Childhood Bronchial Asthma

Mona El Falaki Prof.of Pediatric Allergy And Pulmonology Head of Pediatric Allergy And Pulmonology Unit

The prevalence of bronchial asthma

has more than tripled over the last 3 to 4 decades, particularly in children and young adults. Bronchial asthma is the most common chronic disease of childhood reaching a prevalence of up to 20 to 30% in some parts of the world.

It is the leading cause of childhood morbidity as measured by school absences, emergency department visits, and hospitalizations. In asthma the airways are hypersensitive and easily irritated in response to different environmental triggers.

The diagnosis of asthma should be considered in children with:

recurrent episodes of cough with or without wheezing (whistling sound coming from the chest), nocturnal awakening because of cough, cough that is associated with playing or exercise. The presentation of asthma may be subtle.

Recurrent cough or nocturnal awakening because of cough is usually associated with asthma, even if other typical asthma symptoms, such as wheeze or shortness of breath, are not present. It is important to recognize that exercise-induced asthma may reflect suboptimally controlled asthma that requires adjustment of overall therapy.

The goal of therapy is to live a life that is as much as possible close to normal, to facilitate normal activity levels, including competitive sports, at least to the point that there is no interference with normal physical activity and what the child wishes to be able to do.

At the same time it is important to recognize that many children with exercise-induced asthma will decrease their activity levels and choose not to be more active because of the discomfort they personally experienced from these activities.

Patient education is a very important part of asthma management. The child (if old enough) and parents need to understand that asthma is treatable, but not yet curable and that it is not contagious but can be inherited. Care givers should be warned that it can be life-threatening. Environmental “triggers” of asthma, which are different for everyone, should be recognized and can be controlled to reduce asthma symptoms.

Most of the common asthma triggers are found indoors (secondhand smoke, dust, mites, mold, pets, cockroaches). Nonspecific irritants such as strong odors, cleaning solvents, burning wood, candles, coal, kerosene and natural gas should also be avoided. Colds and Respiratory infections are a major triggering factor for all ages but particularly in infants and young children.

Not only are they an important source of morbidity and mortality but also foreshadow an increased risk of recurrent wheezing and the inception of the asthma .It seems that respiratory viral infection occurring in a genetically susceptible child at a critical time period in either the development of the immune system or the lung is a risk factor for the development of asthma.

A common practice among doctors and parents of asthmatic children is to exclude certain foods (eggs, milk, banana, fish, etc.) from their diet for fear of asthma attacks. Foods as a trigger for asthma symptoms affect about 5% of children under the age of 5 and that number drops to 4% for older teens and adults. Food avoidance practice should not be generalized unless allergy to a particular food is proven by history or/and investigations.

There are excellent medicines available now that can control asthma some must be taken on a daily basis. Two main types of medications are available: - Controller or everyday prophylactic medications. These control inflammation in the lungs and should be taken on an everyday basis. The corner stone for prophylactic therapy in asthma are inhaled corticosteroids.

- The second type of medications is rescue or “Quick-Relief” medications. These help to control broncospasms and release “squeezing” of the airways and difficulty in breathing. - In contrast to common believes, inhalation therapy is the preferred route for administration of medication in bronchial asthma in all age groups because they allow for a maximum and quick therapeutic effect using much smaller doses with minimal or no systemic absorption and hence no side effects .

Theories behind the world asthma epidemic In spite of extensive research, the reasons behind the worldwide asthma epidemic are still far from understood. This lag is probably related to the nature of asthma, which is in itself a complex multifactorial disease, the expression of which is the outcome of interaction between genetic susceptibility and environmental factors. Of the environmental factors, the role of microbial challenges has attracted much attention.

Several recent studies have shown that children raised in microbial rich environments (e.g. farms) are less likely to develop asthma and allergic sensitization. These findings represent an extension of the “hygiene hypothesis”, which was first introduced by Strachan in 1989.

