Child and Chest Health Care Delhi NCR

Asthma is the most common chronic respiratory disease in children.

It is both underdiagnosed and overdiagnosed in children

The standard treatment for childhood asthma is inhalational corticosteroid(ICS) in different doses according to the severity of asthma.

If the asthma is not controlled, on highest permissible doses of inhalational steroid,Long acting beta agonist(LABA) is added to control it, provided the technique of inhalation is correct,comorbidities have been addressed properly and allegen avoidence has been taken care of and adherence to treatment is good.

If it is not controlled on ICS+LABA,other add on options are LTRA(Monteleukast) and Tiotropium

If still the asthma is not controlled ,biologicals in the form of Omalizumab(IgE antagonist) and Meplozumab(IL5 antagonist) are given to control the asthma

Biologicals are costly with the disadvantages of adverse events and it is not widely available.

Asthma control is usually assessed by Asthma control test(ACT) ,Childhood asthma control test(CACT) and more easily by GINA guideline for control of asthma

Higher the ACT,CACT scores ,better is the control of asthma.

Researchers from the division of Pulmonology,department of Pediatrics,All India Institute of Medical Sciences,conducted an open label randomized control trial for a drug Azithromycin.Azithromycin is recommended drug by Global Initiative of Asthma(GINA) and British Thoracic Society(BTS) guideline for control of Asthma in adults.It improves spirometer parameter and reduces number of exacerbation of asthma in adults.There is no sufficient data for its use in children.

This the reason, researchers from Pediatric Pulmonology, division of the department of Pediatrcs AIIMS New Delhi, studied on 120 children between the age group of 5-15 years,mostly male(74% ) with poorly controlled asthma according to ACT and CACT.They divided these children into two groups.One group (n60) received Azithromycin in the dose of 10 mg/kg thrice weekly for 12 weeks along with standard treatment.The other group(n60) received only standard treatment.

The primary outcome was level of control of Asthma, according to ACT and CACT.Secondary outcomes were spirometry parameter,number of exacerbations,,Fractional excretion of NO(FeNO),throat swab culture positivity and adverse events

At the end of study period,the group who received Azithromycin along with standard care were having high ACT and CACT score (21.71 vs. 18.33; P < .001))indicating better asthma control.They also required less number of emergency visits due to asthma exacerbation and less use of oral or injectable steroids(0 vs. 1; P < .001).) ,higher number of good control of asthma by GINA guideline(41 vs. 10; P < .001).)

Spirometry parameters,throat swab culture ,FeNO reports and adverse events were not much different between two groups.

The benefits of Azithromycin was not different whether the child was suffering from eosinophilic or non eosinophilic asthma.

The study was published in CHEST.

CONCLUSION and BOTTOM LINE: Azithromycin in the dose of 10mg/kg,thrice weekly for 3 months may be added in treatment for children who could not achieve good control of asthma with standard therapy

REFERENCES:: Ghimire JJ, et al. Chest. 2022;doi:10.1016/j.chest.2022.02.025.

Please click below to watch DR.D.K.JHA discussing management of asthma in children in accordance with GINA guideline.

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Asthma,only as cough

Asthma is a leading cause of respiratory morbidity all over the world whether it be adult or children.In cough variant asthma,patients have only symptom of troublesome cough for a long period.They do not complaint of tightness of chest,difficulty in breathing,or wheezing any time in the course of their illness.On CHEST auscultation,there is no adeventitious sound in the form of wheeze.This type of cough presents a difficulty in front of treating physician for the accurate diagnosis.It may be asthma or other diagnosis which needs meticulous investigations.It is also difficult to convince to patients or parents that it may be asthma,because there is a common belief among patients and parents that asthma means difficulty in breathing.On the other hand,spirometry,which is a goldstandard diagnostic test for asthma, done on such type of asthma patients are usually normal.

FeNO(Fractional excretion of nitric oxide) is measured by a portable machine,which is hand held and subject is asked to exhale through the mouth piece connected to a hand held device.The measurement is in part per billion(ppb).The normal and abnormal levels have been validated in adults,not in children.But its level when it is high,well correlates with eosinophilic inflammation of airways in children and it can be performed easily in school going children.

In a study ,32 patients with an average age of 42.5 years were included.All had only cough for a long period(chronic cough),normal blood eosinophil count,normal chest X-Ray,normal spirometry results but abnormal ACT(Asthma control test) and positive skin prick test for environmental antigens.9 healthy persons were included for control with the mean age of 47 years.FeNO measurements were taken with the help of FeNO analyser.

FeNO were significantly elevated with the mean value of 64.4ppb in 91%(n29) of patients.The normal cut off value for adults is 25ppb.In healthy controls,the mean value measured was 16ppb.

