MANAGEMENT OF CHILDHOOD ASTHMA AT PRIMARY CARE LEVEL

DR. M.A.SUBHANI
MBBS, DCH

ASTHMA IS HYPER REACTIVITY OF AIRWAYS
While managing the suspected patients of asthma, the physicians should try to find out the
answers to the following questions and act accordingly.

Majority of the patients consult the physician during the attack not during the remission. It is the foremost duty of the physician to control the current attack at the earliest by the judicious use of the drugs.In addition to it the physicians should not forget to apply the the prevention for the future attacks and the education of the patients and family members.

* Is it asthma?     * Is it severe?    *  Does it need admission?       * Investigations are required?

* What treatment is needed?--OPD, dose, form of the drugs to be used. * What about long term management?

* What other supportive treatment is needed and would be helpful?-- Antibiotics, cough syrups, antihistaminics, chest balms, immunoglobines, steam, chest physiotherapy

* How to prevent the future attacks?      * What to avoid?                   * What education of the family would be helpful?

* Have we achieved the desired control?

Contrary to common thinking asthma is quite common in children. It is uncommon below 2 years of age though this may occur.Heredity plays a role in asthma, but family history is not found in about 40% patients.By nature the illness runs a long or life long course in recurrent episodes with remissions in between.
Asthma usually present as cough breathlessness and wheeze, but "all that wheeze is not asthma" at the same time wheeze maynot be detected in all the asthmatics.Usually there is history of similar attacks in the past (recurrent attacks) responsive to bronchodilators.In between the attacks the child may not have any problem and there may not be any abnormal finding. In some patients it may present only with cough or wheeze without breathlessness. Generally the problems are more common in the night

CONSIDER THE POSSIBILITY OF ASTHMA IF THERE IS HISTORY OF :

  • Repeated attacks of cough, breathlessness, and or wheezing,either singly or in combination. History of improvement with the use of bronchodilators also favors the diagnosis of asthma.
  • Repeated diagnoses of bronchitis or repeated and prolonged attacks of cold
  • Repeated diagnoses of nonpyogenic pneumonia
    •

    Precipitating factors may not be identified in some patients but it is not a must for the management of acute attack . Identification of precipitants / triggering factors is helpful in the prevention of attacks
    The  documented  factors are :
    viral URIs, allergens, irritants,emotions,drugs, food additives, cold air, exercise,and reflux esophagitis, contact with pets
    this is not the complete list. Despite all the precautions taken by the patient's attendants (e.g. about food, weather) the child may develop asthmatic attack as some of the triggering factors remain undetected or contact with them is unavoidable

    The most important aspect in the management is identification of severe attack at the earliest.

    FOLLOWING ARE SUGGESTIVE  OF  SEVERE   ATTACK

    Following are suggestive of very severe attack and may be life threatening.
    Drowsiness
    Cyanosis
    Silent chest (absence of wheezing) in presence of breathlessness
    Sudden severe chest pain (possible airleak)

    Laboratory tests which document reversible airway obstruction (peak flowmetry at home or in clinic, spirometry is more helpful) are highly suggestive of asthma. They are difficult to be used in small children and are not practicable in all practices. Eosinophil countand  x-ray chest are commonly used but  they are not to be used routinely, as presence of abnormal findings is not confirmatory of asthma and their absence does not exclude the possibility of asthma.Skin allergy test have limited usefulness they can be used selectively.
    X-ray is to be advised on the first attack,severe attack / worsening of attack or noimprovement despite the treatment, the main aim in these patients is to find out / exclude coexistent pneumonia,air leak, collapse or foreign body.
    ABG( arterial blood gas)and oxygen saturatione stimation is not practicable in primary care

    IN PRIMARY CARE SETTINGS DIAGNOSIS OF ASTHMA AND ASSESSMENT OF ITS SEVERITY FOR THE MAJORITY OF THE PATIENTS IS DONE CLINICALLY ( HISTORY AND CLINICAL EXAMINATION )

    Aims of the treatment are :

    * relief from the symptoms      * prevention of recurrence of attacks    *  Restoration of physical activity, undisturbed sleep, speech and growth      * minimization of drug toxicity

    The plan for the treatment is based on :
    a) severity of the current and past attacks b) frequency of attacks in the past

    COMMONLY USED DRUGS

    DRUG                    ROUTE   DOSE & FREQUENCY          CONTRA-INDICATION                SIDE-EFFECTS

    FOR  TREATMENT

    ADRENALINE           0.01ml/kg S/C (maximum0.3ml)                                             palpitation,tremor, irritability,

    AMINOPHYLLINE       10-15mg/kg/day divided 8-12 hrly orally             anorexia, nausea, vomiting, palpitation,  convulsions
                                       4-6 mg/kg IV  diluted slowly     continuous infusion is not advisable in family practice.

