Training of Inhalation Therapy

& Pediatric Asthma Management

Module 5

Diagnosis of
asthma
Departemen IKA FKUI-RSCM
UKK Respirologi PP IDAI

Dr. Nastiti Kaswandani, Sp.A

Born: Surabaya, November 12, 1970
Education:
1. Faculty of medicine University of Indonesia, 1995
2. Medical Post Graduate (Pediatrics), Faculty of
Medicine Universitas Indonesia, 2004
Recent position :

Staf member of Division of Respirology

Lecturer on Pediatric Pulmonology and Respirology,

Dept of Child Health, Faculty of Medicine University of
Indonesia

Foreign affairs of Yapnas

Definition of asthma
Reversible respiratory tract obstruction

spontaneously or after treatment

1950-es

1960-es

Episodic obstruction because of the increasing of bronchi

response to the stimulant (bronchi hyperreactivity)

1970-es

Chronic state which is indicated with repeated

bronchospasm due to the narrowing of respiratory tract as
a response to the stimulant, which not causing the same
narrowing in other persons

PREVENTION OF BRONCHOSPASM
WHO, 1975

1990-es

Chronic inflammation in respiratory tract
cellular

infiltrates, edema, epithelium damage, even fibrosis

ANTI-INFLAMMATION USAGE

 Chronic inflammation of the respiratory tract

Many cells take part (mast cell, eosinophil,
2002 lymphocyte-T)
In susceptible person, chronic inflammation

recurrent wheezing, cough, dyspnea, chest
tightness
Related to the narrowing of respiratory tract

partially irreversible or relieved spontaneously or
with treatment

GINA, 2004

The definition is very complete
clinical application

is difficult and not practicable, especially in babies
and children

Pathogenesis
Environment

Genetic susceptibility

Chronic allergic inflammation

(Mast cells, T-Cells, Eosinophils)

Airway Wall Thickening

(Remodeling)

Resume
Resume..

Bronchoconstriction

Chronic
inflammation

Remodeling

Inflammation in asthma
Inflamasi akut

Steroid
response

Chronic inflammation
Structural changes

Time

Barnes PJ

Operational definition
A condition with episodic wheezing and/or cough with
asthma as the most possible etiology, while other
infrequent causes have been excluded

1989:

Arch Dis Child 1992;67:240-8.

1992:
Recurrent wheezing and/or persistent cough with
asthma as the most possible etiology, while other
infrequent causes have been excluded
Warner dkk. Pediatr Pulmonol 1998;25:1-7

1998:

INDONESIA (RESPIROLOGY WG, IDAI)

PNAA 2004
Wheezing and/or cough with characteristics:
appear episodic and/or chronic, tends at night/early
morning (nocturnal), periodic, has triggers such
as physical activity, reversible either
spontaneously or with treatment, and has asthma
history or other atopic in patient/family.

Diagnosis
Cough and/or Wheeze
Clinical history
Physical examination
Mantoux test

Suggestive of asthma:
Episodic
Nocturnal
Seasonal
Exertional
Atopic

If possible frequent peak flow

measurements :
Reversibility (20%)
Variability (20%)

Indeterminate features or suggestive

of alternative diagnosis
Neonatal onset
Failure to thrive
Chronic infection
Vomiting/choking
Focal lung or CVS signs

Consider
Chest and sinus x rays
Lung function
Bronchial challenge and/or
Bronchodilator response

Bronchodilator response
Response

No
response

.. Consider :
Sweat test
Immune function
Ciliary & Reflux studies

WD/ Asthma
Assess severity and etiology

- ve

+ ve

Chest x ray if more than

mild episodic disease

Alternative diagnosis and treatment

Trial of anti asthma treatment

Consider asthma as an Not asthma

associated problem

Review diagnosis and compliance

if poor response to treatment

PNAA, 2004:
Entry point of asthma diagnosis:

Recurrent Wheezing
and/or
Chronic Recurrent Cough

Batasan operasional
Recurrent cough and/or wheezing with
characteristics episodic, nocturnal (variability),
reversible (relieve with or without treatment) plus
atopic

Cough and/or wheezing

A/ + PE + SE
Not typical

TYPICAL
Episodic
Nocturnal
After activity
Atopic (+)

Reversibility (+)
Variability (+)

Bronchodilator
Not Asthma

ASTHMA

FVC

Lung
Function
Test

AEJ
AES
AP
.

