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Pediatrics, Reactive Airway Disease
Updated: Jun 30, 2009
Introduction
Background
Not all children who wheeze have asthma. Most children younger than 3 years who wheeze are not predisposed to asthma. Only 30% of infants who wheeze go on to develop asthma. Reactive airway disease has a large differential diagnosis and must not be confused with asthma.
Clinical factors suggestive of childhood asthma include recurrent wheezing, symptomatic improvement with a bronchodilator, recurrent cough, exclusion of alternative diagnoses, and suggestive peak flow findings.
Asthma Resources from Medscape and eMedicine On June 25, 2009, The American Thoracic Society and the European Respiratory Society jointly released new official standards on asthma evaluation for clinical trials and practice.1 The Medscape Medical News article, New Guidelines Issued for Asthma Assessment, has a more detailed discussion.Pathophysiology
Numerous environmental stimuli induce an allergen-antibody interaction, causing a release of mediators that create airway inflammation. Airway inflammation is the primary factor responsible for smooth muscle hyperresponsiveness, edema, and increased mucous production, resulting in increased work of breathing. A complex interaction occurs between inflammatory cells and airway epithelium. Mediators released from mast cells induce edema, mucous secretion, and bronchospasm. These mediators include histamine, tryptase, heparin, leukotrienes, platelet-activating factor, cytokines, interleukins, and tumor necrosis factor. The other inflammatory cells (ie, eosinophils, lymphocytes) also release mediators and create a toxic environment to respiratory epithelial cells.
In infants and children younger than 3 years, the intrapulmonary airways are so small that any lower airway infection results in diminished airway function. Other anatomical factors, such as poor collateral ventilation, decreased elastic recoil pressure, and a partially developed diaphragm, may predispose the very young child to respiratory compromise.
Speculation exists that all infants are born with highly responsive airways. Increased immunoglobulin E (IgE) levels have been found in those younger than 2 years. A decrease in airway responsiveness may be associated with environmental allergens, viral respiratory diseases, and hereditary factors.
Rhinovirus infections are an important contributor to asthma exacerbations in children. Hence, therapies against rhinovirus might reduce the risk of severe exacerbations.2
Breastfeeding might protect children younger than 24 months of age against recurrent wheezing. The cytokine, TGF-B1, in human milk may have both suppression and enhancement functions in the immune reaction.
Exposure to maternal environmental tobacco smoke during pregnancy or the first year appears to predispose children to reactive airway disease.
Current research on the genetic basis for the pathogenesis of asthma may lead to new diagnostic and preventive treatments. The ADAM33 gene on the short arm of chromosome 20 is hypothesized as being important in the development and pathogenesis of asthma.
Frequency
United States
Risk of developing asthma is 7% if neither parent has asthma, 20% if one parent has asthma, and 64% if both parents have asthma. In the United States, approximately one half of all ED and clinic visits for asthma are children younger than 18 years. Pediatric asthma is a chronic, multifactorial, lower airway disease that affects 5-15% of children (2.7 million children in the United States alone). ED visits peak in the fall. School holidays disrupt the spread of infections with a subsequent decrease in hospitalization. Asthma prevalence appears to be increasing worldwide. Air pollutants may play a role in the prevalence increase. Higher prevalence occurs in poverty stricken urban areas where children are less likely to have routine doctor visits and access to the availability of medications.
A correlation may exist between high levels of exposure to cockroach allergen and the frequency of asthma-related health problems in inner-city children.3 Homes in poverty areas were more likely to have high cockroach allergen levels. Asthma may develop in children from early exposure to cockroach allergen.4
Status asthmaticus appears to be on the rise; several retrospective studies reflect an increase in hospital admissions, particularly in those younger than 4 years. Fewer hospital and ED visits occur in children using inhaled corticosteroid therapy.
An algorithm has been developed to determine the risk factors for developing persistent asthma symptoms among children younger than 3 years of age who had 4 or more episodes of wheezing during the previous year.5 The Asthma Predictive Index included either (1) one of the following: parental history of asthma, a physician diagnosis of atopic dermatitis, or evidence of sensitization to aeroallergens; or (2) two of the following: evidence of sensitization to foods, ≥4% peripheral blood eosinophilia, or wheezing apart from colds.