    SALBUTAMOL(Ventolin)  0.3mg/kg/day divided6-8 hrly                                                     palpitation,tremor, irritability,
                                      4-6micro gram/kg / dose S/C or IM
                  Metered dose inhaler (MDI 100micro gram/ puff )      1-2 puffs 6 hrly
        Nebulization solution 0.01ml / kg in 1-2 ml saline  It is considered best mode , quick and relatively  toxicity free

    TERBUTALINE (Bricanyl)
                                             10mcg/kg/dose S/C or IM                                                                palpitation,tremor, irritability,
                         Metered dose inhaler (MDI_250mcg/puff)            1-2 puffs 6 hrly

    THEOPHYLLINE      15-20mg/kg/day divided 8-12 hrly                  anorexia, nausea, vomiting, palpitation,  convulsions

    MDI are relatively safe & have no extra risk for children. 1-2 puffs can be used every 6 hrs without the risk of overdose. The main disadvantage is that some patients develop  false sense of security, this may lead to undue delay in consultation in emergency situations.

    FOR  PREVENTION  not  effective in all the users & effect start after few weeks (4-6)
    CROMOLYN (Intal)        20 mg by inhalation every 6hrs
    KETOTIFEN (Zaditen) 0.5mg (below 3years) 1.0mg ever y 12hrs             

    MONTELUKAST  is marketed as a once daily   preparation, 10 mg plain tablets with 5 and 4 mg chewable tablets for younger children. It's efficacy is modest but often adequate for those with mild chronic disease. There is some additive effect with inhaled steroids. So far no toxicity or drug interactions has been described.

    Tolerance may develop to B1agonists.  Tolerance to xanthines has not been reported.
    B1agonists and xanthines may be used in combination. when used in combination the dose is to be reduced for both the drugs.
    In severe attacks steroids are required and used, they act as anti-inflammatory They are not the replacement of bronchodilators. Bronchodilators need to be continued with steroids. Oral, injectable and inhaler forms are available.

    Benefits of using antihistaminic , cough syrups, and immunotherapy have not been proved. In fact these may worsen the condition in some patients. Avoid sedatives in asthma patients specially during the severe attacks
    Antibiotics are not to be used in all the asthmatics but do not avoid their judicious use.

    MANAGEMENT OF ACUTE ATTACK

    THE MOST IMPORTANT DECISIVE FACTOR ABOUT THE TREATMENT OF ACUTE ATTACK, IS SEVERITY OF CURRENT ATTACK

    For the control of acute attack use any of the following

    MDI ( metered dose inhaler)  2 puffs, in very young children the drug can be pushed by pressing the inhaler against the inner aspect of cheeks. The drug is absorbed effectively from there. Spacers also increase the ease of use of MDI. MDI can be repeated after one hour, if there is no response again 2 puffs.

    Beta stimulants ( salbutamol ) can also be given by nebulization route : 0.01 ml / kg in 1-2 ml saline, nebulization can also be repeated after one hour, if there is no response, in the same dose

    Injection adrenalie or salbutamol 0.01ml kg subcutaneously. The injections can be repeated after 15-20 minutes if there is no response.

    In addition to the bronchodilators steroids can also be used specially if the attack is moderately severe. Steroids are very effective but they take long(few hours) to exert their effect.

              Anti-asthma drugs may be used on suspicion by the attendants, and may be life saving at times.

    LONG TERM TREATMENT

    PLAN FOR LONG TERM TREATMENT IS BASED ON SEVERITY AND FREQUENCY OF  ATTACKS

    All asthmatic children do not need long term maintenance treatment. If the attacks in the past were not frequent  ( less than 2/ week in the day time or less than 2 / month in the night time) long term treatment is not required, these children need treatment only for the control of acute attack on SOS basis. If the frequency was more than this the child needs long term maintenance treatment

    Maintenance Therapy
    Start with
    Low-dose Inhaled Corticosteroids or long acting bronchodilators( theophylline or salmeterol )
    (montelukast for mild chronic asthma)

    if not improving.

