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Asthma is a disease characterised by chronic airway inflammation and increased airway responsiveness leading to bronchial constriction. The airways are narrowed by a combination of bronchiolar smooth muscle, mucosal oedema and mucus plugging.
Wheezing is a number of respiratory noises occur in children. It is important to signalise the wheezing, whether it is frequently or not, high pitched musical sound coming from the chest or other respiratory noises.
There are different causes of wheeze and some clinical phenotypes of wheezing also recognised in children. The clinical phenotypes in childhood are Episodes of wheezing, Difficulty to breath, cough and viral upper respiratory infections.
High probability of asthma:
Symptoms like wheeze, cough, shortness of breath and chest tightness, if more than one symptom are frequent, recurrent, worse at early in the morning or night, worse after exercise, other triggers and family history of atopic and asthma may high probability of asthma.
High risk of developing wheezing or asthma in children associated by several factors, those are increasing the probability of asthma with respiratory symptoms in child. Those factors are, Age at presentation, Sex, Severity and Frequency of previous wheezing, Family history of atopy, abnormal lung function and Coexistence of atopic disease.
This phenotype is mostly resolved by the age three, when they not have a family history or allergic sensitization asthma. The main risk factor of this phenotype is reduced pulmonary function and prematurity. Children have less resistant power, when they have transient phenotype of asthma. It is mainly caused by smoking during pregnancy and exposure to tobacco smoking.
Classic atopic asthma:
Atopic asthma phenotype basically starts before the age of six. According to epidemiological studies, the risk factors of this phenotype are atopy and bronchial hyper responsiveness. Mainly we monitored the lung function frequently, because in this type of asthma patientâ€™s loss their lung functions in the first five years period. Other risks of atopic phenotype are obstructive disease, pulmonary function and airway inflammation.
Non atopic asthma:
This type of phenotype is mainly seen after the age of three, who have wheeze continue from the child. The main risk factor of this asthma phenotype is episodes of bronchial obstruction to respiratory syncytial virus (RSV). Non atopic asthma is less severe, prevalent and persistent nature according to clinical picture.
The main goal of treatment is to control asthma by reducing the symptoms, use of short acting beta-2 agonists, maintain normal pulmonary function, normal active levels, such as exercises and physical activities.
According to guidelines there are several stages to care the asthma, those are
Assessment and monitoring:
Focused on the frequency and intensity of asthma symptoms and there functional limitations, asthma aggravation, adverse effects from medication, the progression of lung function, monitor every one or two years or frequently for controlled asthma.
Patient education is very important in asthma. Self management education is very important to the patients to recognise the signs and level of control of asthma symptoms by their own. Educational strategies also focus on environmental control and use of medicines. Environment exposures and irritants can play a vital role to increase the symptoms of asthma, so patients should exam the skin test and vitro test to find the allergies and also educate to avoid the tobacco smoking.
Medicinal care includes control of chronic and exercise induced asthma symptoms and treatment of acute asthma. Pharmacologic management is used to control medication, such as inhaled corticosteroids, long acting bronchodilators and anti immunoglobulin E (IgE) antibodies.
The stepwise management of pharmacologic therapy is recommended to control of asthma. The type, amount and schedule of medication are important to asthma severity and the level of control. This is mainly to identify the minimum medication necessary to maintain control.
The pharmacotherapy is divided the treatment based on age. For all patients quick relief medications include rapid acting beta-2 agonists as needed for symptoms control. Generally patients should assess every one to six months for asthma control adherence, environmental control and comorbid condition checked in every visit.
Treatment in Britain:
In Britain there are five stepwise management treatments for asthma. These are used mainly to control of the disease. This stepwise treatment is stepped up and stepped down to control the asthma depends on patient condition.
Step 1: (Mild intermittent asthma)
In this stage short acting bronchodilators are used, such as inhaled short acting beta-2 agonists, inhaled ipratropium bromide, beta-2 agonist tablets or syrups and theophyllines. Short acting beta-2 agonist is a good medicine to reduce symptoms more quickly and it is have low said effects, when compare to alternatives. Short acting beta-2 agonists are mainly used for short term relief from the asthma symptoms and it require to take four times a day for regular administration, if asthma control, no need to take the beta-2 agonists.
Step 2: (Interdiction of regular preventer therapy)
Inhaled steroids are used in this stepwise treatment. It is a very good effective drug to prevent and achieve the treatment goals in adults, older children and it is safe and effective for younger children also. Drug dosage is depends on age, for example inhaled steroids are used 400 mcg/day in adults, but for child 200 mcg/day, sometimes younger children may required more than 200 mcg/day dose, if they have any drug delivery problem.
Inhaled steroids should used for adults, children age 5 to 12 and young children, when inhales beta-2 agonists are using three times or more a week, symptoms are seen more than three times or equal in a week and waking a night a week. Inhaled steroids are use with oral corticosteroids in adults and children (5-12 ages), who had exacerbation of asthma in the last two years.
Step 3: (Initial add on therapy)
Before starting this stage patient should check compliance, inhaler technique and eliminate trigger factors. In this step 3 treatment, long acting beta-2 agonists (LABA) are used along with inhaled steroids. LABA is very effective drug; it is improve lung function and reduce the exacerbations.
Start the medication with low dose inhaled steroids and long acting beta-2 agonists. If any benefits by the use of LABA, continue LABA and increase the dose of inhaled steroids. If it is not response to LABA, stop LABA and increase the inhaled steroids 800 mcg/day in adults and 400 mcg/day in older child.
Step 4: (Persistent poor control)
If control remain indicates after step three management, continue the increasing inhaled steroids with long acting beta-2 agonists. The dose of increased inhaled steroids are 2000 mcg/day in adults and 800 mcg//day in older children. Use leukotriene receptor agonists or slow release beta-2 agonists tablets or theophyllines additionally.
Step 5: (Continuous or frequent use of oral steroids)
Very a few numbers of patients are unable to control the symptoms at step four, so steroid tablets are used in step five management for control of asthma symptoms. It is very effect to control the symptoms even a lower dose, but it has high risk of systemic side effects.
The main aim of the treatment to use of steroid tablets with lower dose is control asthma, if possible, to stop the use of steroid tablets. Increasing dose of inhaled steroids 2000 mcg/day in adults and 800 mcg/day in older children to reduce or eliminate the use of steroid tablets. Very carefully monitor the dose of inhaled steroids in children before going to use.
Stepping down the management:
Once asthma controlled the stepwise management therapy is stepping down. Inhaled steroids used every three months, who are stabled after using 900 mcg/day. In this process patients should review regularly. Then reduce the dose of medicines, side effects of the treatment, severity of asthma, time of current dose, beneficial effects and patientâ€™s preference.
Maintain the lower dose of inhaled steroids and reduced the inhaled steroid dose lowly depends on patients. These dose reductions should review every three months and reduced approximately 25 to 50% of dose each time.