An association may exist between obesity and childhood asthma. Increased resistin, an adipokine produced by adipose tissue, may play a negative predictive role in asthma.6
International
Worldwide, the prevalence of asthma is increasing. Asthma is found to be more common in Western countries than in developing countries. Asthma is more prevalent in English-speaking countries. Prevalence increases as a developing country becomes more Westernized and urbanized.
Mortality/Morbidity
- One third of all children younger than 18 years are significantly affected.
- Reactive airway disease accounts for 13 million health care visits annually in the United States and 200,000 hospitalizations for which approximately $1.8 billion is spent annually.
- Mortality rates are increasing despite new pharmacologist advances.
Race
Reactive airway disease is more common in black and Hispanic children; hospitalization rates in African Americans are 4 times greater than in the white population.
No correlation exists with income or education level from a retrospective review.
Sex
The male-to-female ratio is 1.5:1
Age
The peak prevalence of asthma is in those aged 6-11 years.
Clinical
History
- The following information should be elicited:
- Initiation of symptoms (More than a few days decreases the chance of quick reversal in the ED because of prolonged inflammation and mucous plug formation)
- Upper respiratory infection (URI) symptoms, fever, and production of phlegm
- Precipitating factors
- Use of an bronchodilator inhaler; how often it was used in the past 24-48 hours prior to the ED visit; how often it was used over the past week or month
- How many inhalers were used in the past month
- How many puffs are being administered with each use and if the inhaler is being used with a spacer
- Compliance with use of corticosteroid inhaler (Ask if it was used daily despite any symptoms of wheezing)
- Date of last ED visit; how severe the current episode is compared with previous episodes7
- Date of the last hospital admission
- Number of admissions in the past year; number of intensive care unit admissions
- History of intubation and how long ago it was
- Recent use of oral steroids
- Factors that usually initiate symptoms
- Whether this is a typical episode
- Presence of any underlying cardiac, GI, or immunologic diseases
- Other current medications
- Exposure to tobacco smoke and allergens (ie, cat dander)
- Ability to tolerate fluids
- Recent mental status changes
- Baseline peak expiratory flow rate (PEFR)
- History of atopic dermatitis or other allergic skin conditions8
- Dry cough or wheezing that is often worse at night
- History of recurrent wheezing and dyspnea
- Wheeze or cough after active playing
- Relationship to emotional expressions
- Relationship to menses
Physical
- Fever
- Tachycardia
- Tachypnea, dyspnea
- Wheezing
- Coughing
- Flushing, cyanosis
- Flaring of nasal alae
- Presence of nasal polyps and nasal secretions
- Intercostal retractions
- Poor feeding
- Diaphoresis
- Distant breath sounds, hyperresonance (Beware of "silent chest," too little air movement to hear wheezing.)
- Pulsus paradoxus (mild asthma pulsus paradoxus = 10, moderate = 10-20, severe >20)
- Altered mental status
- Decreased peak expiratory flow rate
- Inspiratory-to-expiratory ratio (An increased inspiratory-to-expiratory ratio is a bad sign.)
- Allergic shiner (ie, dark semicircles of skin under the eyes)
- Transverse nasal skin fold from repeatedly rubbing the nose
- Increased anteroposterior diameter or pectus carinatum
- Murmur
- Clubbing
- Subcutaneous emphysema
- Mild asthma: the child can speak in sentences and is not short or breath at rest, slight increase in respiratory rate but no accessory muscle usage
- Moderate asthma: the child is short of breath while talking and speaks in short phrases, respiratory and heart rate increased, loud wheezes throughout expiratory phase
- Severe asthma: the child is short of breath at rest, very agitated, sitting upright and not speaking or using only one single word, wheezes throughout inspiration and expiration
- Respiratory arrest imminent if child is drowsy and wheezes are absent
Causes
- Precipitants of asthma exacerbation
- Infection -Respiratory syncytial virus (RSV) most commonly isolated from infants and preschool-aged children; Mycoplasma pneumoniae most commonly isolated from school-aged children
- Tobacco smoke
- Pet dander, cockroach and dust mite allergen
- Molds
- Pollen
- Exercise
- Weather changes
- Stress
- Drugs
- A precipitant of bronchiolitis is respiratory infection, usually due to RSV.
