Asthma in children

Asthma is a chronic inflammatory disease of airways. It is a heterogenous disease with various phenotypes which include – allergic asthma, non-allergic asthma, adult -onset asthma and asthma with obesity. 

SYMPTOMS

1. Children with asthma have repeated episodes of respiratory symptoms including

• Cough 
• Chest tightness
• Noisy breathing (wheezing)
• Shortness of breath / breathing difficulty

2. These symptoms change with time and in severity also 

3. Symptoms are more at night or in the early morning 

4. Episodes are often triggered by 

• Viral infections
• Seasonal change
• Exposure to cold
• Exercise
• Allergen exposure
• Irritants 

5. These episodes may start in early childhood or in older children also

6. They often have multiple such episodes with frequent hospital visits and respond to inhalation treatment

7.They may have associated allergies including eczema, allergic rhinitis or food allergy

8. There may be family history of asthma or allergy 

DIAGNOSIS

• Characteristic respiratory symptoms suggestive of asthma 
• Low forced expiratory volume in one second (FEV1) with spirometry (Lung function tests)
• Low FEV1/FVC ratio (FVC-Forced vital capacity) with spirometry
• Excessive variability in lung function  – Measured by bronchodilator reversibility or average diurnal variability 
• Few children may need other test like allergic testing, CXR as per clinical condition

CONSEQUENCES IF NOT TREATED ADEQUATELY

• Recurrent respiratory symptoms requiring frequent hospital visit / hospitalization
• Can develop life threatening asthma attack
• Impaired growth 
• Loss of school because of frequent respiratory exacerbations
• Poor lung growth and risk for chronic lung disease because of recurrent respiratory symptoms
• Economic burden

MANAGEMENT 

Prevention – Avoid triggering agents

• Precautions during season change
• Avoid contact with persons with acute respiratory infections
• Avoid cold air/food
• Avoid known allergens 

Inhaled medications

• As the main pathology is in airways, inhaled medications are the primary treatment modality
• Two types of medications are available – one for acute symptom relief and other for controlling ongoing inflammation of airways 
• The choice of drugs depends on the age of the child and frequency of symptoms
• The drugs can be taken either by nebulization or by Metered-Dose Inhaler (MDI)
• MDI treatment is preferred in the long term as they are safe, effective and can be used outside home settings as well
• Reliever medications
  • For acute symptom relief – Bronchodilators which increase the size of the airways and provide immediate symptom relief; Action is short lasting
  • Include salbutamol and Levosalbutamol
• Controller medications
  • Inhaled steroids which control the ongoing inflammation of airways and decrease the frequency of asthma attacks
  • Include – Budecort, Beclomethasone, Fluticasone, Ciclesonide
• Allergic rhinitis

• Antihistamines – cetirizine, fexofenadine 
• Intranasal steroids – Mometasone, budesonide and beclomethasone
• Other medications

• Anticholinergics – Ipratropium, tiotropium
• Leukotriene receptor antagonist (LTRA) – Montelukast and Zafirlukast
• Long acting beta agonists (LABA) – Salmeterol and Formoterol
• Oral corticosteroids
• Omalizumab and other biological agents 

POOR SYMPTOM CONTROL DESPITE THERAPY

• Look for proper technique; Use of spacer in every child and mask in younger children
• Compliance to therapy – check the number of canisters used with time, doses left in the canister
• Identifiable triggers
• Comorbidities – Obesity, rhinitis, rhinosinusitis and  gastroesophageal reflux
• Review the diagnosis of asthma 

ACUTE ASTHMA ATTACK

• Every child should have a written asthma action plan
• Identified by increased respiratory symptoms including cough, chest tightness, difficulty in breathing with viral infections or exposure to trigger
• Give reliever medication every 6 hourly at home; Continue controller medication
• Supportive treatment including paracetamol for fever and antihistamines for running nose
• If improvement in symptoms, give reliever medication for 1-2 days and stop
• If there is no improvement in symptoms in 48 -72hours or if any further worsening, visit a nearby hospital immediately and exacerbation treated as per the severity of symptoms

Most children with asthma do well with inhaled therapy if compliance is good; Only few children may need advanced therapies