Management of Pediatric Asthma

Summary

Asthma is the most common chronic disorder in children and young adults ,contributing substantially to the overall morbidity and mortality rates , and health care costs throughout the world. The incidence of asthma is higher under the age of 5 years than at any subsequent age .

    In addition to the rising mortality from this disease , asthma has major impact on the quality of life , activity level , and school Performance of millions of children throughout the world . The recent alarming increase in asthma morbidity and mortality has led to an increased worldwide focus on asthma research , ranging from basic studies on its molecular and cellular mechanisms to new therapeutic interventions in its management. With enhanced understanding of the pathogenic mechanisms underlying the disease , improvements in its therapeutic intervention, and implementation of preventive measures, new information is anticipated that should facilitate the control of sumptoms and improve the quality of life children with asthma.

    It is well recognized that the proper management of a child with asthma represents an intergrated approach that is focused on minimizing the impact of the disease both on the child and his/her family. Moreover , it is recognized further that two of the major issues contributing to asthma morbidity and mortality are “underdiagnosis” and “inappropriate management”. both of which are often due to a lack of adequate education.

    Advances in the scientific understanding of the underlying mechanisms of asthma have led to treatment that can significantly improve the health of asthma patients.The Guidelines for the Diagnosis and Management of Asthma (“Guidelines”) developed by collaboration between the World Health Organization (WHO) and the National Heart. Lung and Blood Institute (NHLBI) of the United States and Updated in 1997,recommend Global Strategies for Asthma Management and Prevention. The Guidelines emphasiza:

1) assessment , monitoring of symptoms and follow up;

2) control of environmental factors to limit exposure to allergens and other triggers

3) use of appropriate medication ;and

4) education of the patient and family in asthma care. These recommendations promote a fundamentally new understanding of asthma and it’s treatment by emphasizing the role of inflammation in disease development , noting the importance of object monitoring of lung function , and stressing the need to establish partnership between patients and health care providers through patient education.

     Classification of bronchial asthma can be based on age , etiology , associated characteristics or severity . Classifications based on severity have been primarily designed as an approach to treatment . Generally a step-wise approach is employed to classify asthma severity as   intermittent ; mild moderate or severe persistent disease to guide pharmacotherapy , to prevent and control asthma symptoms , reduce the frequency and severity of asthma exacerbation, and reverse airflow obstruction. Thus, management of mild intermittent disease may require a comprehensive approach to controlling inflammation as well as bronchodilator treatment.

      Severe asthma can become a major clinical problem that requires specialist care and many different approaches to treatment . Recommendations in this component reflect the scientific concept that asthma is a chronic disorder with recurrent episodes of airflow limitation, mucus production , and cough . Asthma medications are thus categorized into two general classes:

1)Long-term control medications (anti-inflammatory agents) to control chronic symptoms, taken daily on a long-term basis to achieve and maintain control of persistent asthma (these medications are also known as long-term preventive, controller , or maintenance medications) and

2)quick-relief medications (short-acting bronchodilators) taken to provide prompt reversal of acute sumptoms due to airflow obstruction and relief of accompanying bronchoconstriction (these medications are also known as reliver or acute rescute medications).

    Patients with persistent asthma require both classes of medication.Anti-inflammatory agents for the child include cromolyn sodium and inhaled steroids.Bronchodilators include short-acting B2-adrenergic bronchodilators; the ophulline and oral long-acting B2-adrenergic agents are used as adjunctive therapy. Systemic corticosteroids are used in short bursts (ususally days) for acute severe asthma; long-term use is reserved for severe chronic asthma not adequately controlled with inhaled steroids at approved higher doses. Aerosolized preparations are preferred for the child because these generally induce fewer side effects. B-agonists, ipratropium bromide , and cromolyn sodium can be delivered by nebulizer. Spacers can be helpful for delivery of medications through metered dose inhalers in children and all other age groups and when used with a face mask in very young children.