- Gastroesophageal fistula
- Mediastinal mass (external compression of the airway)
- Cystic fibrosis
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| Multimedia: Pediatrics, Reactive Airway Disease |
| References |
| Further Reading |
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References
[Guideline] Reddel HK, Taylor DR, Bateman ED, et al. An official American Thoracic Society/european Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Am J Respir Crit Care Med. Jul 1 2009;180(1):59-99. [Medline].
Szefler SJ. Advances in pediatric asthma in 2007. J Allergy Clin Immunol. Mar 2008;121(3):614-9. [Medline].
Rosenstreich DL, Eggleston P, Kattan M, et al. The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. N Engl J Med. May 8 1997;336(19):1356-63. [Medline].
Litonjua AA, Carey VJ, Burge HA, et al. Exposure to cockroach allergen in the home is associated with incident doctor-diagnosed asthma and recurrent wheezing. J Allergy Clin Immunol. Jan 2001;107(1):41-7. [Medline].
Castro-Rodríguez JA, Holberg CJ, Wright AL, Martinez FD. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med. Oct 2000;162(4 Pt 1):1403-6. [Medline]. [Full Text].
Kim KW, Shin YH, Lee KE, Kim ES, Sohn MH, Kim KE. Relationship between adipokines and manifestations of childhood asthma. Pediatr Allergy Immunol. Sep 2008;19(6):535-40. [Medline].
Federico MJ, Wamboldt FS, Carter R, Mansell A, Wamboldt MZ. History of serious asthma exacerbations should be included in guidelines of asthma severity. J Allergy Clin Immunol. Jan 2007;119(1):50-6. [Medline].
Stewart LJ. Pediatric asthma. Prim Care. Mar 2008;35(1):25-40, vi. [Medline].
Hederos CA, Janson S, Andersson H, Hedlin G. Chest X-ray investigation in newly discovered asthma. Pediatr Allergy Immunol. Apr 2004;15(2):163-5. [Medline].
Hsu KH, Jenkins DE, Hsi BP, et al. Ventilatory functions of normal children and young adults--Mexican- American, white, and black. II. Wright peak flowmeter. J Pediatr. Aug 1979;95(2):192-6. [Medline].
[Best Evidence] Sorkness CA, Lemanske RF Jr, Mauger DT, Boehmer SJ, Chinchilli VM, Martinez FD, et al. Long-term comparison of 3 controller regimens for mild-moderate persistent childhood asthma: the Pediatric Asthma Controller Trial. J Allergy Clin Immunol. Jan 2007;119(1):64-72. [Medline].
Blackhall K, Appleton S, Cates CJ. Ionisers for chronic asthma. Cochrane Database Syst Rev. 2003;CD002986. [Medline]. [Full Text].
Amirav I, Newhouse MT. Metered-dose inhaler accessory devices in acute asthma: efficacy and comparison with nebulizers: a literature review. Arch Pediatr Adolesc Med. Sep 1997;151(9):876-82. [Medline].
Apter AJ, Szefler SJ. Advances in adult and pediatric asthma. J Allergy Clin Immunol. Mar 2004;113(3):407-14. [Medline].
Baren JM, Zorc JJ. Contemporary approach to the emergency department management of pediatric asthma. Emerg Med Clin North Am. Feb 2002;20(1):115-38. [Medline].
Beasley R, Crane J, Lai CK, Pearce N. Prevalence and etiology of asthma. J Allergy Clin Immunol. Feb 2000;105(2 Pt 2):S466-72. [Medline].
Becker A, Watson W, Ferguson A, et al. The Canadian asthma primary prevention study: outcomes at 2 years of age. J Allergy Clin Immunol. Apr 2004;113(4):650-6. [Medline].
Clainche LL, Timsit S, Rigourd V, et al. Asthma and the child below 5 years of age: diagnosis and treatment [in French]. Rev Mal Respir. Feb 2000;17(1 Pt 2):213-23. [Medline].
