Background

Asthma is a chronic inflammatory disease. The severity of asthma varies from a relatively mild, infrequent wheeze to abrupt, life-threatening airway closure. It commonly presents in childhood and is related with characteristics of atopy to hay fever and eczema.

Childhood asthma is a common condition that results in numerous hospital stays and higher healthcare costs. The main characteristic is airway hyperresponsiveness. If left untreated, asthma has a significant fatality rate.

Epidemiology

Asthma affects 15%–20% of people in developed nations and 2–4% in less developed nations. Children are commonly affected. Childhood asthma affects up to 40% of children and is usually reversible. Asthma is more prevalent in populations exposed to cigarette smoke, inhaled particles, and environmental factors.

Asthma is more prevalent in boys during childhood, with a male-to-female ratio of 2:1 until adolescence, then the ratio changes to 1:1. After adolescence, females are more likely to develop asthma, and after age 40, females account for most adult-onset cases.

Due to decreased lung function and airway reactivity, asthma prevalence is higher in older individuals. About 66% of all cases of asthma are diagnosed before the age of 18 years. About 50% of asthmatic children’s symptoms completely resolve after attaining early adulthood.

Anatomy

Pathophysiology

An acute and reversible airway inflammation frequently develops after contact with an environmental trigger. The pathogenic process starts with inhaling an allergen or irritant, such as pollen, which results in airway inflammation and increases mucus production due to bronchial hypersensitivity.

As a result, there is a significant rise in airway resistance, which is most noticeable during expiration. Airway blockage occurs due to inflammatory cell infiltration, hypersecretion with mucus plug development, and smooth muscle contraction.

If asthma is not treated soon, it may deteriorate further because the formation of mucus blocks the inhaled medicine from accessing the mucosa. The swelling from the inflammation becomes worse.

Etiology

Asthma is a disease with a wide range of comprehensive and varied phenotypes. Genetic predisposition, specifically the family history and tendency to allergy, is typically observed as hay fever, eczema, and documented factors associated with asthma.

Asthma has a multi-factorial etiology that is influenced by genetics and environmental exposure, even though the general cause is complicated and still not completely understood, particularly when it comes to predicting that children with pediatric asthma will continue to have asthma in adulthood.

The following factors usually trigger asthma:

• Tobacco smoke
• Chronic sinusitis
• Viral respiratory tract infections
• Gastroesophageal reflux disease (GERD)
• Obesity
• Stress or emotional response
• Use of beta-blockers, aspirin
• Chemical fumes, insects, plants

Genetics

Prognostic Factors

Asthma causes one mortality per 100,000 individuals, making it a severe condition. Asthma causes missed work and school days and multiple hospitalizations, which increases healthcare costs. Poor asthma control can make the functioning difficult and lower quality of life

Clinical History

Physical Examination

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

The treatment paradigm for asthma typically involves a combination of medications, lifestyle modifications, and long-term management strategies. The goal is to achieve and maintain asthma control, reduce symptoms, prevent exacerbations, and improve overall quality of life for individuals with asthma. It’s important to note that while I strive to provide accurate and up-to-date information, treatment approaches may have evolved beyond my knowledge cutoff in September 2021. It’s always best to consult a healthcare professional for the most recent guidelines and recommendations.

Quick-relief medications (short-acting bronchodilators): These are used as needed to relieve acute symptoms and provide immediate relief during asthma attacks. Examples include albuterol (salbutamol) and levalbuterol.

Long-term control medications:

• Inhaled corticosteroids (ICS): These are the most effective medications for long-term control of asthma. They reduce airway inflammation and help prevent asthma symptoms. Examples include fluticasone, budesonide, and beclomethasone.
• Long-acting beta-agonists (LABAs): These medications are often used in combination with ICS to provide additional bronchodilation and control of symptoms. Examples include salmeterol and formoterol.
• Combination inhalers: Some medications combine an ICS and LABA in a single inhaler device for convenience and improved adherence. Examples include fluticasone/salmeterol and budesonide/formoterol.
• Leukotriene modifiers: These medications block the action of leukotrienes, which are substances involved in inflammation. They are used as an alternative to ICS or in combination with them. Examples include montelukast and zafirlukast.
• Other medications: In certain cases, other medications such as theophylline or oral corticosteroids may be prescribed.