FEV1

V50

PEF

V25

Asthma, 2 aspects
Asthma : chronic respiratory disease that
can have acute attack (two in one
disease)

Chronic Asma

Asthma
Acute Asthma

Classification of pediatric asthma

Chronic asthma

Acute asthma

1. Infrequent
episodic asthma
2. Frequent
episodic asthma

1. Mild attack
2. Moderate
attack
3. Severe attack

3. Persistent
asthma

Infrequent Episodic Asthma

75% of children with asthma

Episode
<1 time per 46 weeks
Wheezing after high activities
No symptoms between episode of attacks
Normal lung function between attacks
No need of prophylaxis

Frequent Episodic Asthma

20% of children with asthma

More frequent attacks
Wheezing after moderate activities
Could be prevented with 2-agonist
Symptoms
<1 time/week
Normal or almost normal lung function
between attacks
Needs controller

Persistent Asthma

5% of children with asma

Frequent acute episodes
Wheezing after mild activities
Needs 2-agonist between attacks, >3
times/week, either because of night
arousals or heavy chest in the morning
Needs controller

Classification of disease
Clinical parameters
and lung function

Infrequent episodic
asthma

Frequent episodic
asthma

Persistent asthma

Freq of attacks

< 1x /month

> 1x /month

Daily

Duration of attacks

< 1 week

>1 week

Daily

Between episodes

No symptoms

Symptoms (+)

Frequent nocturnal
symptoms

Sleep and activity

Normal

May affect

Affect

Physical exam

Normal

May affect

Abnormal

Controller

No need

Steroid/combination

Steroid/combination

Lung function
(No attacks)

PEF/FEV1 >80%

Variability (attacks)

>15%

PEF/FEV1 <60%
PEF/FEV1 60-80%
Variability 20-30%

> 30%

> 50%

Diagnosis
ASTHMA
Asthma Attack

Severe Asthma

Asthma labelling
Chronic condition + present condition
Chronic condition: infrequent -- persistent
Present condition:
(-)
Symptom
attack (-)
(+)
attack (+)

Every asthma patients

The classification should be include class. disease and
severity of asthma attacks, example:
 Infrequent episodic asthma without asthma
attacks
 Infrequent episodic asthma with mild asthma
attacks
 Frequent episodic asthma with severe asthma
attacks
 Frequent episodic asthma without asthma
attacks
 Persistent asthma with severe asthma attacks
 Severity of disease not depends on level of
attack

How about preschool children???

Does every wheezing

mean asthma?????

Allergic March
Rinitis

Asma

Dermatitis atopik
Alergi makanan
0

6
bulan

1
tahun

3
tahun

7
tahun

15
tahun

Transient

Asthma

Wheezing prevalence

Wheezers Low LFT

at birth

Non-Atopic
Wheezers

BHR of atopic
asthma

Post
RSV
0

6
Age (years)

11

Fig. 6. Hypothetical peak prevalence by age for the 3 different wheezing phenotypes.
The prevalence for each age interval should be the area under the curve. This does not
imply that the groups are exclusive.
Taussig LM, et al. JACI 2003; 111:661-675

Recurrent wheezing

Major :
Atopic dermatitis
Asthma in parent
Skin test (+) aeroallergen
Minor
Hypereosinophilia
Wheezing beyond flu
Rhinitis allergic
Skin test (+) ingestion
Asthma: if
2 major and/or
1 major + 2 minor

Cost ?
Availability ?

Conclusion
Alteration of asthma pathogenesis:
bronchospasm
chronic inflammation

remodeling
Diagnosis of asthma must included
classification and severity of attack
It is difficult to diagnose asthma in
preschool children
There is asthma prediction index in children
<3 years of age (major and minor criteria)

Thanks for
your attention
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