2013 Update

Asthma Training Module©

based on

Asthma By Consensus
IAP
National Guidelines for the
Management of Childhood Asthma
 2013 Update

Asthma Training Module©

Protected under copyright.

Any further usage of this presentation implies that you have read and
accepted the terms of use of this module.

The material is meant for the training of a registered medical

practitioner only.

The module provides overall guidelines for managing childhood

asthma. The decision for individual case management should be
based on their own merit.
 Today’s tasks…

Must know
– Basic pathophysiology
– Diagnosis of asthma
– Long term management
– Managing acute attacks
– &
Demonstration time
 Watch for these symbols…

• This symbol calls for

interact ! interaction with the speaker

PEP Talk • This symbol indicates a Parent

Education Point
Basics - brick and mortar !
 Asthma

Characterized by

Airway
– chronic inf lammation
– hyper responsiveness
– obstruction-reversible
 INDUCERS
Allergens
Maternal smoking, Chemicals,
Air pollutants, Virus infections

Genetic propensity

INFLAMMATION

Airway
Hyper-responsiveness Airflow Limitation

TRIGGERS
Exercise
Cold Air, SO2
SYMPTOM
Particulates S
Virus infections
 Inf lammation in asthma
Superimposed
acute
inf lammation

Chronic inf lammation

Structural changes Airway

remodeling

Time
Diagnosis of asthma

The story begins……

 Clinical evaluation

• Ascertain diagnosis

• Identify co-morbid conditions

• Think of alternate diagnosis

• Grade severity

• Identify triggers
 Diagnosis of asthma

Lets look at some case histories…

 Case…..Arpit

6 year old Arpit was seen for recurrent cough

for about 1 year. His mother reported that he
frequently had colds which ‘went to the chest’

What further questions will you ask?

interact !
 Ask for..
– Recurrent cough?
– Recurrent wheeze?
– Recurrent breathlessness?
– Activity/stress induced cough/wheeze?
– Nocturnal cough?
– Tightness of chest?

Symptoms of airf low obstruction

 …And qualifiers of asthma
Recurrent episodes of airflow obstruction
with several of the following:

• Afebrile episodes
• Personal atopy or Family h/o atopy / asthma
• Nocturnal exacerbations
• Stress/Activity induced symptoms
• Trigger induced symptoms
• Seasonal exacerbations
• Relief with bronchodilators ± oral steroid
 Arpit… continued

What do you expect to find when you

examine Arpit?

interact !
 Look for..

Signs of airf low Other features of

obstruction atopy

• Atopic dermatitis /
• Generalized wheeze Eczema

• Prolonged expiration • Allergic rhinitis /

In the hyperinf
• Chest interval period, conjunctivitis
lation chest examination may be normal
 Arpit… contd
Arpit’s mother reported that every episode started with a cold
and sneezing. Arpit often reported an earache and had taken
multiple courses of antibiotics for ear infections.

“Is Arpit a mouth breather and snorer ?” I asked…

What is the relevance of this history?

interact !
 Ascertain diagnosis

• Identify co-morbid conditions

• Think of alternate diagnosis

• Grade severity

• Identify triggers
 PEP Talk
Co morbid conditions
• Allergic rhinosinusitis
– Sneezing in the morning, nasal itching
– Running /Blocked nose, snoring, mouth breathing

• Adenoidal hypertrophy
– Colds, ear infections
– Blocked nose, snoring, mouth breathing

• Gastroesophageal ref lux disease (GERD)

– Nocturnal cough / vomiting
– Theophylline / Oral β2 agonist usage
 Look for..

Signs of allergic rhino-sinusitis

– Nasal mucosa – edema, pale or violaceous
– Clear nasal discharge /Blocked nose
– Post nasal drip
– Cobblestone pharynx
 Ascertain diagnosis

 Identify co-morbid conditions

• Think of alternate diagnosis

• Grade severity

• Identify triggers
 Think of alternate diagnosis!

If presentation is below six months of age

Consider

Virus associated wheeze

Aspiration syndromes e.g. GE reflux disease
Congenital airway anomalies
Congenital heart disease (look for murmurs)
 Think of alternate diagnosis!
If localizing signs are present

– Unequal air entry

– Unilateral emphysema
– Radiological localization

Consider airway obstruction

– Foreign body aspiration

– Congenital anomalies
 Think of alternate diagnosis!

With persistent respiratory symptoms

Consider

Rhino sinusitis
Foreign Body
Tuberculosis
Pertussis
 Think of alternate diagnosis!
If unusual features present

– Failure to thrive
– Multiple multifocal infections
– Clubbing
– Consanguinity
– Malabsorption
Consider
– Cystic fibrosis
– Primary ciliary dyskinesia
– Immunodeficiency
 Arpit…. continued

How will you proceed to investigate

Arpit?

interact !
 Asthma is a clinical diagnosis

– Typical history
– CBC – may show eosinophilia
– Xray chest-may be normal/hyperinf lated
– Predictable bronchodilator response

Investigations help to rule out alternate

diagnoses, not to prove asthma.
 Breaking the news!

“Arpit has asthma” I told the mother. She looked

bewildered. “Nobody told me that” she said.

“My previous doctor called it ‘allergic bronchitis’

and the family physician says its ‘asthmatic
bronchitis’”

What will you tell her?

interact !
 What’s in a name ?

Acceptance of the diagnosis is the f irst

step to successful management
“But doctor” she exclaimed, “Asthma! And no
breathlessness?… Are you sure?”

How do you convince this anxious lady?

interact !
 PEP Talk
The asthma iceberg
Breathlessness … the tip

e nt co ugh
Recur r
Recu
rrent
whee
g h ze
al co u
rn
Noctu Ti
ghtne
ss of
chest

All Asthma Does Not Wheeze

Arpit’s mother asks whether lung function testing /
allergy testing will help to prove what I am telling
her?

