Childhood Asthma Part One: Initial Assessment, Diagnosis, and Education
Childhood Asthma Part One: Initial Assessment, Diagnosis, and Education
Asthma is a chronic inflammatory disorder of the airways that affects 5% to 13% of the pediatric population (Centers for Disease Control 2006, Masoli et al 2003). Over the past 20 years, progress has been made in understanding the pathophysiology of asthma and in identifying crucial domains of preventive and therapeutic care, as well as appropriate levels of pharmacologic therapy. Morbidity and mortality related to asthma appear to have stabilized or decreased in the last 4 years (Mannino et al., 2002).
"Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role, in particular, mast cells, eosinophils, T lymphocytes, neutrophils, and epithelial cells. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and in the early morning. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. The inflammation also causes an associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli." (National Heart, Lung, and Blood Institute [NHLBI], 1997)
In response to the need to improve the diagnosis and management of asthma, the NHLBI initiated the National Asthma Education and Prevention Program to educate patients, health care providers, and the public about asthma and its treatment. The guidelines for the care of children with asthma where first developed in 1991 and updated in 1997, and selected topics were again updated in 2002 (NHLBI, 2003). Asthma changes over time, depending on multiple factors affecting the patient, i.e., environmental conditions, family and past medical history, life style, activity level, and illness. Maintenance of asthma therapy is continuous with frequent reevaluation and medical treatment adjustments.
Part one of this clinical guideline will focus on the initial assessment and diagnosis, evaluation, and education associated with asthma. Part two will focus on the management of children with asthma.
Background
Asthma is a chronic inflammatory disorder of the airways that affects 5% to 13% of the pediatric population (Centers for Disease Control 2006, Masoli et al 2003). Over the past 20 years, progress has been made in understanding the pathophysiology of asthma and in identifying crucial domains of preventive and therapeutic care, as well as appropriate levels of pharmacologic therapy. Morbidity and mortality related to asthma appear to have stabilized or decreased in the last 4 years (Mannino et al., 2002).
"Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role, in particular, mast cells, eosinophils, T lymphocytes, neutrophils, and epithelial cells. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and in the early morning. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. The inflammation also causes an associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli." (National Heart, Lung, and Blood Institute [NHLBI], 1997)
In response to the need to improve the diagnosis and management of asthma, the NHLBI initiated the National Asthma Education and Prevention Program to educate patients, health care providers, and the public about asthma and its treatment. The guidelines for the care of children with asthma where first developed in 1991 and updated in 1997, and selected topics were again updated in 2002 (NHLBI, 2003). Asthma changes over time, depending on multiple factors affecting the patient, i.e., environmental conditions, family and past medical history, life style, activity level, and illness. Maintenance of asthma therapy is continuous with frequent reevaluation and medical treatment adjustments.
Part one of this clinical guideline will focus on the initial assessment and diagnosis, evaluation, and education associated with asthma. Part two will focus on the management of children with asthma.
General Evaluation
Identify symptoms associated with asthma ( Box 1 )
Obtain medical history ( Box 2 )
Differential diagnosis for children with cough or wheezing ( Box 3 )
Physical Examination
Vital signs and oxygen saturation
Height and weight, body mass index
Physical examination of the nasal passages, respiratory tract, chest, and skin
Diagnostic Tools Available as Needed
Spirometry measurements for children starting at age 4 to 7 years to establish diagnosis, after treatment has started and symptoms have stabilized, and every 1 to 2 years
Assessment of diurnal variations in peak expiratory flow (PEF)
Bronchoprovocation
Chest radiograph may be needed to exclude other diagnoses
Allergy testing
Evaluation of nose for polyps and sinuses for sinus disease
Evaluation for gastroesophageal reflux
Asthma classification
See Table
Referrals
Referral to an asthma specialist is recommended when:
Patient has had a life-threatening asthma exacerbation
Asthma is unable to be controlled after 3 to 6 months of treatment
Problems with compliance issues with medical regimen are identified
Patients are diagnosed with moderate to severe persistent asthma
Patient require continuous oral corticosteroids or require more than 2 short courses of oral corticosteroids in 1 year
Making the diagnosis of asthma is difficult
Additional testing is required for the diagnosis or exclusion of asthma
Allergist if allergies are suspected
Patients with psychiatric or family issues interfering with control of asthma should be referred to a mental health provider
Patient Education
Review asthma pathophysiology
Review signs and symptoms of asthma exacerbations
Identification and avoidance of triggers ( Box 4 )
Environmental controls
Understand the importance of medication
Quick relief medicines
Controller medicines
Understand the proper us of nebulizers, metered dose inhaler/dry powder inhaler, and spacers
Daily use of peak flow monitoring
Review asthma action care plan
Annual influenza vaccine
Follow Up
Close follow up of signs and symptoms and exacerbations
Every month until stable then every 3 to 6 months thereafter
Monitor pulmonary function tests and PEF initially, after treatment begins, and every 1 to 2 years thereafter
Monitor medications use and relief of symptoms
Monitor patient activities and quality of life