Lifestyle modifications:

• Identify and avoid triggers: Common triggers include allergens (pollen, dust mites, pet dander), irritants (tobacco smoke, strong odors), respiratory infections, and exercise. Taking steps to minimize exposure to these triggers can help reduce symptoms.
• Regular exercise: Although exercise can trigger asthma symptoms, regular physical activity is beneficial for overall health and can help improve lung function. It’s important to work with your healthcare provider to develop an appropriate exercise plan.
• Maintain a healthy lifestyle: Eating a balanced diet, staying hydrated, getting adequate sleep, and managing stress can contribute to better asthma control.

Long-term management:

• Asthma action plan: Developing a written action plan in consultation with your healthcare provider helps you understand how to adjust medication use based on symptoms and peak flow measurements. It also guides you on when to seek medical assistance.
• Regular monitoring: Monitoring your symptoms, peak flow readings (a measure of lung function), and response to medications helps assess asthma control and determine if any adjustments are needed.
• Periodic check-ups: Regular follow-up visits with your healthcare provider are crucial to evaluate your asthma control, adjust medications as necessary, and address any concerns or questions.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Allergen Control

Tobacco smoke: Avoid smoking or exposure to secondhand smoke.

Strong odors and chemicals: Use fragrance-free and non-toxic cleaning products, avoid using air fresheners, and limit exposure to strong-smelling chemicals.

Dust mites: Use dust-proof covers on pillows and mattresses, wash bedding regularly in hot water, and keep humidity levels below 50%.

Improve Air Quality

Keep your home clean and free of dust by regular vacuuming, using allergen-proof covers for mattresses and pillows, and washing bedding frequently in hot water.

Consider using air purifiers with HEPA filters to remove airborne allergens. Minimize the use of harsh chemicals, strong perfumes, and cleaning products with strong fumes that may irritate your airways.

Stay informed about the outdoor air quality in your area, especially during times when pollution or allergen levels are high. On days with poor air quality, consider staying indoors or taking precautions like wearing masks designed to filter out allergens or pollutants.

Pet management

If you are allergic to pet dander, it may be necessary to keep pets out of your home or at least restrict them from certain areas like the bedroom. Regularly groom your pets, vacuum upholstered furniture and carpets, and wash bedding that may have come in contact with pet dander.

Use of Beta-Agonists in Acute Exacerbation

Short-acting beta-agonists (SABAs) are the first-line medications used in the acute management of asthma exacerbations. The most commonly used SABA is albuterol (salbutamol). Here’s how beta-agonists are typically used in this situation:

• Inhalation via Metered-Dose Inhaler (MDI): Albuterol is often administered using a handheld inhaler, also known as a metered-dose inhaler. The patient should shake the inhaler, remove the cap, exhale fully, and then place the inhaler mouthpiece in their mouth while maintaining a tight seal with their lips. They should then inhale deeply while simultaneously pressing down on the inhaler to release the medication. After holding their breath for a few seconds, they can exhale slowly. The inhaler should be used as directed by a healthcare professional, usually with a recommended number of inhalations per dose.
• Inhalation via Nebulizer: In more severe cases or when the patient has difficulty using an inhaler, nebulized albuterol may be utilized. A nebulizer is a device that converts the medication into a fine mist, allowing the patient to inhale it more easily. The nebulizer is connected to a mask or mouthpiece, and the patient breathes in the mist for a specified duration as instructed by a healthcare professional.

The frequency of beta-agonist administration during an acute exacerbation depends on the severity of symptoms and the individual patient’s response. Initially, a healthcare professional will determine the appropriate dosage and frequency of beta-agonist use. Patients may be advised to administer the medication every 4 to 6 hours as needed, with close monitoring of their symptoms. It is essential for patients to follow the prescribed dosing regimen and seek medical attention if their symptoms worsen or do not improve with medication.