Can PEFR help in the diagnosis ? Asked the

physician who accompanied the anxious family?
 PEP Talk
Spirometry /PEFR/
Allergy testing
• Spirometry

– when clinical diagnosis is in doubt – older children

– Effort dependent- proper technique critical

• Peak f low

– has a limited role in diagnosis

– Best used for monitoring

• Allergy testing / IgE levels / RAST have no role in diagnosis

Demonstration time…
 Coming to terms

“I now understand what you have said so far…”

said Arpit’s mom. “Tell me, doc, what exactly is

asthma?”

Simplify the story for her

interact !
 PEP Talk
Asthma components
Healthy Airway Asthmatic Airway

Alveolar partition Mucus and plasma

Inflammation
and swelling outpouring

Smooth muscle Smooth muscle

constriction Epithelial shedding /
Epithelium damage
(lining)
 The first time wheezer…

Its December. Amit, Arpit’s younger brother is 9

months old. He presents with a wheeze for the first
time along with a fever, cold and cough. “Not
again!” exclaimed the parents!

How will you manage this case and counsel

the family?

interact !
 Acute Bronchiolitis

• First episode of wheezing in a young child (up

to 2 yrs)

• Starts with coryza, usually with fever

• Clustered in winter and rainy months

• No atypical features
 PEP Talk
The first time wheezer…

< 3 episodes of airflow obstruction

AND
a family h/o asthma/atopy or personal
h/o atopy

Follow up for other qualifying features

before assigning a diagnosis of
asthma
 PEP Talk
Risk factors for Asthma

• Other atopies
– atopic dermatitis
– Allergic rhinitis / conjunctivitis

• Asthma / atopy in family

– sibling - doubles risk
As compared to
– one parent - doubles risk general population
– both parents - triples risk
 The early wheezer

Indu, who is Arpit’s neighbour, has come to see

you. She is eighteen months old and she has been
getting recurrent cough, cold, fever and wheezing
since she joined a creche six months ago..

Could this be asthma?

Will she outgrow this?
interact !
 Episodic (viral) Wheezer

• Associated with a febrile viral respiratory

infections

• Discrete episodes of wheezing

• Well between episodes

• Usually no personal or family history of atopy

 Another early wheezer

Sushil, 2 years old, has been getting recurrent

cough, cold and wheezing with fever since joining
the creche as well. He also starts wheezing when
exposed to cigarette smoke or his visit to his
farmhouse.

Could this be asthma?

interact !
 Multi trigger wheezer

• Triggers apart from viral URTI

• Afebrile episodes also present

• Discrete episodes

• Often symptomatic between episodes

• Strongly suspect asthma when associated
with personal and family history of atopy

43
 Under five wheezers
- a mixed bag
All that wheezes is NOT asthma

●
Episodic (viral)wheezer
●
Multi-trigger wheezer
●
Wheezer with atypical features
●
Acute Bronchiolitis

44
Under 5 wheezing - summary
 Summary so far…..
Diagnosis is clinical

• Recurrent episodes of airflow obstruction are present

• Airway obstruction is reversible

• Alternative diagnoses are excluded

• Co-morbid conditions are identified

• The under-5 wheezer is a mixed bag

 Managing asthma-long term
&
Managing under 5 wheezing

Some pharmacology and

essentials of inhaled therapy.
 Drugs

Relievers Controllers
• Used in a need based • Used on daily long term
manner for treatment of basis for control of
bronchospasm and to inflammation and to
relieve acute attacks prevent further attacks
 Controllers

Inhaled Oral

• Corticosteroids(ICS) • Leukotriene antagonists

• Long acting inhaled • Theophylline - SR

β 2-agonists (LABA)
• Oral prednisolone
 Inhaled Corticosteroids

Estimated equipotent daily doses of ICS

Children < 12 years
Drug Low dose Medium dose High dose
(µg) (µg) (µg)
Budesonide 100-200 >200-400 >400
Fluticasone 100-200 >200-500 >500
Beclomethasone 100-200 >200-400 >400
 Inhaled Corticosteroids

Estimated equipotent daily doses of ICS

Children > 12 years
Drug Low dose Medium dose High dose
(µg) (µg) (µg)
Budesonide 100-400 >400-800 >800
Fluticasone 100-250 >250-500 >500
Ciclesonide 80-160 >160-320 >320
Beclomethasone 200-500 >500-1000 >1000
 Why Steroids ?
Superimposed Acute
acute inf lammation inf lammation Systemic
steroids

Chronic inf lammation Chronic inf lammation Inhaled steroids

Airway remodeling
Airway remodeling

Structural changes Structural changes

Time Time
 PEP Talk
Inhaled steroids
-practice points

• Anti-inf lammatory effect evident in 1-2 weeks.

• Local adverse effects – thrush/dysphonia minimized by
spacer/gargling

• Usually required inhaled doses- negligible systemic effects

• Prolonged high dose - monitor growth and eyes (cataracts).

In practice, most children need low doses

 PEP Talk

Uncontrolled asthma is more likely to cause

growth failure than usually needed doses of
inhaled steroids
 LABA (Salmeterol, Formoterol)
-practice points
• Only as add on to ICS and never alone as controller

• Steroid sparing and synergistic effect with ICS

• Advised for use > 4 years of age for want of data in

younger children

• Oral LABA have no role in asthma management

 Leukotriene antagonists
- practice points

• Weak anti–inflammatory effect compared to ICS

• Add-on in moderate /severe asthma

• Inferior to ICS in mild persistent asthma

• Useful in Exercise induced asthma

• May be used when concomitant allergic rhinitis

• Montelukast approved for > 6 months of age

 SR-Theophylline
- practice points

• Anti-inf lammatory/immunomodulator

• Currently used as a controller

• Used as adjunct to inhaled steroids (older children)

No role of syrup formulations

• Monitor adverse effects- clinically and blood levels

• Beware f luctuations in levels - fever, anti TB

treatment, anticonvulsants, quinolones, macrolides
 Long term oral steroids
- practice points

• Use limited to severe persistent asthma

• Minimal possible dose

• Alternate day morning dose is preferred (to reduce HP axis

suppression).

