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1、Asthma Diagnosis and Management in preschool childrenWheezing and Asthma in Preschool childrenlWheezing attacks are extremely common in young childrenlMost children with wheezing will not become asthmatics lViral infections are the most common precipitants of wheezing and asthma attacks213 month old
2、 boy- presented 2 day history of fever, URI followed with first episode of wheezinglWhat is the diagnosis?lResp rate 40 per minute, SaO2 in room air 89%, diffused rhonchi bilaterallylDo you prescribed bronchodilator?lShould we use systemic steroid?3Diagnosis in preschool childrenlDiagnosis mostly ba
3、sed on historylRecurrent episodes of wheezing attacks associated with coughinglSymptoms, family history, personal history of atopic diseases, responses to treatmentlInvestigations lung function study not possible except in the research centers4Differential diagnoses:The younger the child, the more l
4、ikely that it is not asthmalStructural abnormalities:lTracheomalasia, vascular ring, congenital heart conditionslFunctional: lReflux, foreign bodylInfections:lRecurrent viral infections, TBlOthers:lImmunodeficiency, BPD, Cystic fibrosis5Danger signal:Poor response to RxFailure to thriveThe difficult
5、ies of treating wheezing illness in pre-school childrenVariable to no responseGood response to RxGood response to RxGood response to RxAcute wheezing Mild-severe, few 3 / yr 3 /yr episodesSymptoms /URI Short lasting, 7 days 7 daysInterval symptoms Little/none some interval interval symptoms& Family
6、Hx Atopy symptoms exercise Family history Viral infections (common colds) trigger the majority of asthma exacerbationsChildrenAdultsNicholson et al. BMJ (1993) 307:982 Johnston et al. BMJ (1995) 310:1225ChildrenAdultsRuuskanen et al. (2006)Wark et al. ERJ (2002) 19:68 Johnston NW et al. (2005) JACI
7、115:132 The September asthma epidemicAcute asthma is preceded by common coldsJohnston et al. Johnston et al. BMJ BMJ (1995) 310(1995) 310: :1 122225 5Rhinoviruses & wheeze in Asia60 infants & children. Hospitalized for asthma in SingaporeDetection rate: 80%, RV: 53%Ong et al. Singapore Med J (2007)
8、48:291Out of 289 nasal specimens from hospitalized children in Thailand, 87 (30%) infected with RV, association with wheeze. RV-C prevalentLinsuwanon et al. J Infect (2009) 59:115426 nasal specimens from hospitalized children in Hong Kong. Total virus detection rate 239/426 (56%). RV 151 (35.4% of a
9、ll, 63% of positive). Cheuk et al. Pediatr Infect Dis (2007) 26:99562% (145/231) virus detection rate in children hospitalized with wheeze in Korea. RV 33%Chung et al. J Med Virol (2007) 79:1238Clinical and laboratory features of patients and controls : Mak et al Pediatr Infect Dis J. 2011;30:749-53
10、.FeatureAsthma exacerbation (n = 128)Inpatient controls (n = 192)PAge, years5.6 (3.6)5.4 (3.8)0.601Male, n (%)86 (67.2)128 (66.7)0.923HRV detection in NPA Any HRV (%)107 (84.9)63 (33.0)0.001 HRV-A (%)19 (15.1)23 (12.0)0.501 HRV-B (%)04 (2.1)0.153 HRV-C (%)88 (69.8)36 (18.8)0.001 Duration of hospital
11、ization, days3.0 (3.3)4.4 (5.0)0.005Supplemental oxygen, n (%)6 (4.7)8 (4.2)1.000Need for intensive care, n (%)02 (1.0)0.519Mortality, n (%)01 (0.5)1.000Results expressed in mean (S.D.) unless stated otherwise. NPA was insufficient for testing in 2 cases. Odds ratio (95% confidence interval): 10.04
12、(5.93 16.97)Mechanisms: bronchiolitis and viral induced wheezeNEJM Jan 7th 201613Pathophysiology of bronchiolitisMeissner HC NEJM Jan 7th 2016Many RCTs, meta-analysis, review performed:Gadomski Cochrane Review 2010 Glen Flores Pediatrics 1997Bronchodilators for bronchiolitis: Duration of hospitaliza
13、tion:Gadomski & Bhasale. Cochrane Review 2010Bronchodilators for bronchiolitislNo effects on oxygenationlNo effects on duration of hospitalizationlNo reduction of admission if used in outpatientslTransient and minor improvement of clinical symptoms scoresWhat if the child comes from high risk family
14、 with recurrent episodes of wheezing?lDoes systemic steroid reduce the severity of the acute episode?lDoes early use of steroid have long lasting effect?lWhat should be the most appropriate treatment?What if the child comes from high risk family with recurrent episodes of wheezing?lDoes systemic ste
15、roid reduce the severity of the acute episode?lDoes early use of steroid have long lasting effect?lWhat should be the most appropriate treatment?Systemic steroid for hospitalized preschooler with viral induced asthmaStudy designlRCTl687 Subjects: 10 -60 months l(mean age 26 months)lViral induced whe
16、eze admitted to 3 hospitals in UKlTreatment: 5 day course of oral prednisolonelPrimary outcome: duration of hospitalizationResults: Oral prednisolone of no benefitsMeissner HC. New England Journal of Medicine Jan 7th 2016Table 2 Steroid for acute wheezinglFor hospitalized patients, oral steroid will
17、 not reduce the severity or shorten the length of hospitalization.lFor outpatients, oral steroid will not reduce the severity of wheezing attacked associated with respiratory infections.lWhat about intermittent use of ICS/LTRA for recurrent wheezing?Intermittent use of ICS or LTRA?Research design:23
18、8 randomized96 allocated LTRA95 analysed96 allocated Budesonide96 analysed47 allocated placebo46 analysedSubjects: n=238Inclusion: 12-59 months, at least 2 wheezing attacks in past yr, one within 6 months, one witnessed by doctor, no use of maintenance controllersAssessment: Validated Pediatric Asth
19、ma Caregiver DiaryTreatment started at the first symptoms of respiratory tract infections for 7 days5 mg daily 1 mg budesonide by neb placeboResults:Bacharier et al JACI 2008Intermittent ICS or LTRA in preschool children: Intermittent ICS or LTRA in preschool children: The CARE network AIMS trial Th
20、e CARE network AIMS trial Budesonide Montelukast PlaceboBudesonide Montelukast Placebo n=96 n=94 n=47 Trouble breathing 4.2 * 4.2 * 6.7 Activity Interference 4.8* 4.3* 7.0 Wheezing 4.3 3.8* 5.7 Total Symptom score 5.8* 5.4* 7.6 * p 0.05 * p 3 / yr 3 /yr episodesSymptoms /URI Short lasting, 7 days 7
21、daysInterval symptoms Little/none some interval interval symptoms& Family Hx Atopy symptoms exercise Family history ConclusionslCurrently, the treatment aim is symptomaticlDiagnosis: Clinical historylViral induced wheeze: Treatment of acute episodes unchangedlOxygen, lSystemic steroids: Not usefullHigh-dose inhaled steroids, montelukast- some effectslAtopic asthma: lMaintenance ICS or LTRACareful evaluation of each patients to decide the types of treatmentJayson, 22 monthsKristy, 25 monthsYee Wah, 19 monthsNo smokingThank you
