BRONCHIAL ASTHMA PEDIATRICS SLIDESHAReee
- 1. BRONCHIAL ASTHMA CLINICAL FEATURES AND MANAGEMENT Nanditha Aravind,Navya ak Roll no:69 and 70
- 2. BRONCHIAL ASTHMA • It is a group of disorders characterized by an increased responsiveness of the airways to various stimuli. • It manifests by widespread narrowing of the airways causing paroxysmal dyspnea, wheezing or cough.
- 3. BRONCHIAL ASTHMA PATHOPHYSIOLOGY Airway obstruction in asthma is caused by i) edema and inflammation of mucous membrane lining the airways ii) excessive secretion of mucus, inflammatory cells and cellular debris iii) spasm of the smooth muscle of bronchi. Obstruction is diffuse but not uniform
- 4. BRONCHIAL ASTHMA PATHOPHYSIOLOGY Asthma has been classified as 1. atopic (lgE mediated, triggered by allergens) 2. nonatopic (non lgE mediated, triggered by infection) 3. mixed 4. exercise induced or aspirin induced Inhalation of an allergen leads to a biphasic response with early and late reactions ultimately causing bronchoconstriction.
- 6. BRONCHIAL ASTHMA LATE REACTION • develops 3-4 hr later and peaks at 8-12 hr. • The release of mast cell mediators is not prevented by premedication with beta2 -agonist. • it is inhibited by premedication with steroids suggesting that airway narrowing is mainly due to an inflammatory reaction and mucosal edema. This phase presents as clinical asthma.
- 7. BRONCHIAL ASTHMA TRIGGERS • Viral Infections • Exercise • Weather Changes • Emotional factors • Food • Endocrine Factors
- 8. BRONCHIAL ASTHMA • Dyspnea • May develop cyanosis • Restless • Chest becomes barrel shaped • Hyperinflation of chest • Clubbing of fingers • Recurrent Cough • Wheezing • Air Hunger • Hyper resonant chest due to air trapping • Prolonged Respiratory phase • Feeble breath sounds
- 9. O Symptoms occur with change in season , aggravated by exercise,and more in nights O Acute asthma usually begins with a cold ,bouts of spasmodic coughing
- 10. BRONCHIAL ASTHMA DIFFERENTIAL DIAGNOSIS • Bronchiolitis • Congenital Malformation • Aspiration of foreign body • Hypersensitivity Pneumonitis • Cystic Fibrosis
- 11. GRADING OF SEVERITY OF ACUTE ASTHMA
- 12. BRONCHIAL ASTHMA INVESTIGATIONS • Complete blood count,ESR(normal values are expected ;may have eosinophilia • Pulse oximetry –mild ->955,moderate-90-95%,severe<90% • Chest X Ray-normal or show bilateral symmetric air trapping • Patches of atelectasis of varying sizes due to mucus plugs • Allergy Test- blood IgE elevated in atopic asthma and normal in non atopic asthma • Spirometry-mild ->80%,moderate -60-80%,severe<60%
- 13. BRONCHIAL ASTHMA MANAGEMENT The goals of the therapy are 1. Maintenance of near normal pulmonary function 2. Maintenance of near normal physical activity 3. Prevention of night time cough/wheeze with minimal chronic symptoms 4. Prevention of exacerbation 5. Avoiding adverse effects of medications
- 14. O Management 1. Identification and elimination of exacerbating factors 2. Pharmacotherapy i. Acute exacerbation management ii. Long term mangement
- 15. ACUTE EXACERABATION OF ASTHMA MILD O Nebulization- salbutamol 150 mcg/kg/dose n 3 ml of saline once O Assess for response O Response is adequate and child is comfortable discharge on oral salbutamol ,0.1-0.2 mg/kg/dose,6hrly or salbutamol inhaler puffs ,2 puffs 4-6hrly O if the child is not improving a adequately shift to the management protocol of moderate exacerbation
- 16. MODERATE Nebulized salbutamol every 20 minutes for 3 times in one hour. Assess for response the if the response is adequate, space out nebulization intervals 2-4hrly . observe the child for six to eight hours if the relief is sustained discharge the child on oral salbutamol or salbutamol inhaler 2puffs 4-6hrly
- 17. response is only partial start oral steroids prednisolone 1 to 2 mg / kg / day continue nebulization .when improved (usually takes 1 to 2 days ),discharge the child on Oral salbutamol and steroid for 3 to 5 days. the child is fit for discharge if he feeds well and sleeps well In case of deterioration manage as severe exacerbation. if the nebulizer is not available, 2 to 4 puffs of salbutamol by MDI every 20 minute for 3 times or subcutaneous injection of terbutaline may be considered
- 18. SEVERE Admit in the ICU Connect to Pulse oxymeter oxygen inhalation oxygen driven nebulization with salbutamol and ipratropium (125 mcg for infants and toddlers ,250 mcg for > 5 years, 500 mcg for adolescence) every 20 minutes for 3 doses .