• Prednisolone - best option

• Monitor growth (height/weight), eyes, skin, bone density,
immune suppression, HPA suppression.
 Drug delivery - inhaled route

Inhalation Device Delivery

• MDI with spacer 10- 15%

• Metered dose inhaler (MDI) 5 - 10%
• Dry powder inhaler (DPI) 5 - 10%
• Nebulizer 1- 5%
 PEP Talk
Role of spacers

• Eliminate need for hand - breath co-ordination

• Reduce local side effects of inhaled steroids
• Improve drug delivery
• Dilute taste of inhaled sprays.
• Eliminate cold freon effect (with CFC)

When using MDIs, Spacer is a must

 Types of spacers

• Small volume vs large volume

• Valved vs non valved
• Polyamide vs polycarbonate

Use any spacer

but
USE A SPACER
 PEP Talk
Role of mask

• Spacer with well fitting mask

– Below ~ 3 years or anyone who cannot breathe
consciously through mouthpiece of spacer.

• Spacer alone
– Above ~ 3 years, or
– Once a child learns to breathe through mouthpiece
mask should be removed.
How do you initiate inhaled therapy?

interact !
 The 4 steps

1. Explain advantages of inhaled therapy

2. Dispel myths and fears

3. Select an appropriate device

4. Demonstrate how to use the selected device

 PEP Talk
Advantages of inhaled therapy

Inhaled Oral

Route Direct Indirect

Dose Small Higher

Onset of action Rapid Slow

Adverse effects Mild-none Greater

Smaller dose, target delivery, quicker action, lesser side
effects
 The 4 steps

 Explain advantages of inhaled therapy

2. Dispel myths and fears

3. Select an appropriate device

4. Demonstrate how to use the selected device

 PEP Talk
Dispelling myths and fears

• Is inhaler therapy ‘strong’? NO Emphasize micrograms

• Is inhaler therapy ‘addictive’? NO

None of the drugs cause dependence

• Is inhaler therapy expensive? NO

Initially yes, but ultimately NO

• Is inhaler therapy easy for children to use? YES

The first choice, not the last resort !!!

 The 4 steps

 Explain advantages of inhaled therapy

 Dispel myths and fears

3. Select an appropriate device

4. Demonstrate how to use the selected device
 PEP Talk
The right device…

Criteria for selection

– Age
– Controller use
– Acute episodes
 PEP Talk
Selecting the right device

• Age
– < ~3 years – MDI + spacer + mask
– > ~3 years – MDI + spacer

– > 6 years – MDI + spacer

– - Dry Powder Inhaler(DPI) is an option

MDI + spacer is the most versatile device

 PEP Talk
Selecting the right device

• Controller regimen
– Moderate to high dose ICS
• Use MDI + spacer instead of DPI even in
older children
 PEP Talk
Selecting the right device

• Acute episodes
– Home - MDI + spacer + mask / DPI
– Hospital - MDI + spacer + mask
– - Nebuliser in severe episodes
– Do not use DPI in moderate/severe
exacerbations
 The 4 steps

 Explain advantages of inhaled therapy

 Dispel myths and fears

 Select an appropriate device

4. Demonstrate how to use the selected

device

Demonstration time…
Managing the under 5 wheezer
 Amit (recap)
– the first time wheezer

Its December. Amit, Arpit’s younger brother is 9

months old. He presents with a wheeze for the first
time along with a fever, cold and cough. “Not
again!” exclaimed the parents!

How will you manage him?

interact !
 Bronchiolitis
Management
Acute episode
– Oxygen in severe cases
– Oral / nebulised β2 agonists
– Nebulised adrenaline is preferred
– Symptomatic therapy

Long term therapy

– Not indicated
 Indu (recap)
- the early wheezer

Indu, who is Arpit’s neighbour, has come to see

you. She is eighteen months old and she has
been getting recurrent cough, cold, fever and
wheezing since she joined a creche six months
ago..

How should she be treated?

interact !
 Episodic (viral) Wheezer
Management
Acute episode
– Oxygen in severe cases
– Oral/Inhaled β2 agonists
– Steroids – when severe or with associated risk factors

Long term therapy

– If severe or frequent episodes (> once a month)
– Daily ICS may be beneficial
– Intermittent LTRA- Limited effect
 Sushil (recap)
– the multi trigger wheezer

Sushil, 2 years old, has been getting recurrent

cough, cold and wheezing with fever since joining
the creche as well. He also starts wheezing when
exposed to cigarette smoke or his visit to his
farmhouse.

Should he be treated as asthma?

interact !
 Multi trigger wheezer
Management

Acute episode
– Oxygen (in severe cases)
– Treat with inhaled or oral bronchodilators
depending on severity.
– β2 agonists are main stay of therapy
– Use steroids early, particularly if personal /
family history of atopy present
 Multi-trigger wheezer
Management

Long Term Therapy

– A trial of ICS (400 mcg per day)
• If no clear benefit within 4-6 weeks of initial therapy –
Consider alternative diagnoses
• If good response, give for 8-12 weeks and stop.
– If recurrence on stopping, label and treat as
asthma
– LTRA - a less effective alternative
Back to long term management of
asthma

…and the story of Arpit and his

friends
 PEP Talk
Management Goals
• Freedom from
– Symptoms including nocturnal cough
– Acute asthma attacks
– Emergency doctor/hospital visits

• Minimal need for relievers

• Minimal adverse effects from drugs
• Normal
– Physical activity including participation in sports
– Growth Charts
– Lung function
 Management strategy

• Identify and avoid triggers

• Use controllers

• Treat acute attacks with Relievers

• Educate family regarding management

• Monitor and modify therapy to maintain control

 Recapitulating …
clinical evaluation

 Ascertain diagnosis

 Identify co-morbid conditions

 Think of alternate diagnosis

• Grade severity

• Identify triggers
 Grading severity

• Over a period of time

helps to decide regarding need and choice of
controller medications for long term control

