Bronchial asthma in children

BRONCHIAL ASTHMA INBRONCHIAL ASTHMA IN
CHILDREN (treatment)CHILDREN (treatment)

Plan of the lecturePlan of the lecture
 1. INDICATIONS for HOSPITALIZATION
 2. Exacerbation treatment
 3. MEDICATIONS for basic therapy of BA3. MEDICATIONS for basic therapy of BA
 4.4. Step therapy of BA
 5. Inhalation technology by MDPI
 6. Allergen specific immune therapyAllergen specific immune therapy

INDICATIONS for HOSPITALIZATION
 Severe attack
 Poor efficacy for 2-6 hours of treatment
 Children with high mortality risk from BA:
Intubation or arteficial breathing supply in anamnesis;
Exacerbations for the last year that demand
hospitalization
Children with oral GCS treatment or those who stop it.
Children with frequent usage of β-agonists ( more than
1 inhalator per mo)
Psycho-social family problems or poor compliance.

Exacerbation treatment at ambulatory stage
 Inhaling short-acting β2-agonist every 20 min during the hour through
matured inhalator or spacer.
Fine response Incomplete response Bad response
 FEV1 more than
80%,
 effect of β2-
agonist is preserved
for 3-4 hours,
 continue β-
agonist every 3-4
hours for 24 hours
FEV1 60-80%, continue
β-agonist for 1-2 hours,
 add oral GCS0,5-1
mg/kg ( after prednisone)
 add inhalative
cholinolytic
 FEV1 less than 60%,
 continue β-agonist with
interval less than an hour
 add oral GCS 0,5-1 mg/kg
Add inhalative cholinolytic,
 Hospitalization with
emergency
Attend the doctor
for
recommendations
Immediately call the
doctor for
recommendations
Emergency hospitalization

Asthma exacerbation treatment algorithm in
hospital
Symptoms evaluation ( BA severity criteria)
Taking history, physical examining, lab data.
Initial therapy
1. О2 inhalation until saturation by О2 will be more than 95%;
2. Inhalation short-acting β-agonist: 2 inhalations of salbutamol through
matured device or 2,5 ml of salbutamol through nebulizer every 20 min for 1
hour.;
3. If response is absent or patient has previously take systemic GCS or attack
is severe : prednisone 1-2 mg/kg/day, max 20 mg for children of lessthan 2
years old and 30 mg of 2-5 years old.;
4. Sedative therapy is contraindicated during the exacerbation period.
Repeat evaluation of patients condition severity an hour later
FEV1, О2 saturation, another tests if necessary.

Attack of moderate severity Severe attack
FEV1 60-80%;
Symptoms of moderate severity,
accessory muscle involvement into
respiration act;
Therapy
 Inhalation β-gonist or cholinolytic
every 60 min;
 Oral GCS;
 Usage of methylxantines;
If treatment efficiant continue for 1-
3 hours.
Evaluate anamnesis : patient from the
list of high risk;
FEV1 less than 60%,
Symptoms are severe, retractions of
subclavicular pits;
Efficacy of previous therapy is absent
THERAPY
Oxygen therapy
Inhalation β-agonist or cholinolytic;
Systemic GCS;
It can be used IV injection of
methylxantines

Efficacy evaluation 1-2 hours later
Nice response Incomplete response Bad response
Condition improvement
is preserved 1 hour after
last medication intake
Physical examining is
normal ;
FEV1 is ore than 70%;
Distress is absent;
Sat О2 more than 95%
Evaluate anamnesis: patient of
high risk;
Physical examining: symptoms
are ranged from slight to
moderate;
FEV1 is less than 60%;
Sat О2 isn’t improve;
 Evaluate anamnesis: patient of high
risk;
Physical examining: symptoms are
severe, dizziness, conscience
confusion;
FEV1 less than 30%
РаСО2 45 mmHg;
РаО2 60 mm Hg;
Discharging home Continue treatment in hospital Transfer patient to rhehanimation
 FEV1 more than 60%,
Inhalation β-agonist
Oral GCS 3-5 дней
Patient tuition of correct
medication intake,review
of treatment plan,
physician observation.
Oxygen therapy;
 Inhalation β-agonist,
cholinolytic;
Oral or IV GCS 1-2mg/kg every 6
hours 1 day, later every 12 hours,
later once per day for 3 days .
FEV1, Sat О2 , pulse monitoring
Oxygen therapy;
 Inhalation β-agonist, cholinolytic;
IV GCS;
Possible IV injection of β-agonist;
Possible IV injection of methylxantines;
Possible intubation and artificial
ventilatory therapy (AVT);

