Asthma in children and adolescents: a comprehensive approach to diagnosis and management

Abstract

Asthma is a chronic disease that has a significant impact on quality of life and is particularly important in children and adolescents, in part due to the higher incidence of allergies in children. The incidence of asthma has increased dramatically during this time period, with the highest increases in the urban areas of developed countries. It seems that the incidence in developing countries may follow this trend as well. While our knowledge of the pathophysiology of asthma and the available of newer, safer medication have both improved, the mortality of the disease has undergone an overall increase in the past 30 years. Asthma treatment goals in children include decreasing mortality and improving quality of life. Specific treatment goals include but are not limited to decreasing inflammation, improving lung function, decreasing clinical symptoms, reducing hospital stays and emergency department visits, reducing work or school absences, and reducing the need for rescue medications. Non-pharmacological management strategies include allergen avoidance, environmental evaluation for allergens and irritants, patient education, allergy testing, regular monitoring of lung function, and the use of asthma management plans, asthma control tests, peak flow meters, and asthma diaries. Achieving asthma treatment goals reduces direct and indirect costs of asthma and is economically cost-effective. Treatment in children presents unique challenges in diagnosis and management. Challenges in diagnosis include consideration of other diseases such as viral respiratory illnesses or vocal cord dysfunction. Challenges in management include evaluation of the child's ability to use inhalers and peak flow meters and the management of exercise-induced asthma.

Fig. 1

Historical chart showing recommendations in asthma treatment worldwide

Fig. 2

Diagnosis and clinical assessment of the asthmatic child—the appropriate parts of the history and physical examination should be performed depending on the circumstances (e.g., is this a new patient with a history of cough presenting to the office as a consult, or is this a patients with known asthma who is in the midst of an asthma exacerbation presenting to the emergency room)

Fig. 3

a An exercise challenge protocol. b Exercise challenge test results sheet—sample. c Guidelines/criteria for exercise challenge testing

Fig. 4

Avoidance measures for common allergens

Fig. 5

Inhaler technique. a Open mouth technique. b Closed mouth technique. c Using a spacer and a mask

Fig. 6

A sampling of peak flow meters and spacer devices. Clockwise from upper left Aerochamber Plus spacer device, Pocket Peak peak flow meter, Aerochamber with mask, Truzone peak flow meter, Airwatch electronic peak flow meter, Piko-1 electronic lung health meter, Personal Best adult range peak flow meter

Fig. 7

An asthma diary

Fig. 8

A sample asthma assessment tool

Fig. 9

An asthma management plan. An asthma action plan must include information on how to assess the child’s condition. Known triggers should be listed and the PEF zonal system can be used to provide easy instructions for patients and parents. The form also allows for entering medication doses

Fig. 10

Mechanism of action of glucocorticoids

Fig. 11

Structure of the β-adrenergic agonists. Comparison of the structures of albuterol and salmeterol helps to explain the long half-life of salmeterol. The long chain connects the binding site to the active site of the molecule. Once bound at the binding site, the long chain is theorized to swing back and forth, allowing the active site to repeatedly come in contact with the receptor site, prolonging the action of the drug

Fig. 12

Structure and anti-inflammatory effects of cromolyn and nedocromil

Fig. 13

Mechanism of action of leukotriene pathway modifiers

Fig. 14

Structure and bronchodilatory effects of theophylline and known actions of theophylline and caffeine. Actual mechanism for the bronchodilatory effect of methylxanthines is not completely understood. Phosphodiesterase inhibition appears to be the most likely mechanism, but theophylline is known to have other activity, as shown

Fig. 15

Algorithm for the treatment of the acute asthmatic child

Fig. 16

A comprehensive asthma management program