• At a point in time
helps to decide regarding the level of care and drugs for an
acute exacerbation
 Grading severity
Symptoms Peak
1 of airf low
Night time
expiratory
symptoms
obstruction f low (PEF)
•< once a week • < twice a • > 80 % of
month personal best
Intermitte • < 20 % diurnal
•
nt Asymptomatic variation**
and normal
between
attacks
** Normal diurnal variation - <10 % in PEF values.
Lowest PEF levels are seen on waking and highest levels about 12 hours later.
 Grading severity
Symptoms
2 of airf low
Night time
Peak
expiratory
symptoms
obstruction f low (PEF)
Mild • > once a • > twice a • > 80 % of
week but month personal best
persistent • 20-30 %
< once a day
diurnal variation
 Grading severity
Symptoms Peak
3 of airf low
Night time
expiratory
symptoms
obstruction f low (PEF)
Moderate • > once a day • > once a • 60 - 80 % of
week personal best
persistent • > 30 % diurnal
• Attacks
affect activity variation
 Grading severity

4 Symptoms
Night time
Peak
of airf low expiratory
symptoms
obstruction flow (PEF)
Severe • Continuous • Frequent • < 60 % of
personal best
persistent • > 30 %
• Limited
physical diurnal
variation
activity
 Grading severity -simplified

• Frequency of symptoms
– daily/weekly/ monthly/ or less

• Duration of symptoms
– day or two/ week or so/ or more
 Grading severity - simplified

• Interval between symptoms

– no symptoms/ some cough/ nocturnal cough

• Severity of symptoms
– Hospitalizations/ ICU
 Asthma
Treatment

• Avoid triggers

Step 1 - Intermittent

• Inhaled / oral short acting β2 agonists as

required
No controllers
 Asthma
Treatment
• Avoid triggers; Treat acute episodes

Step 2 - Mild Persistent

Preferred treatment :
• Low dose ICS
Alternative treatment
• Leukotriene antagonists

Step 1 - SA β2 agonists prn

 Asthma
Treatment
• Avoid triggers;Treat acute episodes

Step 3 - Moderate Persistent

Preferred treatment :
• Low dose ICS + inhaled LABA
• Medium dose ICS (in children < 5 years)

Alternative treatment:
• Low dose ICS + Leukotriene antagonist / SR theophylline (> 5
years)
Step 2 - Low dose ICS

Step 1 - SA β2 agonists prn

 Asthma
Treatment
• Avoid triggers; Treat acute episodes

Step 4 - Severe Persistent

Preferred treatment :
• Medium/High dose ICS+ LABA
If uncontrolled add:
●
Oral steroid/ Anti-IgE

Step 3 – Add LABA

Step 2 - Low dose ICS
Step 1 - SA β2 agonists prn
 Now let ’s plan
Arpit ’s management…
 History - recap…
6 year old Arpit was seen for recurrent cough since
about 1 year. On enquiry, the cough bothered him
once every two months lasted for three to four
days. The cough was much more in the early
morning hours.

How will you grade and treat Arpit?

interact !
 Grading severity

Arpit has intermit tent asthma

 The crux of the matter

CONTROLLERS ??
Or

NO CONTROLLERS ??
That is the question…
 No controllers …

Intermittent asthma
– Infrequent (monthly or less),
– short duration (2-3 days),
– mild episodes

However, severe exacerbations, even if infrequent,

qualify for controller therapy
 Asthma
Treatment (recap..)

Step 1 - Intermittent

• Inhaled / oral short acting β2 agonists as

required
No controllers

• Avoid triggers
 Clinical evaluation….

 Ascertain diagnosis

 Identify co-morbid conditions

 Think of alternate diagnosis

 Grade severity

• Identify triggers
 PEP Talk
Triggers / precipitants

• Allergens

• Irritants

• Precipitants
– Viral infections
Inhaled allergens/ irritants and viral
infections are the most important triggers
 PEP Talk
Irritants……
• Smoke
– Avoid tobacco smoke, agarbattis, fumes from kerosene
stove, wood, cow dung

• Fine dust
– Avoid chalk, sprays, talcs

• Strong odors
– Do not use strong perfumes

• Mosquito repellent mats & coils

– Advise use of mosquito nets, long clothing
 PEP Talk
……Allergens
• Dust mite antigen
– Remove carpets / upholstery
– Cotton sheets rather than woolens.
– Expose mattresses to sunlight
– Wash soft toys periodically

• Cockroach antigen
– Preserve unused cooked foods in covered
containers
 ……Allergens
• Molds and spores
●
Attend to damp walls / leakages.
●
Clean air-conditioner filters monthly

• Animal dander /Pollen

●
Avoid f lowers/perfumes indoors
●
Stay indoors during harvesting season.

• Pets
●
Bathe pets weekly
●
Make them sleep outdoors
“Should we change our home and move to a dry
climate?” asked the anxious granddad.
“What food stuffs should we avoid?” asked the
grandma.

What will you advise these senior citizens?

interact !
 PEP Talk

Diet - over-emphasized !!!

A general avoid list to all patients is
irrational.

Address the environment

rather than
change the address
 Arpit… contd

A year later, Arpit’s parents stated that he was

wheezing a lot more often. He needed the reliever
puffs more than twice a week.

Is he still Intermittent?

How will you treat him now ?

interact !
 Gradation of severity

Asthma is a dynamic condition.

At presentation, asthma severity is graded to

guide introduction of medication.

On therapy, the titration of medications is based

on the assessment of asthma control.
 Assessment of Asthma Control
Level of Control Controlled Partly Controlled Uncontrolled
(All of the (Any measure
following) present in any
week)
Characteristic
Daytime symptoms None (twice or More than twice/week
less/week)
Limitations of None Any
activities Three or more
Nocturnal None Any features of
symptoms/awakenin partly
g controlled
asthma present
Need for reliever/ None (twice or More than twice/week
less/week) in any week
rescue treatment
Lung function (PEF Normal < 80% predicted or
or FEV1) personal best (if
known)
Exacerbations None One or more/year* One in any week†
Arpit’s Levels of Asthma Control
Level of Control Controlled Partly Controlled Uncontrolled
(All of the (Any measure
following) present in any
week)
Characteristic
Daytime symptoms None (twice or More than twice/week
less/week)
Limitations of None Any
activities Three or more
Nocturnal None Any features of
symptoms/awakenin partly
g controlled
asthma present
Need for reliever/ None (twice or More than twice/week
less/week) in any week
rescue treatment
Lung function (PEF Normal < 80% predicted or
or FEV1) personal best (if
known)
Exacerbations None One or more/year* One in any week†
 Asthma -treatment

• If control is not achieved with current

regimen, then treatment is to be stepped up
until control is achieved.