    Inhaled corticosteroids and long acting bronchodilators( theophylline or salmeterol )
    (or montelukast if great effect not needed)

    or

    Alternate-morning oral corticosteroids
    and
    theophylline
    and

    SOS  intervention with inhaled brochodilators and regular use of oral steroids

    MDI are quick acting, relatively toxicity free and in the long run cheap. They are also easy to use( if the consumer is    properly trained), the spacers further ease up the use.

    Inhaled steroids are relatively safe. They do not have the significant toxicity as compared to systemic steroid use. Common side effects of inhaled steroids include cough, dysphonia, throat irritation and oropharyngeal candidiasis. Using a spacer, rinsing the mouth after using the inhaler and decreasing the frequency of use can reduce the incidence of these side effects.

    Majority of the patients do not remember the frequency of attacks and do not maintain a record for it. That is why step therapy plan may not be practicable. The above mentioned plan is essentially the same but without the categorization of the patients.

    Patient treatment should be reviewed every 3-6 months; stop  high dose oral steroids if the response is  prompt i.e. within a few days, ( use inhaled steroids ) otherwise continue to make them stable for 1-3 months before attempting more gradual cut down.

    Supportive treatment

    The best cough remedy for the majority of asthmatic children are bronchodilators. There is no additional benefit of using cough syrups and antihistminics. In fact they may cause harm as they cause thickening of the sputum.

    Antibiotics are not needed for all the asthmatics. They are beneficial if the patient develops super added infection.

    Chest balms and lotions are not needed but they are commonly used. In some patients they may cause allergy and worsening of the condition. Chest physiotherapy is helpful in some patients. Cool mist is more helpful than the steam.

    Have we achieved the desired control?

    Criteria for Control the  of Asthma

    COMMON MISCONCEPTIONS ABOUT ASTHMA   ---- It is commonly believed that asthmaa is caused by the exposure to cold, sleeping under the fan or use of air conditioner.Some of the foods are also believed to cause this e.g. ice cream,cold drinks lassi( yogurt drink) etc. It is to be explained that they are not the cause but may precipitate asthma.
    --- It is a common misconception that the diagnosis is not justified in the absence of abnormal findings on x-ray chest / laboratory tests.
    --It is a common fear that regular, repetitive / prolong use of drugs, cause dependence, (asthma attack will occur at the discontinuation of the drugs and will be more severe). The attendants need to be convinced to continue the drugs for long period if required.
    ---Inhalers are considered difficult to use and more harmful for the children, this is not true.
    ---Asthma is considered incurable,this is true but attendants should be explained that it is completely controllable with effective treatment in the majority of the patients, control it and  patients lead normal life .
    ---It is believed that asthma is spontaneously cured at puberty, this is not universal, it should be explained quite clearly that in the majority frequency and severity of attacks decrease significantly at puberty

    COMMON PITFALLS ABOUT ASTHMA:-                                                                                                  Exclusion of the possibility of asthma in absence of family history / findings (clinical or laboratory)
    -- underestimating the severity of attack
    -- Thinking that MDI are more toxic and difficult to use
    - - undue avoidance or use of steroids
    -- undue fear about the use of adrenaline in emergency situations, it may be life saving
    --  undue faith on cough syrups, antihistaminics  and Vicks, some times they may aggravate the attack
    --Use of sub therapeutic doses of drugs because of undue fear of toxicity
    --- undue reliance on preventive drugs, thinking that regular use of
    preventive drugs prevents further attack in all patients
    - unneeded use of antibiotics in all asthma patients
    --not educating the attendants for: how to identify severe attack and what to do in this situation

    EDUCATION OF THE ATTENDANTS                                                                                                        Motivation for the acceptance of diagnosis in the absence of abnormal findings.

    Educate for compliance and not to discontinue the drugs too early even if there is apparent  improvement

    Explain that asthma is not curable but tell them, in the majority of patients it is completely controllable and patients lead normal life without any sufferings. Educate the patients not to loose hopes unduly.

    Always explain how to identify severe attack and what to do in these situations

    How to use MDI, spacer, and nebulization at home

    NOTE :- in young children response to therapy is unpredictable and compliance is not upto the desired level. For these reasons management of asthma in young children requires more attention and efforts
    In the developing countries where sanitation is not upto the desired level, for all the children suspected as asthma patients, do not forget the possibility of intestinal worms. Deworming drugs can be used on suspicion, as they are cheap and relatively toxicity free.
    Another possibility is Tropical pulmonary eosinophilia.
    These possibilities should specially be considered if the suspected asthma patients do not improve with conventional asthma treatment.

    Hosted by www.Geocities.ws

    1