Craig VL, Bigos D, Brilli RJ. Efficacy and safety of continuous albuterol nebulization in children with severe status asthmaticus. Pediatr Emerg Care. Feb 1996;12(1):1-5. [Medline].
Crain EF, Mortimer KM, Bauman LJ, et al. Pediatric asthma care in the emergency department: measuring the quality of history-taking and discharge planning. J Asthma. 1999;36(1):129-38. [Medline].
Csonka P, Mertsola J, Klaukka T, et al. Corticosteroid therapy and need for hospital care in wheezing preschool children. Eur J Clin Pharmacol. Nov 2000;56(8):591-6. [Medline].
Darr CD. Asthma and bronchiolitis. In: Emergency Medicine: Concepts and Clinical Practice. 4th ed. 1998:1137-45.
Eggleston PA, Wood RA, Rand C, et al. Removal of cockroach allergen from inner-city homes. J Allergy Clin Immunol. Oct 1999;104(4 Pt 1):842-6. [Medline].
[Guideline] Expert panel commissioned by the National Asthma Education and Prevention Program (NAEPP) Coordinating Committee(CC), coordinated by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. The Expert Panel Report 3 (EPR–3) Full Report 2007: Guidelines for the Diagnosis and Management of Asthma. August 28, 2007;[Full Text].
Farber HJ, Johnson C, Beckerman RC. Young inner-city children visiting the emergency room (ER) for asthma: risk factors and chronic care behaviors. J Asthma. 1998;35(7):547-52. [Medline].
Garde Garde Jf, Haro E, Sanchez-Lucas C, Garde Noguera J. Antileukotrienes. Their use in pediatrics [in Spanish]. Allergol Immunopathol (Madr). May-Jun 2000;28(3):136-43. [Medline].
Gibbs MA, Camargo CA, Rowe BH, Silverman RA. State of the art: therapeutic controversies in severe acute asthma. Acad Emerg Med. Jul 2000;7(7):800-15. [Medline].
[Best Evidence] Guilbert TW, Morgan WJ, Zeiger RS, Mauger DT, Boehmer SJ, Szefler SJ, et al. Long-term inhaled corticosteroids in preschool children at high risk for asthma. N Engl J Med. May 11 2006;354(19):1985-97. [Medline]. [Full Text].
[Best Evidence] Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database Syst Rev. Apr 18 2005;CD001002. [Medline]. [Full Text].
Kellner JD, Ohlsson A, Gadomski AM, Wang EE. Efficacy of bronchodilator therapy in bronchiolitis. A meta-analysis. Arch Pediatr Adolesc Med. Nov 1996;150(11):1166-72. [Medline].
Kemp JP, Dockhorn RJ, Shapiro GG, et al. Montelukast once daily inhibits exercise-induced bronchoconstriction in 6- to 14-year-old children with asthma. J Pediatr. Sep 1998;133(3):424-8. [Medline].
Kitch BT, Chew G, Burge HA, et al. Socioeconomic predictors of high allergen levels in homes in the greater Boston area. Environ Health Perspect. Apr 2000;108(4):301-7. [Medline].
Le Clainche L, Timsit S, Rigourd V, et al. Asthma in children below 5 years of age: diagnosis and treatment. Rev Mal Respir. Feb 1999;16(1):17-27. [Medline].
Newson T, McKenzie S. Cough and asthma in children. Pediatr Ann. Mar 1996;25(3):156-8, 161. [Medline].
Qureshi F, Zaritsky A, Lakkis H. Efficacy of nebulized ipratropium in severely asthmatic children. Ann Emerg Med. Feb 1997;29(2):205-11. [Medline].
Roback MG, Dreitlein DA. Chest radiograph in the evaluation of first time wheezing episodes: review of current clinical practice and efficacy. Pediatr Emerg Care. Jun 1998;14(3):181-4. [Medline].
Rubin BK, Albers GM. Use of anticholinergic bronchodilation in children. Am J Med. Jan 29 1996;100(1A):49S-53S. [Medline].
Rudolph CD. Supraesophageal complications of gastroesophageal reflux in children: challenges in diagnosis and treatment. Am J Med. Aug 18 2003;115 Suppl 3A:150S-156S. [Medline].