MEDICATIONS for basic therapy of BAMEDICATIONS for basic therapy of BA
 Membrane stabilizers of mast cells: derivates of chromolicate acid -
(intal, chromohexal, chromogen), SODIUM NEDOCROMYL (tiled, tiled-
mint);
 Glucocorticosteroids
 Systemic (hydrocortizonehydrocortizone,, dexamethazonedexamethazone,, methylprednisolonemethylprednisolone,, prednisoloneprednisolone,,
polcortolonepolcortolone),
 Inhalation
 BeclamethasoneBeclamethasone ((becodisk,becodisk, becotidbecotid,, aldecinaldecin))
 Fluticasone propionatFluticasone propionat ((seretidseretid,, flixotidflixotid))
 BudesonidBudesonid ((PulmicortPulmicort))
 FlunisolidFlunisolid ((IngacortIngacort))
))
 β-agonists long-acting
 SalmaterolSalmaterol ((Serevent, Serevent rotadiskSerevent, Serevent rotadisk))
 KlenbuterolKlenbuterol ((SpiropentSpiropent))
 FormoterolFormoterol ((FormoteroloxisFormoteroloxis,, ForadilForadil))
 Leukotrien receptors antagonists (Acolad ((ZafirlucastZafirlucast),), SingularSingular
((MontelukastMontelukast)).)).

Control level Therapeutic activity
Controlled BA Minimal basic therapy to provide BA
control
Partially controlled BA Increase therapy (“step up”)
Uncontrolled BA Increase therapy until complete
control will be achieved
BA exacerbation Treat as an exacerbation
increase
Treatment approach based on control level

Обострение БА. Критерии тяжести
Criteria
Mild Moderate Severe
Threatening of
asphyxia
Dyspnea While moving While speaking In rest
Position Can lay Prefer to sit Orthopnoe (sitting
in banding
forward position
with fixing by
hands)
Speech Normal Interrupted, by
interrupted
sentences
By separate
words
Conscience Irritation is
possible
Usually agitation Usually agitation Somnolence,
sopor
RR Increased Increased Frequently
>30/min
Accessory
musculature
invovement
Usually NO Usually Usually Paradoxical
diaphragm
movement
+ SCS + urgent
allergologist
consulting/
hospitalization
Urgent
hospitalization!
Short acting
bronchodilators
Адаптировано из: GINA 2010: www.ginasthma.org

Clinic recommendations of children allergology and immunology 2010
(Ukraine)based on GINA (2009)
Step 1 Step 2 СStep 3 Step 4 Step 5
Patient tuition
Elimination measure
Short acting β2
– agonists per need
NO
Choose one of
the options
Prescribe one of the
options
Prescribe moderate or high
dosages of IGCS
ADD one or more
options to step 4
Low dosages
of IGCS
Low dosage of IGCS+ β2
–
agonist long acting
(LABA)
(preferable)
or
Add one or more options Minimal oral GCS
Or/and
or
Antileikotriens
(ALT)
Moderate or high
dosages of IGCS
or
LABA
Or/and
Anti- IgE
Low doasges of IGCSС +
ALT
or
ALT
Or/and
Low dosages of IGCS +
teophylline long released
Theophylline long released
Therapy increasing

Step therapy of BA
 Step 1, including reliever medication usage per need, is
assigned only for patients without support therapy. In the cases
of more frequent symptoms or episodic exacerbations constant
support therapy is necessary (Step 2 or more) as addition to
reliever medications.
 Steps 2-5 include reliever medications combination per need
together with support therapy. IGCS is recommended as initial support
therapy in patients with BA of any age at step 2.

