Asthma is a chronic inflammatory disease of the airways. These inflamed pathways, when exposed to the influence of various risk factors, become hyperreactive, obstructed and have limited patency due to bronchoconstriction, the presence of mucus glands and increased intensity of inflammation. The clinical manifestation is repeated wheezing, shortness of breath, chest pressure and cough, especially at night and early in the morning. The prevalence of asthma is constantly increasing, especially in children. Asthma is one of the most common chronic diseases.[1][2]
In Europe, the prevalence is about 5% (with a variance of 10-12%), with up to 63% occurring before the age of 5.
Pathophysiology
The essence of asthma
inflammation of the airways, which is present even if the disease is without clinical symptoms;
genetic, developmental and environmental factors;
in childhood, allergic eosinophilic inflammation is usually present , which induces remodeling of the airways.
Changes in the bronchi (sometimes irreversible)
smooth muscle hypertrophy , increased vascularization and angiogenesis, cellular inflammatory infiltration, collagen deposition, basement membrane thickening, and reduced elasticity;[1]
triggering factors – allergens, infections, harmful substances, physical or mental stress, sudden changes in temperature, cold
Clinical picture
It manifests itself in conditions of difficult breathing or expiratory dyspnea, often with whistling or wheezing on exhalation;
typically occurs in the second half of the night or after exertion;
the child feels distress, pressure on the chest, a feeling of lack of air;
it is often accompanied by an irritating dry cough;
further: frequent episodes of wheezing without seasonal variability, coughing or wheezing caused by physical exertion, night cough outside the period of respiratory infections, symptoms appear or worsen in the presence of animals, when exposed to pollen, house dust, tobacco smoke, changes in temperature, strong emotional experiences, ...[1]
Age considerations
Asthma can arise at any age (purely theoretically, it cannot arise before the age of 1 - the smooth muscles of the bronchi are not yet developed and it can hardly be considered a chronic disease in the first year, similar to asthma at this age - recurrent obstructive bronchitis).
in half of the cases it starts before the age of 3 - childhood asthma - the symptoms are not yet typical - the child suffers from respiratory infections (mainly viruses), the common denominator is obstructive bronchitis;
the most important indicator is the severity of the disease;
if the child wheezes several days a week during the last 3 months, after ruling out other causes, we are talking about persistent wheezing type of asthma ;
in the case of intermittent manifestations, we further distinguish between light and severe intermittent type .
asthma of school age and adolescence is no longer very different from the symptoms in adulthood (only the so-called triggers of the acute condition differ);
1. in the interim period between asthma symptoms, the child is completely symptom-free;
A – problems are provoked by colds – asthma induced by viruses;
B – problems arise after greater movement – stress-induced asthma;
2. asthma induced by allergens or the cause of asthma has not been determined .
adolescence - new problems: irregular use of medicines, smoking, changing doctors, ...[1]
Diagnosis
Airway before and after a seizureAnamnesis - information about family burden, relationship of symptoms to place, seasonality, living situation, ...;
clinical picture;
physical examination – outside of an acute condition, it is usually normal;
functional examination of the lungs ( spirometry ) – for cooperating children (over 4-5 years of age), it belongs to the basic procedures;
positive skin tests with allergens, event. positivity of specific serum IgE antibodies:
FEV1 may be normal, but the flow-volume curve shows small airway obstruction. honor;
It is based on a detailed description of symptoms, their frequency and severity (an important indicator – consumption of relief bronchodilators);
completeness also includes assessment of bronchial reactivity and lung function;
the goal is for the patient (school children, adolescents) and parents (small children) to participate in the assessment.
Ongoing assessment includes:
daily symptoms;
nocturnal symptoms: record the frequency of nocturnal symptoms – at night and in the morning, feelings of tightness in the chest;
activity limitation: how it limits normal daily activities;
the need for relief drugs: indication of the use of β2-agonists for acute problems;
lung function: monitoring of lung function and bronchial reactivity;
spirometry – recording of the flow-volume curve reliably reveals latent obstruction;
by administering a bronchodilator, we evaluate the reversibility of the obstruction;
asthma (even asymptomatic) should be min. spirometrically checked once a year;
inhalation provocation test with histamine or acetylcholine, serves to objectify bronchial reactivity;
use – for diagnosis of asthma, for evaluation of therapy, for assessment purposes;
indicative examination of PEF with an exhalation meter (peakflowmeter) – every asthmatic should have one;
while standing, after a labored inhalation, a labored exhalation into the device (we record the best value from three attempts), it is usually measured in the morning and in the evening;
the norm is the best value of the patient inspired at rest;
the important value is the variability of daily values;
IV = (PEF evening – PEF morning) / average of these PEFs × 100;
variability up to 20% indicates stabilized asthma.
The main goal is to bring asthma under control so that it does not manifest itself in shortness of breath and does not limit the child in normal activities.
Asthma control means:
disappearance of chronic symptoms;
reduction of symptoms to isolated acute exacerbations;
no or minimal consumption of relief drugs;
stabilization of lung function, low variability of PEF;
normal physical performance.
Pharmacotherapy + elimination of contact with possible allergens allergen immunotherapy + climatic treatment (spa, stay by the sea, speleotherapy, rehabilitation, psychotherapy).
Education of the child's loved ones - we inform the family, the child, for school children the teacher should also receive the information.
Care of the environment – optimal temperature and humidity (19–20 °C, 40–50% relative humidity), creating an allergen-free environment (making the bed, pets), removing harmful substances from the apartment (hood above the gas stove, parental smoking, etc.) .
Remediation of infectious sites - repeated HCD infections can often trigger asthma or accompany it - in preschoolers, the routine examination includes the verification of adenoid vegetation, always adenotomy if positive.