• If asthma is partly controlled, then increase

in treatment should be considered subject
to safety and cost
 Arpit…contd

Arpit is partly controlled.

• He needs stepping up of therapy (from

step 1 to step 2)
• He now needs regular controller therapy.
 Asthma
Treatment (recap…)
• Avoid triggers; Treat acute episodes

Step 2 - Mild Persistent

Preferred treatment :
• Low dose ICS
Alternative treatment
• Leukotriene antagonists

Step 1 - SA β2 agonists prn

 Sanjana…
Sanjana is a 9 year old who weighs 21 kg. She has been
hospitalized for wheezing at least thrice in the last 6
months and has had frequent midnight visits to the ER.

She has been referred to you after an acute episode and

is not receiving any interval therapy.

How will you grade and manage Sanjana ?

interact !
Sanjana has moderate persistent
asthma.
 Asthma
Treatment (Recap…)
• Avoid triggers; Treat acute episodes

Step 3 - Moderate Persistent

Preferred treatment :
• Low dose ICS + inhaled LABA
• Medium dose ICS (in children < 5 years)

Alternative treatment:
• Low dose ICS + Leukotriene antagonist / SR theophylline (> 5
years)
Step 2 - Low dose ICS

Step 1 - SA β2 agonists prn

 Sanjana .. contd
Sanjana followed up 4 weeks later. She was not better. I wondered why!
“Who gives the medicines to Sanjana” I asked her mom?
“I taught her initially” she replied “now she is old enough to take them on
her own”.
“Are you?” I asked Sanjana. She coyly looked away………

What do you think is going wrong?

interact !
 PEP Talk
Reasons for non-adherence
Intentional Unintentional
• Feel better (‘cured’) • Forget treatment
• Denial of diagnosis
• Poor supervision
• Fear side effects/addiction
• Misunderstand regimen
• Don’t notice any benefit in
the initial phase • Unable to use delivery
• Fear of ‘invalid’ label system
• Complex regimen • Empty canister
• Cost
 Sanjana……contd

She was seen six weeks later. She was now

adherent and the mother was supervising therapy.
She still woke the night coughing and wheezed
frequently.

What would be your approach now?

interact !
 If a child requires
rescue steroids / β2 - agonists frequently,

explore reasons for poor control.

 Poor control of asthma
Summary
Check Diagnosis • Rule out alternate
diagnosis
• Co morbid conditions

Check the following

The 3Ds Triggers Adherence Functional

Dose
Device
Delivery
 Poor control of asthma
Summary
Check Diagnosis Rule out D/D
Co morbid conditions

Check the following

The 3Ds Triggers Adherence Functional

Dose
Device Trial of rescue steroid
Delivery

THE 4TH D

Step up – Drug dose / regimen

 Asthma
Treatment (Recap..)
• Avoid triggers; Treat acute episodes

Step 4 - Severe Persistent

Preferred treatment :
• Medium/High dose ICS+ LABA
If uncontrolled add:
●
Oral steroid/ Anti-IgE

Step 3 – Add LABA

Step 2 - Low dose ICS
Step 1 - SA β2 agonists prn
 Abbas…
Abbas is a 7 year old boy with moderate persistent
asthma on therapy. He reported a nocturnal cough and
sneezed every morning. His mother was regular with the
inhalers and the technique was appropriate as checked in
the clinic.

What could be wrong now?

interact !
Co-morbid conditions (recap..)
– Allergic rhinosinusitis
– GER
– Obesity
 Allergic rhinitis
Intermittent Persistent
• < 4 days per week • ≥ 4 days per week
or < 4 weeks and ≥ 4 weeks

Mild Moderate-severe
one or more items
• normal sleep
& no impairment of daily • abnormal sleep
• impairment of daily
activities, sport, leisure
activities, sport, leisure
& normal work and school
& no troublesome symptoms • abnormal work and school
• troublesome symptoms
in untreated patients
 Allergic rhinitis
Drugs approved for children

• Topical • Oral
Nasal steroids Antihistaminics
Mometasone furoate &
Cetirizine & Desloratadine: ≥ 6
Fluticasone furoate: ≥ 2 years
months of age
Fluticasone propionate: ≥4 years
Loratadine: ≥ 2 years
Budesonide ≥ 6 years
Fexofenadine: ≥ 6 years
Nasal Antihistaminics
Azelastine: ≥ 5 years
Olopatadine ≥ 12 yrs LTRA
• Montelukast: ≥ 6 months of
age.
Allergic Rhinitis : Treatment
Intermittent Persistent
 Co-morbid conditions (recap..)

• Gastroesophageal reflux disease (GERD)

– May cause wheezing / exacerbate underlying asthma
especially in 2 subgroups:
• Difficult-to-control asthma
• Young infants with severe recurrent wheezing episodes

– Investigate with GER scintiscan/24 hour esophageal

pH monitoring or both
 Co-morbid conditions (recap..)

• Gastroesophageal reflux disease (GERD)

– Trial of Anti-ref lux treatment with PPI can be given in such
cases for 8-12 weeks

– Although recent data has failed to show a therapeutic benefit

in children with severe asthma and proven GERD.

– Oral bronchodilators/theophylline to be avoided

 Co-morbid conditions (recap..)

• Obesity
– Diet / life style modification
– Physical activities
 Follow up . . ..

Whenever Sanjana, Abbas or Arpit visit your

office,

What will you ask or look for?

interact !
 At clinic -follow up
• S ymptoms and signs
– bronchodilator usage
– nocturnal symptoms
– school absenteeism
– limitation of activity
– growth monitoring

• P arental concerns
– Regimen prescribed

• I nhaler therapy- Delivery/Drugs

• C ompliance (Adherence)
• E nvironment control
On a subsequent visit, Sanjana’s dad asked if there was an
objective way of monitoring her.