Step therapy of BA
 At step 3 is recommended combination of IGCS in
low dosage together with LABA in fixed
combination Thanks to additive effect of combined
therapy low dosages are quite sufficient.
Increasing of IGCS dosage is necessary for
patients who hasn’t get control of BA after 3-4 mo
of therapy.

Step therapy of BA
 Monotherapy of BA without GCS is prohibited because it increases
significantly mortality risk for patients
 If control of BA is gained on the basic therapy by combination of
IGCS and LABA and is sustained more than 3 mo long it’s possible
to decrease steadily the dosages of medications.
 In severe BA and long non adequate previous therapy this period
may be more long – 6-12 months.
 Termination of support therapy is possible if complete control of BA
is present on minimal dosages of anti-inflammatory drug and
absence of symptoms recurrence during one year.

How to perform basic therapy in children with BA?
 To define control level of disease
 To choose medications
 To choose the type of inhalator device
 To define the date of next visit for
monitoring treatment efficiency

Sustaining treatment of BA:
Chromons
Sodium chromoglycate, Sodium nedocromil
 Activity mechanism: suppress inflammatory mediator releasing from mast cells;
influence on inflammatory process in respiratory tract during prolong therapy
hasn’t been proved
 Significance in BA treatment isn’t established
 It has been proved that Sodium nedocromil decrease relapsing of BA
exacerbations, but influence to another condition parameters in BA doesn’t
differ from placebo influences. .
 Side effects: irritability of pharynx and unpleasant taste.
Адаптировано из: GINA 2007: www.ginasthma.org; Клинические рекомендации по детской аллергологии и
иммунологии 2008

Sustaining treatment of BA:
Leikotriens antagonists
Антагонисты лейкотриенов
 Zafirlukast, Montelukast
 Activity mechanism: Leukotriens receptors blockage in respiratory tract or blockage of
5-lipoxygenase – prevention of leukotrien effects.
 Significance of BA therapy:
 Has weak variable bronchodilator effect
 Provide partial defending of bronchospasm after physical loading
 Decrease symptoms severity including cough
 Improve respiratory function,
 Decrease inflammatory activity in respiratory tract,
 Usually less effective than low dosages of IGCS
 Side effects: good tolerance. Can’t be completely excluded inducing of Chardge-Stross
syndrome. .
GINA 2007: www.ginasthma.org

Beclomethasone dipropionate, Budesonide, Fluticasone
propionate
Activity mechanism: inflammatory process suppression in respiratory tract
They are the most effective medications that suppress inflammatory process in
BA
They are recommended children of any age
 Effectively decrease symptoms of BA,
 Improve life quality and respiratory tract functioning,
 Decrease bronchial hyperreactivity,
 Inhibit inflammation in respiratory tract,
 Decrease frequency and severity of exacerbations, frequency of hospitalizations
 Decrease mortality rate in asthma
Dosing
 Main effect of IGCS can be gained in dosage of 200 mcg/day in Budesonide
 Dosage increasing provide non significant efficiency raising but increase side effects risk
 To get disease control adding of second medication for sustaining therapy is preferable
comparatively to IGCS dosage increasing
Sustaining therapy of BA: IGCS
Адаптировано из GINA 2009: www.ginasthma.org

Medication Low daily dosages
(mcg)
Moderate daily
dosages (mcg)
High daily dosages
(mcg)
Doses for children less than 12 years old
Beclomethasone
dipropionate 100-200 >200-400 >400
Budesonide 100-200 >200-400 >400
Flutikazone 100-200 >200-500 >500
Dosages for adolescencts
Beclomethasone
dipropionate 200-500 >500-1000 >1000-2000
Budesonide 200-400 >400-800 >800-1600
Flutikazone
100-250 >250-500 >500-1000
Equipotent day IGCS dosages
Эквивалентность (эквипотентность) препаратов определяли на основе их сравнительной эффективности.