- 19. IV hydrocortisone 10 mg/kg initially followed by 4 to 5 mg/kg/dose every 6hrly or IV methylprednisolone 2 mg/kg/dose or oral prednisolone 2mg/kg/day IV MgSO4 ;0.1ml/kg 50% MgSO4 in normal infusion over 30 minute. injection aminophylline 5mg/kg/dose diluted as IV infusion 6 hourly
- 20. if improvement is inadequate ,consider continuous oxygen driven nebulization with salbutamol ,0.5 mg/kg or hourly nebulization. ipratropium can be spaced out to 4 hourly, mixed with the corresponding doses of salbutamol IV TERBUTALINE 10 Mcg /kg bolus infusion over 30 minute, followed by 0.4 mcg/kg/min increasing gradually, to maximum 4 mcg/kg/min ketamine Mechanical ventilation
- 21. Pharmacological -long term i. Assessment of symptom control ii. Assessment of risk of exacerbation iii. Selection of medication iv. Selection of appropriate inhalational device v. monitoring
- 22. ASSESSMENT OF SYMPTOM CONTROL characteristics controlled Partially controlled uncontrolled Day time symptoms none >2 per week 3 or more features of pa rtially controlled prese nt in week Limitation of activity none any nocturnal sumptoms none any Reliever or rescue drug none >2 per week
- 23. Assessment of risk of exacerbation MODIFIABLE o Uncontrolled asthma symptoms o Previous history(1 or more) o Exposures:tobacco smoke,indoor or outdoor air pollution,indoor allergens o Psychological or socioeconomic problems o Poor adherence with controlled medication o Co- morbidities:obesity,rhinosinusitis and food allergy
- 24. Non modifiable o Ever intubated :PICU admissions o >1 severe exacerbation requiring hospitalization in last 12 months
- 25. Selection of medication O Infrequent symptoms –- No controlled medication ,short acting beta agonist with inhaled steroids O Asthma with any risk factors,>twice a month--low dose inhaled steroids as and when required short acting beta agonist Montelukast(other choice)
- 26. O Troublesome – low dose inhaled steroids +long acting beta agonist or medium dose inhaled steroids Low or medium dose inhaled steroids +LTRA or sustained release theophylline O Severely uncontrolled – medium to high dose inhaled steroids+long acting beta agonist short course oral steroid and high dose inhaled steroids or moderate dose inhaled steroids and long acting beta agonist
- 27. Selection of appropriate inhalation device O Metered dose inhaler(MDI) O MDI with spacer O With face mask O Dry powder inhaler O Nebulizer
- 28. monitoring O Every 4-12 wks O Detailed history(frequency of symptoms ,sleep disturbance,physical activity,school absenteeism,visit to doctors,need for bronchodialators) O maintain Symptom diary O Assessed as being controlled,partially or uncontrolled O Poor compliance ,wrong technique of inhalation inappropriate dose ,infections
- 29. O No cause is found-step up O Control is sustained for 3-6 months,and gradual reduction- step down
- 31. OLife threatening asthma: o Cyanosis o Silent chest o Poor respiratory efforts o fatigue o Altered sensorium o PEFR< 30 % o Oxygen saturation <90%
- 32. O MDI o Fixed amount of medication o Aerosol form –activated o Exacerbation and maintanance therapy o Coordination (press and breath) o Pressure ,oropharynx o spacer
- 34. How to use
- 35. MDI with spacer O Large portion being deposited in lung ,with less impaction on oropharynx O Advantage- overcome coordination O Limitations-being bulky ,costly,young infants and toddlers
- 37. How to use 1. Remove cap ,shake ,insert into spacer 2. Place mouth piece of spacer 3. Start breathing in and out-valve 4. Breathing pattern established press canister and continue to breath—5-10 5. Wait for 30 sec
- 38. With mask O Below 2-3 yrs HOW TO USE O Attach baby mask O Shake mdi inserted to mdi end O Mouth and nose O Press canister and encourage child to take breathing mouth open O 30-60
- 40. Nebulizer O Acute severe asthma in young irritable and hypoxic children O Bulky and inefficient aerosol delivery system IMPROVE THE AMOUNT OF DRUG DELIVERED o Total fill volume -3-5 ml o Tapping the side of nebulizer o Optimal flow rate -6-12L/min o Slow,deep inhalation and breath holding
- 42. O Below 4 yrs-MDI with spacer and Face mask O Above 4 yrs-MDI with spacer O Above 12 yrs-MDI may be used directly
- 43. THANK YOU