“Could they predict an attack and start early treatment ?”, he

asked

Sanjana’s mom had a similar query regarding spirometry…

What will you advise them?

interact !
 PEP Talk
Monitoring
• Essentially clinical

• PEFR if
– Trainable i.e. age above 5 years
– Tenable i.e. well initiated to therapy
– Affordable

• Spirometry if
– Age >6years, Affordable, Available

Demonstrationtime…
 Cases…
Sanjana, Arpit and Abbas kept well on their
regimes.

On the next visit, the parents enquired “what

next?”

What will you answer them?

interact !
 Well controlled asthma
Stepping down treatment
• While using ICS alone (med to high doses)
– 50% reduction at 3 months interval

• While using ICS+LABA-

– reduce ICS alone by 50% while continuing LABA.
– When control is maintained reduce ICS till low dose is reached
when LABA can be stopped

• When control achieved at low dose ICS alone

– switch to once a day therapy
 Well controlled asthma
Stopping treatment

• Good control continues on low dose ICS ~ 1 year

– Stop controller regimen
– Trigger avoidance continues
– Written Home management plan for acute episodes (Step 1
regime)

• Follow up 3-6 monthly for 1-2 years

• Counsel regarding possible future resumption of

controller, if recurrences.
 What next ?

Sanjana stays well. At one of the visits the

parents ask

“Is she now cured?”

What will you tell the parents?

interact !
 PEP Talk
Natural history

• Re-emphasize that drugs control but do not

cure,
• As asthma among children often remits,
control can be considered

as good as cure.
• Identify those at risk for persistence
 PEP Talk
Natural history of asthma

Risk factors for asthma persisting into adulthood

– Female
– Eczema
– Onset after age of 3 years
– Severe disease
– Parental history of atopy / asthma
 Case

Sailesh is a 7 year old with mild persistent symptoms. “He’s

in trouble every year between November and March”, says the
mother. I confirm this seeing his past records over two years.

What do you conclude and how will you manage

Sailesh?

interact !
 Seasonal asthma
Management

• Daily controller regimen

– Start a few weeks prior to anticipated onset of
symptoms
– continue through the season

• Encourage indoor activities during such

seasons
 Case…

Daphin plays interschool basketball. Every time he

starts his game, he is wheezing within minutes.
“Will I be able to play the finals?” he asks anxiously

Will you let him play and what will you advise
him?

interact !
 PEP Talk

Daphin has Exercise Induced Asthma

 PEP Talk

Daphin has Exercise Induced Asthma

Bronchoconstriction
Exercise

-the only trigger the asthmatic child should

conquer and not avoid
 Exercise induced asthma
Scenarios

• Child has asthma

– exercise is one of the triggers for bronchoconstriction

• Child does not have asthma

– exercise is the only trigger for bronchoconstriction
 Exercise induced asthma
non pharmacological approaches

• Choice of game

• Nose breathing

• Avoid exercise on cold mornings

• Slow deep breathing

• Warming up
 Exercise induced asthma
Pharmacological advice

• For control
– Suitable controller regimen (consider LTRA/ LABA
with ICS) ICS+ LTRA / ICS + LABA
– In addition :
• Inhaled SA β2 agonist - 15-30 min before planned
exercise.

• For treatment
– Inhaled SA β2 agonist
 Case……

Mrs Reddy had heard of your interest in asthma.

She came you asking to confirm the diagnosis.
She enquired whether homeopathy would have
an answer. She had also heard about fish
therapy!

Will you lose your temper?

interact !
 PEP Talk
Relax…….and explain

• Limited scientific literature on acupuncture,

homeopathy

• Benefits of Yoga

• No scientific literature on ‘fish therapy’ etc

• Current evidence does not suggest benefits.

 Case……..

Mrs Shah brought her 8 year old. She had come on a

very busy clinic day. You quickly tell her the diagnosis
and advise her the inhaled steroid regime. She does
not follow up. You diagnosed right, prescribed right,
but later learn that they have gone to a colleague for a
second opinion and are continuing with him!

Why did you lose this patient?

interact !
 The need of the hour!

At the first meeting give your patient

your time and not just your prescription.

Parent Education Points
1. Nature of disease-need for Controllers
2. Drugs control, do not cure
3. Inhaler therapy issues
4. Steroid issues
5. Usage of inhaler device and regime
6. Time taken to note benefit
7. Triggers
8. Diary of events
9. Acute home care
10. Need for follow up

THE TEN COMMANDMENTS

Managing acute episodes

Some Pharmacology
 Relievers

Short-acting β 2-agonists
Salbutamol Anticholinergics
Terbutaline Ipratropium bromide
Steroids
Non selective β -agonist
Adrenaline
Methylxanthines
(Select situations)

Magnesium sulphate
 Inhaled β2-agonists
• Drugs of choice.

• Salbutamol / Levo-Salbutamol/ Terbutaline are similar.

• Severe acute episode – nebuliser preferred

Dose - 0.15 mg/kg/dose (minimum dose 2.5mg)

or say as rough guideline:
< 4 years - 0.5 ml of salbutamol nebuliser soln
> 4 years - 1 ml of salbutamol nebuliser soln
– Dilute in saline only, NEVER distilled water

• Beware of hypokalemia with high dose nebulization.

 Rescue Steroids
• Early usage - reduces morbidity/ hospitalization

• Oral prednisolone 1 mg/kg for 3-7 days.

– No tapering needed / No adverse effects

• Injectables do not confer quicker benefit.

– Hydrocortisone( 4 mg/kg) q 6hr or
– IV Methylprednisolone (1-2 mg/kg) q6hr
– IV / IM Dexamethasone (0.1 – 0.2 mg / Kg) q 6 hr
if patient unable to take orally (drowsy/distressed/vomiting)

• High dose inhaled / nebulised steroids-not proven

 Anticholinergics

• Ipratropium bromide

• Additive effect to β2 agonist in acute severe asthma

• Neb soln – 0.5 ml <1yr, 1ml>1 yr

(Compatible with β2 agonist solution.)