Sustaining therapy of BA:
Long-acting β2-agonists (LABA)
SALMETEROL, FORMOTEROL
 Activity mechanism: produce bronchial smooth muscle relaxation ,decrease
vessel permeability, improve muco-cilliary clearance
 Its role in BA treatment:
 Can’t be used as monotherapy of BA as there are no evidence of their
antiinflammatory activity
 LABA must be used only in combination with adequate dosage with IGCS,
preferably in the fixed combination.
 They are effective concerning the symptoms, respiratory functioning,
exacerbations.
 Provide control of BA in majority of patients more promptly with lower dosages
comparatively to monotherapy by IGCS.

Why combined therapy is more effective in BA?
Respiratory tract
inflammation
Smooth muscle
dysfunction
Symptoms/Exacerbation
Respiratory tract remodelling
Main pathophysiologic components of BA
Antinflammatory
drugs BroncholyticsBroncholytics

Fixed combinations of IGCS +LABA
 Fluticasone propionate + Salmeterol (Seretide) from 4 years old
 Budesonide + Formoterol (Simbicort) from 6 years old
Usage of fixed combinations:
 Of the same efficiency as separate inhalators usage
 More suitable for patients
 Improves performance of doctor’s prescriptions by patient (compliance)
 Garantees usage not only the bronchodilator but antinflammatory drug as
well
GINA 2007: www.ginasthma.org
Sustaining therapy of BA:

Place of antileukotrien (AL) medications in therapyPlace of antileukotrien (AL) medications in therapy
of BAof BA
GINA recommendations
Toddlers
Controlled BA
Partially controlled BA (GCS or
AL medication)
Noncontrolled BA (GCS+ AL
medication)
Children older than 5 years
old
1 degree
2degree (GCS or AL
medication)
3 degree (GCS + AL
medication)
4 degree (GCS +AL
medication)
5 degree
PRACTALL consensus
or
или
AL medications
(Montelukast,
Zafirlukast,
Pranlukast)
IGCS AL
Insufficient control
Increase
IGCS
dosage
Add AL
1. Increase IGCS dosage,
2. Or add AL,
3. Or add LABA
Theophyllines
Oral GCS

Normal variability of inspiratory flow
Variability of inspiratory flow can provide inaquality
of medication distribution
Spirometric curves in patients with BA
Deep inhale – medication deposition in peripheral lungs
Scheme of medication distribution

Flowmetric curves in BA patient in repeating
respiratory attempts
Normal variability of inspiratory flow
Variability of inspiratory flow can provide
irregularity of medication distribution
Superficial respiration –deposition of drugs in central lung parts
Scheme of medication distribution

Devices for inhalation of medications
 Metered dosed aerosol
inhaler (MDAI)
 Meterd aerosol inhaler with
spacer (MDAI+ spacer)
 Meterd powder inhaler (MPI)
 Nebulizers

Technology of inhalation
with MDAI
 Stand up to increase mobility of diaphragm
 Take off cap from inhaler
 Shake up inhaler*
 Exhale through tightly closed lips to release lungs from
air
 Hold inhaler vertically tightly embrace it by lips and
simultaneously press MDAI and inhale
 Close lips and hold respiration for 10 sec
 Exhale by nose
After inhalation of IGCS obligatory rinseAfter inhalation of IGCS obligatory rinse
mouth by watermouth by water!!
*При использовании новых, бесфреоновых ингаляторов необходимость во
встряхивании баллончика отсутствует.

MDAI (metered dosed aerosol inhaler)
 Spacer usage considerably
decrease medication deposition
in oral cavity and pharynx ,
improve its delivery to lungs,
decrease topical and systemic
side effects due to IGCS
 Spacer usage is recommended
to patients, who can’t
coordinate inhaling with inhaler
activation
If you can’t synchronize MDAI inhaling use it together with
spacer
1. Адаптировано из: GINA 2007: www.ginasthma.org 2. Клинические рекомендации. Педиатрия. Бронхиальная астма.
А.А.Баранов (ред.) Гэотар-Медиа. 2005.