Specific allergen immunotherapy (SAIT) – an essential treatment intervention, mainly for seasonal pollen asthma or asthma with dust mite allergy, it is actually a vaccination, the treatment lasts three years.
Pharmacotherapy
We have two main groups of medicines: short-acting relief medicines to help with acute conditions and preventive , anti-inflammatory medicines for maintenance treatment, controlling asthma.
Preference is given to inhalation administration, while the method of inhalation is as important as the medicine itself - it should be thoroughly practiced with the patients - whenever the administration of the medicine fails, it is necessary to check the method of administration, only then is it possible to consider adjusting the dose, changing the interval or even medicine.
increase mucociliary clearance, stabilize mast cell membranes,
they are used irregularly, as needed to suppress acute attacks, in case of shortness of breath,
they can also be used preventively against physical stress,
the effect lasts about 4 hours, preferably inhalation form,
this includes: salbutamol , fenoterol , terbutaline .[2]
Long-acting β2-agonists
the effect lasts for 12 hours or more, so they can be administered twice a day,
use – for nocturnal attacks, prevention of post-exercise asthma, in combined treatment as a supplement to anti-inflammatory preventive therapy of more severe types of the disease,
they can also be administered regularly for a long time, but only with concurrent anti-inflammatory steroid or non-steroid treatment,
aminophylline po or inj., duration of effect is 4–6 hours;
injection application comes into consideration for severe asthma attacks in combination with β2-agonists and corticoids - mostly during hospitalization;
caution - if the child is already being treated with a retarded form of theophylline - monitor plasma levels;
dampens the effect of pro-inflammatory mediators, leukotrienes, released from cell membranes of mast cells, eosinophils and others;
leukotrienes cause stronger bronchoconstriction than, for example, histamine (they are the strongest endogenous bronchoconstrictor), increase mucus secretion and vascular permeability, increase the amount of eosinophils in the walls of the bronchi;
for the prophylaxis of all forms of persistent asthma, aspirin-induced asthma (suppresses the reaction to ASA or NSAIDs) and exercise-induced asthma;
dosage:
zafirlukast twice a day, its effect is reduced by erythromycin, theophylline or terfenadine;
montelukast once daily in the evening, drug interactions unknown.
Anti-IgE antibodies
recombinant humanized monoclonal antibodies;
mechanism of action:
by binding to IgE, they reduce its levels in the body and at the same time prevent the binding of IgE to receptors on the surface of mast cells and basophils - thereby preventing their degranulation with the subsequent release of mediators;
they also inhibit the release of newly formed IgE from B-lymphocytes;
difficult-to-treat asthma with the participation of IgE antibodies;
by injection, for children over 12 years old - so far only in specialized centers!!![2]
it is administered 4 times a day (with long-term administration, the cooperation of patients and parents decreases);
originally applied in powder form (Intal);
in mild and moderate forms of persistent asthma and in post-exertional asthma;
nedocromil sodium – similar indications, affects chloride channels bb. → also reduces neurogenic sensory irritation, thereby suppressing irritation to cough;
its advantage is administration twice a day.
Combined treatment
If asthma control already requires repeated doses of short-acting β2-agonists and increasing doses of corticoids, then combination therapy is considered;
borderline doses of inhaled corticosteroids;
for children of early and preschool age – 400–600 μg/day;
for school children – 800–1000 μg/day
Inhalation systems
An example of an inhaler
Dosed aerosol inhaler – the most widespread, the dose is compressed in a container, after compression the dose of substance is released;
it is necessary to perfectly coordinate the breath with the application of the substance;
children under the age of five are not able to perform the application themselves;
the inhale must be slow, after the beginning of the inhale we press, after the end of the inhale we hold our breath for 5-10 seconds;
the most common mistakes – not shaking, quick inhalation, late injection;
inhalation attachments - to facilitate administration, in small children;
breath-activated aerosol inhalers – inhalation does not require coordination with the breath;
there is a spring in the system that releases the required dose when inhaled;
powder forms of antiasthmatics – they were developed so that freon propellant gases are not used and inhalation is easier;
all are triggered by inspiration;
the oldest was the Spinhaler, where the capsule (Intal) was inserted, it pierced and the powder was inhaled into the lungs;
Turbuhaler – drug container on a rotating disc, measures the dose;
Easyhaler etc.
nebulizers – solution forms of bronchodilators, the drug is either dissolved in a liquid (solutions) or dispersed in it (suspension) from which an aerosol is then formed – either by ultrasound or jet.
Corticosteroids systemically
acute exacerbation of asthma – we give prednisone for 3-7 days;
maintenance long-term treatment of persistent asthma - only in the most severe forms;
Progressive worsening of shortness of breath, cough, wheezing, chest tightness, or a combination of these symptoms;
the preschool child finds a sitting position, speaks in shorter sentences, takes a breath while speaking;
symptoms worsen with movement;
a severe state of acute asthma - associated with a general alteration, a small child is restless, an infant or toddler does not want to drink, is exhausted, an older child is bent forward, speaks jerkily, wheezing turns into quiet breathing.
Treatment
Asthma spacer
Inhalation of beta-2-agonists with a rapid onset of effect ev. + anticholinergics ; It is appropriate to use a professional or improvised tool - a spacer. A tachypneic respiratory patient inhales undispersed medication only superficially (he is unable to coordinate inhalation).
+ corticosteroids after;
+ oxygen inhalation during hypoxia ;
in an acute state we do not administer: inhaled corticoids, oral β2-agonists, oral theophyllines, antihistamines, sedatives, mucolytics, antibiotics!!!
