CASE 1
18 months old is being treated for recurrent wheeze. He has day time symptoms 3 times a month .he wakes up due to cough often. He is now 10 kg and 79 cm in length
He had recurrent regurgitation in early infancy. He has received salbutamol and presdnisolone several timesHe had oozing lesions on cheek chest and abdomen in infancy
His mother is an asthmatic
Mother reports he is not active like other kids and more so when he gets wheeze.his cough wheeze usually lasts for 10 days or more.he has symptoms in-between wheeze like cough which is precipitated by activity
His father is smoker
He was preterm child with neonatal respiratory distress
CASE 2
6 YR old has recurrent wheezing since 1 yr. He had hospital admissions last year and one demanded icu stay.
He has night symptoms at least twice a month. There is also daytime symptom every week
He uses saba frequently
he was given Monteleucast for 6 months
He had spirometry once fev1/fvc .75
They live in a colony. There is firewood at home. He has a cat.the walls are not plastered
What is your comment?
Discussion
Both children have recurrent wheeze. But causes are different at a younger age
Older child with recurrent wheeze which responded to beta agonists is most likely to be asthma. He has significant daytime and night time aymptom with reduced fev1/fvc.older child with recurrent wheeze is most likely to be asthma
How to dx asthma in a child of 6 years?
H/o variable respiratory symptoms
Confirmed expiration airflow limitation
Cough,wheeze,breathlesdness and chest tightness are classical symptoms
Excessive variability in PEF in over 2weeks( PED Incresing above 13 %)
Ecessive variation in lung function (excessive variation in fev1>12% or PED >15%
BEONCHOdilator reveraibility
Fev risingn above 12%
After exercise a drop of 12% or more is suggestive
Fev1/fec less than .9 is abnormal in a spirometry
For children on inhalers we can ask for variable respiratory symptoms and with hold SABA for 4 hours ICS LABA for 12 hours for checking airflow limitation
What are the triggers?
What is the environmental history ?
How to avoid triggers?
What are the early risk factors asthma?
Parental asthma* Allergy:
•Atopicdermatitis(eczema)* •Allergicrhinitis •Foodallergy •Inhalantallergensensitization* •Foodallergensensitization Severe lower respiratory tract infection:
•Pneumonia •Bronchiolitis requiring hospitalization Wheezing apart fromcolds Male gender Low birthweight Environmental tobacco smoke exposure Reduced lungfunction atbirth Formulafeeding ratherthan breastfeeding
What are the differential diagnosis ?
Differential diagnostic possibilities for asthma
Infants and children
Upper airway diseases d Allergic rhinitis and sinusitis
Obstructions involving large airways
Foreign body in trachea or bronchus
Vocal cord dysfunction (VCD)
Vascular rings or laryngeal webs
Laryngotracheomalacia, tracheal stenosis, or bronchostenosis
Enlarged lymph nodes or tumor
Obstructions involving small airways
Viral bronchiolitis or obliterative bronchiolitis ,
Cystic fibrosis Bronchopulmonary dysplasia ,Heart disease
What are the laboratory findings?
LABORATORY FINDINGS
Lung function tests can help to confirm the diagnosis of asthma and to determine disease severity. Pulmonary Function Testing Forced expiratory airflow measures are helpful in diagnosing and monitoring asthma and in assessing efficacy of therapy.
Lung function testing is particularly helpful in children with asthma who are poor perceivers of airflow obstruction, or when physical signs of asthma do not occur until airflow obstruction is severe. Many asthma guidelines promote spirometric measures of airflow and lung volumes during forced expiratory maneuvers as standard for asthma assessment.
Spirometry is a helpful objective measure of airflow limitation (Fig. 169.3). Spirometry is an essential assessment tool in children who are at risk for severe asthma exacerbations and those who have poor perception of asthma symptoms. Valid spirometric measures depend on a patient’s ability to properly perform a full, forceful, and prolonged expiratory maneuver, usually feasible in children >6 yr old (with some younger exceptions).
Peak expiratory flow (PEF) monitoring devices provide simple and inexpensive home-use tools to measure airflow and can be helpful in a number of circumstances (Fig. 169.4). Similar to spirometry in clinics,poor perceivers of asthma may benefit by monitoring PEFs at home to assess their airflow as an indicator of asthma control or problems. PEF devices vary in the ability to detect airflow obstruction; they are less sensitive and reliable than spirometry to detect airflow obstruction, such that, in some patients, PEF values decline only when airflow obstruction is severe. Therefore, PEF monitoring should be started by measuring morning and evening PEFs (best of 3 attempts) for several weeks for patients to practice the technique, to determine diurnal variation and a “personal best,” and to correlate PEF values with symptoms (and ideally spirometry). Diurnal variation in PEF >13% is consistent with asthma
Superintendent, ICH.