• Limit use to 24 hours to prevent atropine like effects

(e.g.fever)
 Magnesium Sulphate
• Mechanism of action :
– acts through a different pathway ( calcium channel) in
the airway
– has immediate bronchodilator and mild anti
inflammatory effects
• Dose:
– 25-50 mg/kg IV slow infusion dissolved in 50 ml Saline
over 30 minutes (total maximum dose-2g)
• Toxicity :
– Tachycardia/bradycardia, hypotension, muscle weakness at
higher serum level
 Aminophylline
• Retains its role as reliever in acute severe attacks
– improves diaphragmatic contractility
– mucociliary function
– inflammatory modulation

• Dose:
– Loading dose 5 mg/kg – slow diluted IV bolus with 5% Dextrose
– (Avoid if patient on SR theophylline)
– Followed by 0.5–1.0mg/kg/hr as infusion
– (Avoid subsequent bolus doses)

• Toxicity
– Gl , Cardiac, CNS
– Monitor levels if possible
 Oxygen

• Maintain SaO2 > 92%.

• Hypoxia is mainly due to V / Q mismatch.

• β–agonists may paradoxically worsen

hypoxia
Initially use oxygen to nebulise β2 agonists
 Oral drugs as relievers

• Oral β2 agonists for intermittent airflow

obstruction.

• Oral prednisolone for rescue therapy

Managing acute episodes

Back to Arpit and his friends

 Case…..

Arpit decides to help his mother with Diwali cleaning. He

starts coughing continuously soon after and his mother
rushes him to the clinic…

What questions will you ask the mother?

interact !
 During an acute episode
Enquire
– Duration ?
– Relievers taken? - Response?
– Brittleness (Rapid worsening)
– Controller/ trigger factors
– On regular controller?
– Number and severity of previous attacks
– Last theophylline dose (if relevant)
 Case… contd
On examination, Arpit has a respiratory rate of 46 per
minute and a mild increase in accessory muscle activity.
He appears comfortable and is able to talk in sentences.
Auscultation reveals a wheeze towards the end of
expiration.

How will you grade Arpit’s acute attack and

manage him?
 Grading severity

• Over a period of time-

helps to decide regarding need and choice of controller
medications for long term control

• At a point in time -
helps to decide regarding the level of care and
drugs for an acute exacerbation
 Pulmonary score index
Score Respiratory Rate Wheezing* Accessory muscle
<6 years >6 years Sternomastoid activity
0 < 30 < 20 None No apparent activity
1 31–45 21–35 Terminal Questionable increase
expiration with
stethoscope
2 46–60 36–50 Entire expiration Increase apparent
with stethoscope
3 > 60 > 50 During inspiration Maximal activity
and expiration
without stethoscope

Score 0–3 Mild *If no wheezing due to minimal air exchange, score>3
4–6 Moderate
>6 Severe

Those children whose score is > 6 should be admitted to a pediatric ICU

 Home management
PS ≤ 3 (mild grade)

• SA β2 agonist: 2 - 4 actuations through MDI +

spacer + mask

• Repeat every 15 - 20 mins for max 3 times

• If response ill sustained (< 4 hrs), start 1st dose of

rescue steroid
 Case…..

Sanjana calls you in the middle of the night. She is

proceeding to the casualty once again. You rush in to
see her and find her to have a respiratory rate of 40 per
min. She has suprasternal recessions and auscultation
reveals wheeze throughout expiration.

Assess her severity and manage her

interact !
 Pulmonary score index
Score Respiratory Rate Wheezing* Accessory muscle
<6 years >6 years Sternomastoid activity
0 < 30 < 20 None No apparent activity
1 31–45 21–35 Terminal Questionable increase
expiration with
stethoscope
2 46–60 36–50 Entire expiration Increase apparent
with stethoscope
3 > 60 > 50 During inspiration Maximal activity
and expiration
without stethoscope

Score 0–3 Mild *If no wheezing due to minimal air exchange, score>3
4–6 Moderate
>6 Severe

Those children whose score is > 6 should be admitted to a pediatric ICU

 E Room plan
PS 4-6 (moderate)
• O2
• SA β2 agonist
– Nebulised q 20 min x 3
– or
– MDI + spacer + mask 2 puffs q 2 min or so till 6 puffs reached. Give 6
puffs like this q 20 min in the first hour.
– or (if inhaled therapy not available)
– Terbutaline single dose/Adrenaline 0.01mg/kg sc q 20 min x 3
• Commence / Continue rescue steroid
• Continuous assessment for 4-6 hours
• If good response(PS <3), decrease nebulisation to 3-4 hourly
Sanjana does not respond to this treatment. One
hour later, her respiratory rate has gone up to 50
per minute. You decide to admit her to the ward.
“What do we do next?” asks your resident doctor

Outline your plan to him

interact !
 Ward plan
• Continue Oxygen, IV/oral steroid

• Start IV fluids

• SA β2 nebulization - hourly/ back-to-back

• Ipratropium neb q 20 min x 3 and then q 6 hours

• Monitor SaO2 and serum K+

• CBC, X-Ray chest only to identify complications

• Pulmonary score q 15-30 minutes

 Intensify if not better…

• IV Magnesium Sulfate

• Consider blood gas studies if SaO2 < 92%

• IV aminophylline bolus followed by continuous iv infusion (skip

loading dose if already on SR theophylline)

• Terbutaline infusion if no response to aminophylline

• Consider transfer to PICU facility

Your resident doctor is new but means well. “What
complications should I expect?” he asks and
“Sir/Madam, no antibiotics? ” he continues with a
bewildered look.

What will you teach this young lad?

interact !
 Complications

• Atelectasis

• Secondary infection

• Pneumothorax

• Pneumomediastinum

• Subcutaneous emphysema

• Therapy related
 Role of antibiotics
• Limited role
• Consider only in those with
– purulent secretions and
– radiological evidence of pneumonia.