REFERENCES:Nsouli T, Diliberto N, Nsouli S, Zamora S, Nsouli A, Bellanti J. Lack of concordance between FeNO and spirometry in patients with chronic cough. Presented at: American College of Allergy, Asthma, & Immunology Annual Scientific Meeting 2019; November 7-11, 2019; Houston, TX. Abstract A202

• Asthma is the most common chronic respiratory disorders during pregnancy.
• It affects 5%-8% pregnant women in United States.
• Among the women suffering from asthma,almost one third experience exacerbation during second trimester of pregnancy.
• Some women experience the symptoms of asthma first time during pregnancy.
• It has been observed that,about one third of asthmatic women discontinue their asthma controller medications and reliever medications, during pregnancy fearing its adverse effects on fetus.

It has been observed that, there happens no chanage in FEV1,no admissible change in FEV1/FVC and  a slight increase in FVC ,during  normal pregnancy.There should be a cause of concern in case of any deviation seen in these observed parameters.

In normal pregnancy,there happens a change in cardiac output,stroke volume and heart rate.Women already diagnosed asthma may experience exacerbation due to these changes.Some women especially those who are genetically predisposed to develop asthma may experience the symptoms of asthma first time due to these changes during pregnancy.The enlarged gravid uterus my compress the inferior vena cava during third trimester of pregnancy,thereby decreasing cardiac output.This mechanical change along with some hormonal changes may exacerbate asthma and nonallergic rhinitis.

There is a strong correlation of asthma with obstetric and non obstetric comorbidities.Among obstetric ,the important ones are,preeclamsia,placenta previa,abruptio placenta eand obstetrical hemorrhage. There is higher rates of caesarean delivery in women with asthma.Among non obstetric comorbidities are increased rates of gestational Diabetes,increased rates of pulmonary embolism and increased frequency of respiratory infections including influenza.

Asthma exacerbation causes adverse effects on fetuses which includes,prematurity,low birth weight,fetal deaths(still birth) and some congenital anomalies in the form of cleft lip and cleft palate.Low birth weight has been seen more commonly in female while prematurity and still births have been seen more commonly in male fetuses.Children born to mothers having asthma have more chance of developing asthma.

Variuos research studies show that a good control of asthma symptoms and reducing or avoiding asthma exacerbation results in better outcome for mother and babies. There is a growing evidence in literatures that suggest that, inhalational corticosteroids(ICS) and beta-2 agonists(SABA), both are safe to be used during pregnancy for asthma management.Among ICS, the most studied is budesonide.ICS use during pregnancy improves FEV1 and reduces exacerbations.

The safety of biologicals in the form of IgE inhibitor(omalizumab) and anti IL-5(meplozumab and reslizumab),have not been established.However ,the woman already on these medications before becoming pregnant has not been seen to experience any adverse outcome.

Treating comorbidities is an important part to control asthma. If there is coexisting allergic or nonallergic rhinitis,it should be treated with intranasal sterioids.Coexisting GER should be treated with PPI . If there is coexisting anxiety and depression ,these should be addressed properly.

We should not forget to avoid allergen exposure in the form of house dust mite,animal danders,cockroaches,pollen and indoor molds. According to NAEP ,allergen impermeable bed coverings should be used,bed sheets should be washed weekly with water at or above 130 degree F,and humidity should be kept below 50%.

Good control of asthma by non pharmacologic and whenever needed pharmcologic measures gives better outcome for mothers and babies

REFERENCES:

1.Bonham CA, Patterson KC, Strek ME. Asthma outcomes and management during pregnancy [published online September 1, 2017]. Chest.pii: S0012-3692(17)31485-X. doi:10.1016/j.chest.2017.08.029
2.Meakin AS, Saif Z, Jones AR, Aviles PFV, Clifton VL. Review: placental adaptations to the presence of maternal asthma during pregnancy. Placenta. 2017;54:17-23.
3.Global Initiative for Asthma. Global strategy for asthma management and prevention, 2017. www.ginasthma.org Accessed October 3, 2017.
4.Liu X, Agerbo E, Schlünssen V, Wright RJ, Li J, Munk-Olsen T. Maternal asthma severity and control during pregnancy and risk of offspring asthma [published online June 28, 2017]. J Allergy Clin Immunol. 2017. pii: S0091-6749(17)30854-0. doi:10.1016/j.jaci.2017.05.016
5.National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program Asthma and Pregnancy Working Group. NAEPP expert panel report. Managing asthma during pregnancy: recommendations for pharmacologic treatment-2004 update. J Allergy Clin Immunol. 2005;115(1):34-46.
6.Bain E, Pierides KL, Clifton VL, et al. Interventions for managing asthma in pregnancy. Cochrane Database Syst Rev. 2014;10:CD010660. doi:10.1002/14651858.CD010660.pub2