Optimal technology of aerosol inhalation through spacer is deep
slow inhale or two calm deep inhales ( 4-5 inhales for children)
after releasing of one dosage into the chamber or calm usual
breathing for children.
Technology of inhalation through spacer
MDAI combination with spacer
MDAI Spacer

 Special spacers are babyhalers
 They are supplied by the one side valve, that
prevent loosing of aerosol during inhalation
and holding aerosol particles during
exhalation.
 These spacers are used with special masks,
selected to mouth sizes and tightly adjacent
 to face.It can be used in infants and toddlers.
Клинические рекомендации. Педиатрия. Бронхиальная астма.
Inhalation technology through spacer in
infants and toddlers
Babyhalers

MDPI (metered dosed powder inhaler)
 Usage of MDPI doesn’t demand synchronizing of inhaling with inhaler
activation.
 Clinic effect of medications inhalation through MDI and MDPI is the same
as well in exacerbation and remission stage.
 Topical side effects are more rare in IGCS through MDPI.
 Nowadays there are such types of MDPI:
 Multidisk,
 Turbuhaler,
 Diskhaler,
 Aeroliser.

Inhalation technology by MDPI
 Prepare inhaler according instruction
 Perform exhalation
 Tightly cope mouth piece by lips
 Make prompt and deep inhalation

Multidisk
(Diskus, Accuhaler)
Mouth piece
Rod
Blister,
contained
60 medication doses
Free tape
Wheel
of dose
indicator
Device that
releases
medication

Nebuliser
 Types of nebulisers:
compressor
ultrasound
 Medication inhalation by nebulizer is performed for 5
min. Elongation of inhalation to 10 min provides non-
significant additional effect.
 Nebuliser is used predominantly during severe BA
exacerbation

Nebuliser working scheme
Сжатый воздух
Inhaled aerosol
Mouth piece with exhaling valve
Exhaled air
Клапан вдоха
jet
Medication
container

Choice of inhaling device for children
Age Preferable device Alternative device
Less than 4 years
old
MDI + spacer with facial mask Nebulizer with facial mask
4–6 years old MDI + spacer with mouth peace Nebulizer with facial mask
Older than 6
years old
MDPI or MDI with spacer and mouth piece Nebulizer with facial mask or
mouth peace
1. GINA 2007: www.ginasthma.org 2. Клинические рекомендации. Педиатрия. Бронхиальная астма. А.А.Баранов (ред.) Гэотар-

Medications for nebulizer therapyMedications for nebulizer therapy
 VentolinVentolin ((in nebulain nebula 2,52,5 mlml/2,5/2,5 mgmg in undiluted formin undiluted form))
 BerodualBerodual ((solution for inhalationssolution for inhalations 2020 ml in flaconisml in flaconis))
 In mild attackIn mild attack 0,1 – 0,020,1 – 0,02 mlml//kgkg onceonce
 In moderate BA attackIn moderate BA attack 0,15 – 0,030,15 – 0,03 mlml//kgkg
 In severe BA attackIn severe BA attack 0,150,15 ml everyml every 2020 minmin 33 timestimes,, laterlater 0,15 – 0, 30,15 – 0, 3
mlml//kg everykg every 33--44 hourhour..
 Prolong therapyProlong therapy 24 – 4824 – 48 hourshours, 0,25, 0,25 everyevery 44--66 hourshours..

Asthma control is the
main physician task

Allergen specific immune therapyAllergen specific immune therapy
 Nowadays is the only effective treatment methodNowadays is the only effective treatment method
that provides changing of natural course of allergicthat provides changing of natural course of allergic
diseases and prevent BA development in patientsdiseases and prevent BA development in patients
with allergic rhinitis.with allergic rhinitis.
 Standard allergen vaccines are used.Standard allergen vaccines are used.
 Under the influence of allergen specific immuneUnder the influence of allergen specific immune
therapy there is tendency to bronchial reactivitytherapy there is tendency to bronchial reactivity
decreasing . It permit to get full control of BA.decreasing . It permit to get full control of BA.

Bronchial asthma in children

More Related Content

What's hot (20)

Viewers also liked (18)

Similar to Bronchial asthma in children (20)

More from Ganapathy Tamilselvan (20)

Recently uploaded (20)

Bronchial asthma in children

Editor's Notes