It attributed the increased prevalence of asthma and other allergic disorders to a reduced microbial challenges during childhood as a consequence of westernized lifestyle; in other words, living in a too clean environment. The decrease in the ‘microbial load’ was paralleled by an increase in other exposures, such as pollution, tobacco smoke, car exhausts and high allergen concentrations, resulting in the polarization of the immune responses towards an allergy directed profile.

Most recently the hygiene hypothesis has even been taken a step further to the “Biodiversity Hypothesis” which proposes that reduced contact of people with natural environmental features and biodiversity may adversely affect the human commensal microbiota and its immunomodulatory capacity.

What about the increased prevalence of asthma in Egypt?

El Hefny et al 1994 reported an asthma prevalence of 8.4% in a questionnaire based survey involving 13000 children. All of surveyed children were 3-15 years old and attending nursery, elementary or junior high schools in Cairo. Since then several small scale surveillance studies in different parts of Egypt have been conducted showing a prevalence of around 16-18%. So the general worldwide trend of increasing asthma prevalence applies very well to Egypt. Being a developing country (still with many underdeveloped areas) proceeding foreword in the process of (largely uncontrolled) urbanization, Egyptians are losing both the privileges of environmental biodiversity and in the same time not gaining the advantages of a modern lifestyle regarding proper health care.

A large nationwide survey should be conducted to determine the exact magnitude of the prevalence of asthma in Egypt. This is the basic preliminary step for a proper planning of an action plan for asthma control.

The ideal approach would be the implementation of international guidelines e.g. Global Initiative of Asthma (GINA guidelines) with some modifications to suit the local cultural and economic situation.

STEPWISE IMPLEMENTATION OF GUIDLINES IN DEVELOPING COUNTRIES .

Gradual improvement to reduce the initial costs (cost-benefit favorable). . Implementation of an initial stage that is not optimally efficient graduating at a later stage (as funds become available) to a system that is more efficient. .

A great deal of care must be exercised to prevent a temporary situation from becoming permanent (a common occurrence in developing countries). . The country has more time to develop its own standards.

. The country has more time and better conditions for developing a suitable regulatory framework and institutional capacity. Local adaptation and incorporation

- The effective implementation of guidelines may be enhanced if local “Key Opinion Leaders” adapt

- the guidelines for local use, while taking into account geographic, religious, cultural, resources, customs and other factors.

- The process of local adaptation exposes clinicians to the guidelines, increasing the relevant of the guidelines to local conditions, and encourages a feeling of ownership.

- Care should be taken not to impair the scientific integrity of the primary guidelines while making local adaptations. If local groups alter the guidelines in the light of evidence not previously considered, the guideline developers should be informed of the availability of that evidence.

- It is preferable to use existing networks, facilities and publications rather than to develop new processes.

- Guidelines, which are provided through existing channels and are capable of being incorporated in normal practice, are more likely to be accepted as part of the routine than anything that requires new structures or changes in modes of practice. Thereby reducing guideline implementation costs substantially.

- Integrating the guidelines into the local health care delivery processes. Organizations such as health care units, hospitals, and divisions of general practice could establish such an approach. A variety of approaches have been shown to change clinicians’ behavior and/or health outcomes, or both:

- As a general rule, one-to one approaches , that is , ‘champions’ or academic detailing and “Key Opinion Leaders” are most effective

- The interventions, which are most likely to induce change, are those that require the clinicians’ participation in the change process and decision making.

- Short summaries for use in professional or general publications or brochures, and online distribution

- Using the media, professional journals and publications of other groups (medical – nonmedical).

- Reminder systems incorporated in clinicians’ daily work.

- Arranging for credible health providers to visit practitioners in the clinical setting.

- Discussing the guidelines at conferences, seminars and other professional meetings.

- Using the education processes of appropriate colleges and other groups.

- Using new IT methods (Tele conferences – Web viewing) particularly for clinicians in remote parts of Egypt.