2. Preschool Wheezy Children
Gamal Rabie Agmy, MD, FCCP
Professor of chest Diseases, Assiut university

3. Definition of Asthma

A chronic inflammatory disorder of the airways

Many cells and cellular elements play a role

Chronic inflammation is associated with airway
hyperresponsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest
tightness, and coughing

Widespread, variable, and often reversible
airflow limitation

4. Asthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, MD

5. Mechanisms: Asthma Inflammation
Source: Peter J. Barnes, MD

6. Asthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, MD

7. Asthma Pathobiology
Smooth Muscle
Dysfunction
•
•
•
•
Bronchoconstriction
Bronchial Hyperreactivity
Hypertrophy/Hyperplasia
Inflammatory Mediator
Release
Airway
Inflammation
• Inflammatory Cell
Infiltration/Activation
• Mucosal Edema
• Cellular Proliferation
• Epithelial Damage
• Basement Membrane
Thickening
Symptoms/Exacerbations

8. Pathology of Asthma

9. Factors that Exacerbate Asthma






Allergens
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs

10. Factors that Influence Asthma
Development and Expression
Host Factors
 Genetic
- Atopy
- Airway
hyperresponsiveness
 Gender
 Obesity
Environmental Factors
 Indoor allergens
 Outdoor allergens
 Occupational sensitizers
 Tobacco smoke
 Air Pollution
 Respiratory Infections
 Diet

11. Is it Asthma?

Recurrent episodes of wheezing

Troublesome cough at night

Cough or wheeze after exercise

Cough, wheeze or chest tightness
after exposure to airborne allergens or
pollutants

Colds “go to the chest” or take more
than 10 days to clear

12. 90% of the asthma problem is not seen:
The inflammation!!!
Bronchospasm= 10%

13. Symptoms
When this disappears…
Have we eliminated this?
Underlying
disease

14. Pediatric Asthma
Not all wheezing is asthma
Wheezing occurrences in children:
- single episode in 30% to 50% of children
before 5 yr of age
- 40% who wheeze before 3 yr of age continue
at 6 yr (“persistent wheezers”)
- 50% of infants who wheeze once will wheeze
again within several months

15. Wheezing in Children - Phenotypes

16. Childhood asthma phenotypes

17. Childhood asthma phenotypes
*A 2012 study described 2 "new" phenotypes for
young children with wheezing: "boys atopic
multiple-trigger" and "girls nonatopic uncontrolled
wheeze". JACI, 2012.
*Toward a definition of asthma phenotypes in
childhood: early viral wheezers, multitrigger
wheezers (MTWs), and nonatopic uncontrolled
wheezers (NAUWs). Some children have “allergic
bronchitis” rather than “asthma”. JACI, 2012.

18. Diagnosing Asthma in Young
Children – Asthma Predictive
Index
• Major criteria
– Parent with asthma
• > 4 episodes/yr of
– Physician diagnosed
wheezing lasting
atopic dermatitis
more than 1 day
affecting sleep in a
• Minor criteria
child with one MAJOR
– Physician diagnosed
or two MINOR criteria
allergic rhinitis
– Eosinophilia (>4%)
– Wheezing apart from
colds
1Adapted
from Castro-Rodriquez JA, et al. AJRCCM 2000; 162: 1403

19. Modified Asthma Predictive Index (API)

20. Cough-variant asthma
Cough-variant asthma presents as dry
cough at night. It worsens with exercise
(EIA) and nonspecific triggers (cold air).
Cough-variant asthma responds to asthma
therapy with ICS.
Cough-variant asthma is diagnosed with
pulmonary function testing (PFTs) with
response to bronchodilator. The most
common cause of chronic cough in children
is cough-variant asthma.

21. Guidelines National Heart, Lung, and Blood Institute (NHLBI) guidelines
for diagnosis and management of asthma
Key concepts:
- severity dictates therapy
- - distinction between intermittent and persistent asthma
- - "rule of 2s”
- - 4 levels of asthma severity - intermittent; 3 sublevels of
persistent
- - inhaled corticosteroids (ICS) preferred for all levels of
persistent asthma
- - use of asthma action plans
- - spirometry recommended

22. Rule of 2s
- if symptoms are present for more than 2 days per
week or for more than 2 nights per month, asthma
categorized as persistent.
- Within this category, disease must be classified as
mild, moderate, or severe. However, as severity of
asthma not constant, must monitor patients for
changes; as severity changes, therapy should
change too.
- The category of “mild intermittent” asthma was
eliminated in the 2007 guidelines - now it is just called
“intermittent” asthma.

23. The concepts of “impairment”, “risk”, and “control” were
introduced in the 2007 guidelines:
- impairment - refers to symptoms
- - risk - refers to likelihood that the patient will eventually
have exacerbation of asthma and present to emergency
department (ED) or hospital, or need course of oral
corticosteroids
- - control - refers to the level of patient’s asthma control

24. Classification of asthma severity
- impairment domain - daytime and nighttime symptoms
(rule of 2's), use of short-acting beta-agonist (SABA),
interference with normal activities
- - risk domain - number of exacerbations per year (if more
than 2, daily controller medication is needed). Increased
risk is conferred by parental history of asthma or history of
eczema.
- Childhood Asthma Control Test (ACT) is validated down to
age 4 yr. Adult ACT questionnaire should be used for
teenagers (cutoff age is 11 years).

25. Treatment steps
- step 1 - SABA as needed –
- step 2 - low-dose ICS monotherapy vs. leukotriene receptor
antagonist (LTRA)
- - step 3 - low-to-medium dose ICS plus long-acting betaagonist (LABA)
- - step 4 - high-dose ICS therapy plus LABA and (if needed)
systemic corticosteroids. Omalizumab (Xolair; anti-IgE
antibody) is prescribed before placing patient on daily oral
corticosteroids.

26. “Rule of 2s” to determine level of control
- daytime symptoms more than 2 days/wk
- rescue β2 -agonist use more than 2 times per week
- nighttime symptoms more than 2 nights/mo
- more than 2 rescue β2-agonist canisters/yr

27. Step Down or Step Up
When to step down therapy? If patient is well-controlled for
3 mo, consider stepping down therapy.
When to step up therapy? If the patient is not wellcontrolled, step up therapy and re-evaluate in 2 to 6 wk. If the
patient is very poorly controlled, step up therapy 2 steps,
consider short course of steroids, and reassess in 2 wk.

28. When to consider long-term ICS treatment
- positive API and more than 3 wheezing episodes in
previous 12 mo lasting more than 1 day and affecting
sleep
- consistent requirement for SABA treatment (more than
2 times/wk, on average, over 1-2 mo); 2 exacerbations in
6 mo requiring oral corticosteroids

29. Treatmnt

30. Inhaled corticosteroid
Relative binding affinity for glucocorticoid receptor (GR):
mometasone = fluticasone > budesonide > triamcinolone.
Relative anti-inflammatory potency: mometasone
fluticasone > budesonide = beclomethasone
triamcinolone.
=
>

31. Severe asthma - differential diagnosis and management

32. Foreign Body Aspiration

35. Radiographic Signs of Pneumomediastinum
Subcutaneous emphysema
Thymic sail sign
Pneumoprecardium
Ring around the artery sign
Tubular artery sign
Double bronchial wall sign
Continuous diaphragm sign
Extrapleural sign
Air in the pulmonary ligament

40. 40