Biologic Agents used for Severe or Poorly Controlled asthma

Biologic agents, also known as biologics or monoclonal antibodies, are a relatively newer class of medications used in the treatment of severe or poorly controlled asthma. These medications specifically target and modulate specific components of the immune system that play a role in asthma inflammation. Biologics can be a beneficial option for individuals who have not achieved adequate control with conventional asthma medications. Here are some commonly used biologic agents for asthma:

• Omalizumab (Xolair): This biologic targets immunoglobulin E (IgE), which is involved in the allergic response that triggers asthma symptoms. It is typically used in individuals with allergic asthma who have elevated IgE levels.
• Mepolizumab (Nucala), Reslizumab (Cinqair), and Benralizumab (Fasenra): These biologics target eosinophils, a type of white blood cell involved in the allergic and inflammatory response in asthma. They are used in individuals with eosinophilic asthma, characterized by elevated eosinophil levels.
• Dupilumab (Dupixent): This biologic targets interleukin-4 (IL-4) and interleukin-13 (IL-13), which are signaling proteins involved in the inflammatory response. It is used in individuals with moderate-to-severe asthma, often with features of allergic and eosinophilic inflammation.

Biologic agents are administered through subcutaneous injections, typically every few weeks or months, depending on the specific medication. They are usually prescribed by specialists, such as allergists, pulmonologists, or immunologists, who have experience in managing severe asthma.

Treatment for poorly controlled asthma

Administration of a pharmaceutical agent

The medications used in asthma management can be broadly categorized into two main types: long-term control medications and quick-relief medications.

Long-term control medications:

Inhaled Corticosteroids (ICS): These medications are considered the most effective long-term control treatment for asthma in children. They reduce airway inflammation and help prevent asthma symptoms. Examples include beclomethasone, budesonide, fluticasone, and mometasone.

Leukotriene modifiers: These medications block the action of leukotrienes, which are inflammatory chemicals released during an asthma attack. Montelukast is a commonly used leukotriene modifier in pediatric asthma management.

Long-acting beta-agonists (LABAs): These medications relax the muscles around the airways and are often used in combination with inhaled corticosteroids for better asthma control. Common examples include salmeterol and formoterol.

Immunomodulators: In certain cases, pediatricians may consider immunomodulatory agents like omalizumab for children with severe allergic asthma that is not well-controlled with other medications.

Quick-relief medications:

• Short-acting beta-agonists (SABAs): These medications provide quick relief by relaxing the muscles around the airways during an acute asthma attack. Albuterol is a commonly used SABA in pediatric asthma treatment.
• Oral corticosteroids: In severe asthma exacerbations, oral corticosteroids may be prescribed for a short period to reduce inflammation and improve symptoms.

Use of Systemic corticosteroids in severe asthma exacerbations

Systemic corticosteroids are an important treatment option for severe asthma exacerbations in pediatric patients. Severe asthma exacerbations are characterized by a significant worsening of asthma symptoms, including shortness of breath, wheezing, chest tightness, and coughing. These exacerbations can be life-threatening and require prompt medical intervention.

When a child experiences a severe asthma exacerbation, systemic corticosteroids are often prescribed to help reduce airway inflammation and improve lung function. Here are some key points regarding the use of systemic corticosteroids in severe asthma exacerbations:

1. Administration: Systemic corticosteroids are typically given orally, either in tablet or liquid form. In some cases, intravenous administration may be necessary if the child is unable to take oral medications or if the exacerbation is particularly severe.
2. Dosage and Duration: The specific dosage and duration of systemic corticosteroid treatment will vary depending on the severity of the exacerbation and the child’s individual factors. Generally, a short course of high-dose corticosteroids is prescribed, typically lasting from 3 to 10 days. The healthcare provider will determine the appropriate dosage based on the child’s age, weight, and overall health.
3. Mechanism of Action: Corticosteroids exert their effects by reducing inflammation in the airways, suppressing the immune response, and improving the responsiveness of the bronchial smooth muscles. This helps to relieve symptoms, improve lung function, and prevent further deterioration.
4. Side Effects: While short-term use of systemic corticosteroids is generally well-tolerated, they can have potential side effects. These may include increased appetite, mood changes, temporary increase in blood glucose levels, gastrointestinal symptoms, and temporary suppression of the immune system. However, the benefits of treating severe asthma exacerbations usually outweigh the risks of these short-term side effects.
5. Follow-up Care: After starting systemic corticosteroid treatment, it is important for the child to have close follow-up with their healthcare provider. This allows monitoring of their response to treatment, adjustment of medication as needed, and evaluation of any potential side effects.

It is crucial to strictly adhere to the prescribed dosage and duration of systemic corticosteroid treatment. Abrupt discontinuation or improper use of corticosteroids can lead to inadequate control of asthma

Medication

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References

https://www.ncbi.nlm.nih.gov/books/NBK430901/