Tuesday, April 2, 2013


As a result of anatomo-physiologic features of breathing organs  in the children of early age  the pathophysiologic mechanisms of bronchoobstruction and  edema of mucus membrane of bronchial tubes and hypersecretion of bronchial glands come forward on the first plan. It is the reasone of  more gradual beginning and slow  development of disease, “moist” character of asthma, less efficiency of sympatomimetics.

Clinic. Trouble, crabbiness of child at the moderate phenomena of general intoxication and normal temperature of body. Cyanosis  of lips, nasolibs triangle, acrocyanosis. Dyspnoe, noisy, with the prolonged inspiration and   distance wheezes. Downing in of interribs intervals, supraclavicular areas, jugular pit. Attacks of underproductive, sometimes attack cough. A thorax is emphizematous, at percussion above lungs bandbox sound, at auscultation breathing is hard, with the prolonged inspiration and dissipated dry and different moist wheezes. Таchycardia. A liver is often enlarged. There can be eozinophylia in the general analysis of   blood, sometimes there is moderate neutrophyl leucytosis. On the X-ray examination of thorax organs pulmonary  picture is strengthening , areas of promoted pneumatisation without of infiltrative changes in lungs.


                            Further Inpatient Care
Admit patients for treatment of acute severe episodes if they are unresponsive to outpatient care (eg, they have worsening bronchospasm, hypoxia, evidence of respiratory failure).
Once the patient is admitted, further investigations (eg, PFTs, allergy testing, and investigations to rule out other associated conditions and complications) can be performed.

                                Further Outpatient Care
Regular follow-up visits (1-6-mo intervals) are essential to ensure control and appropriate therapeutic adjustments.
Outpatient visits should include the following:
Ø     Interval history of asthmatic complaints, including history of acute episodes
Ø     (eg, severity, measures and treatment taken, response to therapy)
Ø     History of nocturnal symptoms
Ø     History of symptoms with exercise and exercise tolerance
Ø     Review of medications, including use of rescue medications
Ø     Review of home-monitoring data (eg, symptom diary, peak flow meter
Ø     readings, daily treatments)
Ø     Patient evaluation should include the following:
Ø     Assessment for signs of bronchospasm and complications
Ø     Evaluation of associated conditions (eg, allergic rhinitis)
Ø     Pulmonary function testing (in appropriate age group)
Ø     Address issues of treatment adherence and avoidance of environmental
Ø     triggers and irritants.
Long-term asthma care pathways that incorporate the aforementioned factors can serve as roadmaps for ambulatory asthma care and help streamline outpatient care by different providers.
In the author's asthma clinic, a member of the asthma care team sits with each patient to review the written asthma care plan and to write and discuss in detail a rescue plan for acute episode, which includes instructions about identifying signs of acute episode, using rescue medications, monitoring, and contacting the asthma care team. These items are reviewed at each visit.

Inpatient & Outpatient Medications
ü     Bronchodilators (short- and long-acting)
ü     Controlling medications (nonsteroidal, steroidal, newer agents such
             as leukotriene modifiers)
ü     Medications for the treatment of associated conditions (antiallergy
               medications, nasal steroids for allergic rhinitis)
ü     Rescue medications for use in acute episodes (short burst of steroids)

         Any patient with a high risk of asthma should be referred to a specialist. The following may suggest a high risk:
§                   History of sudden severe exacerbations
§                   History of prior intubation for asthma
§                   Admission to an ICU because of asthma
§                   Two or more hospitalizations for asthma in the past year
§                   Three or more emergency department visits for asthma in the past year
§                   Hospitalization or an emergency department visit for asthma within the
§                   past month
§                   Use of 2 or more canisters of inhaled short-acting beta2-agonists per month
§                   Current use of systemic corticosteroids or recent withdrawal from
       systemic corticosteroids
The choice between a pediatric pulmonologist and an allergist may depend on local availability and practices. A patient with frequent ICU admissions, previous intubation, and a history of complicating factors or comorbidity (eg, cystic fibrosis) should be referred to a pediatric pulmonologist. When allergies are thought to significantly contribute to the morbidity, an allergist may be helpful.
The goal of long-term therapy is to prevent acute exacerbations.
The patient should avoid exposure to environmental allergens and irritants that are identified during the evaluation.
§        Pneumothorax, status asthmaticus with respiratory failure
§        Fixed (nonreversible) airway obstruction
§        Death
Of infants who wheeze with URTIs, 60% are asymptomatic by age 6 years; however, children who have asthma (recurrent symptoms continuing at age 6 y) have airway reactivity later in childhood.
Some findings suggest a poor prognosis if asthma develops in children younger than 3 years, unless it occurs solely in association with viral infections.
Individuals who have asthma during childhood have significantly lower FEV1 and airway reactivity and more persistent bronchospastic symptoms than those with infection-associated wheezing.
Children with mild asthma who are asymptomatic between attacks are likely to improve and be symptom-free later in life.
Children with asthma appear to have less severe symptoms as they enter adolescence, but half of these children continue to have asthma.
Asthma has a tendency to remit during puberty, with a somewhat earlier remission in girls. However, compared with men, women have more BHR.
                    Patient Education
Patient and parent education should include instructions on how to use medications and devices (eg, spacers, nebulizers, MDIs). The patient's MDI technique should be assessed on every visit.
Discuss the management plan, which includes instructions about the use of medications, precautions with drug and/or device usage, monitoring symptoms and their severity (peak flow meter reading), and identifying potential adverse effects and necessary actions.
Write and discuss in detail a rescue plan for an acute episode. This plan should include instructions for identifying signs of an acute attack, using rescue medications, monitoring, and contacting the asthma care team.
Parents should understand that asthma is a chronic disorder with acute exacerbations; hence, continuity of management with active participation by the patient and/or parents and interaction with asthma care medical personnel is important.
Emphasize the importance of compliance with and adherence to treatment.
Incorporate the concept of expecting full control of symptoms, including nocturnal and exercise-induced symptoms, in the management plans and goals (for all but the most severely affected patients).
Avoid unnecessary restrictions in the lifestyle of the child or family. Expect the child to participate in recreational activities and sports and to attend school as usual.

                  ASPIRATION SYNDROME
 One of the most common causes of BOS in infants - a syndrome of habitual microaspiration of liquid food associated with dysphagia, often in combination with gastro-oesophageal reflux. Up to 30% of all cases of recurrent cough in infants are associated with aspiration syndrome. Determination of the cause may be difficult. Anamnestic data helps in the diagnosis of aspiration. Usually in these children there are the history and neurological symptoms such as attack coughing that develops in the child during feeding, the appearance of dry or moist rales in the lungs after a meal. The diagnosis is confirmed after examining a patient in the hospital.

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