life Smoking mother only 1.3 MATERNAL AND GRANDMATERNAL SMOKING PATTERNS ARE ASSOCIATED WITH EARLY CHILDHOOD ASTHMA Li YF Chest 2005 3 – 2 – 1 – 0 1.8 338 children with asthma diagnosed in the first 5 years of life 570 control subjects Grandmaternal only smoking during the mother’s fetal period Grandmaternal and maternal smoking 2.6
- 117. Early Wheeze group had lower lung function than any other group shortly after birth(before the first wheezing episode) Continued to have slightly lower function than predicted into young adulthood,suggesting their airways are anatomically smaller than average They may be at increased risk of COPD if they become smokers themselves Transient early wheezing
- 118. European Community Respiratory Health Survey participants aged 20–45 years randomly selected from general populations. Spirometry in 1991–3 (n=13,359) and 9 years later (n=7,738). Early life origins of chronic obstructive pulmonary disease Svanes Thorax 2010;65:14–20 •Maternal asthma •Paternal asthma •Childhood asthma •Maternal smoking and Childhood respiratory infections defined as ‘‘childhood disadvantage factors’’.
- 119. THE ADULT INCIDENCE OF ASTHMA AND RESPIRATORY SYMPTOMS BY PASSIVE SMOKING IN UTERO OR IN CHILDHOOD Skorge AJRCCM 2005 Between 1985 and 1996/1997 an 11-year community cohort study on the incidence of asthma 3.786 subjects OR ratio for adult onset asthma 3 – 2 – 1 – 0 3 Smoking mother
- 120. REGULAR SMOKING AND ASTHMA INCIDENCE IN ADOLESCENTS Gilliland AJRCCM 2006; 174: 1094 2,609 children with no lifetime history of asthma or wheezing Followed annually in schools Regular smoking was defined as smoking 300 cigarettes in the year New cases of physician- diagnosed asthma RR FOR NEW ONSET OF ASTHMA 3.9 4 – 3 – 2 – 1 – 0 In children smoking >300 cigarettes/year
- 121. RR FOR NEW ONSET OF ASTHMA 8.8 10- 8 – 6 – 4 – 2 – 0 In children smoking >300 cigarettes/year and exposed to maternal smoking during gestation REGULAR SMOKING AND ASTHMA INCIDENCE IN ADOLESCENTS Gilliland AJRCCM 2006; 174: 1094 2,609 children with no lifetime history of asthma or wheezing Followed annually in schools Regular smoking was defined as smoking 300 cigarettes in the year New cases of physician- diagnosed asthma
- 123. Persistent early-onset wheezing (before age 3). These children typically have recurrent episodes of wheezing associated with acute viral respiratory infections, The cause of the episode is usually the respiratory syncytial virus in children younger than age 2, while other viruses predominate in older preschool children. Symptoms continue beyond the age of six Persistent Nonatopic Wheezers Viral-associated wheeze
- 124. Ceases in adolescence The symptoms normally persist through school age and are still present at age 12 in a large proportion of children Have no evidence of atopy and, have no family history of atopy. Of all the children who continue to wheeze after the age of 3 years, 40% belong to this second phenotype. Persistent Nonatopic Wheezers
- 125. Unlike children with transient wheezing, these children are born with lung function that is similar to that of the control group and that remains statistically normal up to the age of 18 years, but they show bronchial hyperresponsiveness to methacholine - Airway hyper-responsiveness Nonatopic wheezers have normal lung function in early life & reduced in later life Persistent Nonatopic Wheezers
- 126. – Late-onset wheezing/asthma: 80% before the age of 6yr (esp before 3yr) Symptoms persist into childhood and adult life. Atopic background, often with eczema Children with recurrent wheeze at school age commonly also have a parental history of asthma, or have signs of atopy, like eczema or allergic rhinitis, or have at least one positive skin prick test for an inhaled allergen. Atopic wheezer/ asthma.
- 127. Children with persistent 'atopic' wheezing who develop asthma in later childhood, more often have their first episode of wheeze after the first year of life, discrete attacks with symptom-free intervals, symptoms that worsen at night, frequent symptoms, a family history of asthma, elevated serum IgE and peripheral blood eosinophilia. Furthermore they may respond to bronchodilators and corticosteroids. Increased symptoms with increasing age Lung function normal at birth but deteriorates with recurrent symptoms Atopic wheezer/ asthma
- 128. Lung function according to wheezing history at 6 years Early infancy 6 years of age V max of FRC (ml/s) V max of FRC (ml/s) never early late persistent never early late persistent wheezerswheezers Martinez NEJM 1995; 332: 133 - - - - - - - - - - - - - - - - 160 - 140 - 120 - 100 - 80 - 60 - 40 - 20 - 0 1400 - 1300 - 1200 - 1100 - 1000 - 900 - 800
- 129. 12 9 We have a long way to go!
- 130. The following categories of 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, and symptoms that persist after age 3.
- 131. OUTCOME OF INFANT WHEEZING Low birth weight Pregnancy smoking Male Sex Affluence Atopy Low maternal age (first born) Infant wheeze With viral infection alone With various precipitants Remission in 80% ?? COPD in adults Persistent asthma (with or without evidence of atopy) in 50-60%
- 132. Spectrum of disorders Birth 1 year 5 years Adolescence
- 133. Spectrum of disorders Birth 1 year 5 years Adolescence Bronchiolitis Pre-school wheeze Asthma in school children
- 134. Spectrum of disorders Birth 1 year 5 years Adolescence Bronchiolitis Pre-school wheeze School children RSV, adeno, rhino 50:50 atopic 90:10 atopic
- 137. 0 20 40 60 80 100 Infant wheeze Infant wheeze with atopic parent (s) Infant wheeze + atopic eczema and/or other food allergies Infant wheeze + atopic parent + positive skin prick test + raised sIL-2R 20% 40% 50% 90% % OF INFANTS SUBSEQUENTLY DEVELOPING ASTHMA
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- 144. Asthma in young infants Most common cause of wheezing in infants and young children is viral respiratory tract infection but strongest predictor for wheezing continuing into asthma is atopy
- 145. • Different phenotypes of childhood asthma - Virus associated wheeze - Post-bronchiolitis wheeze - Atopy associated wheeze • Asthma in more than 50% begins <3 years Asthma is not one disease
- 146. In the vast majority of cases asthma has its onset in childhood. In a proportion of asthmatic children, asthma remits in adolescence or early adulthood and the severity of asthma tracks significantly with age.
- 147. Complete remission of childhood asthma may be the exception rather than the rule. Patients with asthma in clinical remission should be monitored with periodic assessment of lung function, bronchial responsiveness, and other markers of inflammation.
- 148. „... there is a belief among general practitioners and paediatricians that children grow out of asthma.“ Issues in Adolescent Asthma. Thorax 1996; 51 (Supplement 1) Childhood asthma „... it is often not the asthma that is outgrown but the paediatrician.“
- 149. Do all children who wheeze have asthma? No. Most children who develop wheezing after age 5 have asthma. However, diagnosis of asthma in children 5 years and younger presents a particularly difficult problem.
- 150. Episodic wheezing and cough are also common in children who do not have asthma, particularly in children younger than age 3 . The younger the child, the greater the likelihood that an alternative diagnosis may explain recurrent wheeze. Do all children who wheeze have asthma?
- 151. Although there is the possibility of overtreatment, episodes of wheezing may be shortened and reduced in intensity by effective use of anti- inflammatory medications and bronchodilators rather than antibiotics. Do all children who wheeze have asthma?
- 153. “No great thing is created suddenly.” Epictetus