Schreck DM, Babin S. Comparison of racemic albuterol and levalbuterol in the treatment of acute asthma in the ED. Am J Emerg Med. Nov 2005;23(7):842-7. [Medline].
Schuh S, Reisman J, Alshehri M, et al. A comparison of inhaled fluticasone and oral prednisone for children with severe acute asthma. N Engl J Med. Sep 7 2000;343(10):689-94. [Medline].
Spahn JD. Pharmacologic management of pediatric asthma. 1998;18 (1):165-81.
Stempel DA, Meyer JW, Stanford RH, Yancey SW. One-year claims analysis comparing inhaled fluticasone propionate with zafirlukast for the treatment of asthma. J Allergy Clin Immunol. Jan 2001;107(1):94-8. [Medline].
Steyer TE, Mallin R, Blair M. Pediatric asthma. Clinics in Family Practice. Jun 2003;5.
Suissa S, Ernst P, Benayoun S, et al. Low-dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med. Aug 3 2000;343(5):332-6. [Medline].
Sun HL, Chou MC, Lue KH, et al. The relationship of air pollution to ED visits for asthma differ between children and adults. Am J Emerg Med. Oct 2006;24(6):709-13. [Medline].
Walsh-Kelly CM, Kim MK, Hennes HM. Chest radiography in the initial episode of bronchospasm in children: can clinical variables predict pathologic findings?. Ann Emerg Med. Oct 1996;28(4):391-5. [Medline].
Welliver RC. Immunologic mechanisms of virus-induced wheezing and asthma. J Pediatr. Aug 1999;135(2 Pt 2):14-20. [Medline].
Werk LN, Steinbach S, Adams WG, Bauchner H. Beliefs about diagnosing asthma in young children. Pediatrics. Mar 2000;105(3 Pt 1):585-90. [Medline].
Williams JR, Bothner JP, Swanton RD. Delivery of albuterol in a pediatric emergency department. Pediatr Emerg Care. Aug 1996;12(4):263-7. [Medline].
Wohl ME, Majzoub JA. Asthma, steroids, and growth. N Engl J Med. Oct 12 2000;343(15):1113-4. [Medline]. [Full Text].
Wolfram RW. Asthma. In: The Clinical Practice of Emergency Medicine. 2nd ed. 1997:1093-96.
Zeffren BS, Windom HH, Bahna SL. Modern Treatment of Asthma in Children. Vol 43. Mosby Year Book; 1996:423-68.
Further Reading
Clinical guidelines
Managing asthma long term in children 0-4 years of age and 5-11 years of age. In: National Asthma Education and Prevention Program (NAEPP). Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda (MD): National Heart, Lung, and Blood Institute; 2007 Aug. p. 281-325.
Global Initiative for Asthma (GINA), National Heart, Lung and Blood Institute (NHLBI). Global strategy for asthma management and prevention. Bethesda (MD): Global Initiative for Asthma (GINA), National Heart, Lung and Blood Institute (NHLBI); 2007. 92 p.
Managing exacerbations of asthma. In: National Asthma Education and Prevention Program (NAEPP). Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda (MD): National Heart, Lung, and Blood Institute; 2007 Aug. p. 373-417.
Keywords
reactive airway disease in children, asthma, pediatric asthma, exercise induced asthma, exercise-induced asthma, asthma treatment, asthma assessment, asthma symptoms, asthma triggers, asthma causes, bronchospasm, obstructive airway disease, childhood asthma, hypersensitivity reaction, wheeze, wheezing, RAD, airway inflammation, upper respiratory infection, tachypnea, dyspnea, cyanosis, intercostal retractions, nasalpolyps, nasal secretions, diaphoresis, hyperresonance, pulsus paradoxus, decreased peak expiratory flow rate, pectus carinatum, clubbing, subcutaneous emphysema, respiratory syncytial virus infection, RSV infection, Mycoplasma pneumoniae, pet dander, cockroach allergen, dust mite allergen, molds, pollen, weather changes, bronchiolitis, gastroesophageal fistula, cystic fibrosis