Bacterial infections seldom trigger asthma

 Do not routinely use
– Antibiotics
– Mucolytics
– Cough suppressants
– Sedatives
– Chest Physiotherapy
– Steam inhalation
 Case……
36 hours later Sanjana is showing signs of improvement. On
your morning round, you find her sitting up comfortably sipping
her tea. She says she slept well through the night. On
examination she is mildly tachypnoeic and her wheeze is now
only in the terminal phase of respiration.

“Can I go home?” she asks

When will you decide to discharge her?

interact !
 Stepping down acute care

Follow the principle “last in first out”

– Discontinue terbutaline /aminophylline drip in 24
hours
– Discontinue ipratropium neb in 24 hours
– Reduce SA β2 agonist to q 2-4 hrly and then q 4-
6hrly
– Replace iv steroid with oral steroid
 Discharge criteria

• Pulmonary score < 3

• Slept well at night

• Feeding well

• Appears comfortable.
• Not on any continuous infusions and receiving
less frequent β2 agonists (say 6 hourly)
 Cases…. contd

What will you advise Arpit and Sanjana when

they are ready to go home?

interact !
 Discharge plan
• Inhaled SA β2 agonist MDI + spacer + mask q 4-6
hour till symptoms abate
• Continue course of rescue steroid for 3-7 days
(Tapering not necessary)
• Educate regarding home plan / long term strategy

• Plan follow up visit within 7-14 days

• Review compliance, trigger elimination, controller

regime
 Case….
Meanwhile, Raju, a 8 year old with asthma is brought to the hospital in an
ambulance with oxygen by mask.

He is too breathless to speak, is sweating and quite agitated. On

examination his nails are dusky and on auscultation you hardly
perceive any air entry.

He has shown no response to 3 doses of nebulized bronchodilator given

while he was rushed in with sirens blaring.

“ACT FAST” beg the parents.

interact !
 Asthma
‘Red f lag’ signs
• Unable to talk or cry
• Cyanosis
• Feeble chest movements
• Absent breath sounds
• Fatigue or exhaustion
• Agitated
• Altered sensorium
• Oxygen saturation < 92%
 Treat or Refer?
• O2 to be continued but monitor SaO2

• Inj adrenaline / terbutaline sc

• Inhaled β2 agonist + Ipratropium to be started

• Inj Steroids and iv fluid therapy

• Arrange proper transport to ICU

Do not send the patient without

giving initial therapy.
Treat and refer!
 ICU plan

• Continue / initiate intensified ward plan

• Blood gas studies

• Possible intubation and mechanical ventilation

with ketamine and midazolam / fentanyl iv
infusion

• Paralysis with vecuronium, if required

 To summarize…

Diagnosis
• Asthma is an inflammatory illness

• Diagnosis of asthma is clinical, and relies on history

• All asthma does not wheeze

• In children < 5 yrs, consider differential diagnosis before labelling

• Many 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

• 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
 To summarize…

Acute management
• Grading at a point in time decides management

• SA inhaled β2 agonists are used to manage acute exacerbations

• Frequent use of SA β2 agonists indicate poor control of asthma

• Taking care of the home environment reduces exacerbations of asthma

Devices

• MDI should always be used with spacer

Ladies and gentlemen,

It’s time to acknowledge…

Asthma Training Module
Concept and
creation

Raju Khubchandani
RD Khare
Ajit Gajendragadkar
Sailesh Gupta
(Late) Jitu Vora
Indu Khosla
Daphin Fernandes
2013 Revision Team

Dr. Raju Khubchandani

Dr. Ajit Gajendragadkar
Dr. Varinder Singh
Dr. Sushil Kabra
Dr. G.R. Sethi
Dr. Sudarshan Reddy
National ATM Team 2011
TU SUKUMARAN President, IAP & Chairperson
President-Elect, IAP & Co-
ROHIT C AGRAWAL
Chairperson
DEEPAK UGRA Imm. Past President, IAP
Vice President, IAP & Writing
RAJESHWAR DAYAL
Committee
Secretary General, IAP & National
TANMAY AMLADI
Convener
SAILESH G GUPTA Treasurer, IAP
YK AMDEKAR Advisor
RP KHUBCHANDANI Advisor
H PARAMESH Advisor
VARINDER SINGH Advisor
SWATI Y BHAVE Advisor
GR SETHI Advisor
National ATM Team 2011
S NAGABHUSHANA National Convener
A BALACHANDRAN National Coordinator
D VIJAYASEKARAN Joint National Coordinator
SS KAMATH Joint National Coordinator
SUSHIL KUMAR KABRA SUBHASIS ROY
B S SHARMA JAGDISH CHINNAPPA
P SUDERSHAN REDDY PRAHALAD KUMAR A
RAJ TILAK SURESH BABU
S SANJAY SOMASHEKAR AR
PRADEEP SIHARE NC GOWRISHANKAR
APURBA KUMAR GHOSH DEVARAJ V RAICHUR
KALI KINKAR GHOSH K NAGARAJU
GAUTAM GHOSH INDU SANJEEV KHOSLA
PALLAB CHATTERJEE SHARAD AGARKEDKAR
 Revision done (2009)

A Balachandran
So Shivbalan
H Paramesh
S K Kabra
S Nagabhushana
Raju Khubchandani
D Vijayasekharan
G R Sethi Shishir Modak

Gautam Ghosh Varinder Singh

J Chinnappa Subhasis Roy

K K Ghosh Pallab Chatterjee
L Subramanium Suresh babu
Mahesh Babu T U Sukumaran
S Balasubramanian N K Subramanya
 Revision done - 2007

• Dr P.S. Suresh Babu &

Dr Gautam Ghosh
• Dr. S. Nagabhushana,
Chairpersons,
IAP Respiratory Chapter Coordinator, ATM ,
IAP Respiratory chapter

• Dr Mahesh Babu & Dr

K K Ghosh Secretary, And team
IAP Respiratory Chapter
 Idea

T U Sukumaran
Sachidananda Kamat
Swati Bhave
Special thanks

Academic grant from