Individuals who have asthma during childhood have significantly lower fev1 and airway reactivity and more persistent bronchospastic symptoms than those with infection-associated wheezing.

Children with mild asthma who are asymptomatic between attacks are likely to improve and be symptom-free later in life.

Children with asthma appear to have less severe symptoms as they enter adolescence, but half of these children continue to have asthma.

Asthma has a tendency to remit during puberty, with a somewhat earlier remission in girls. However, compared with men, women have more BHR.

                    Patient Education

Patient and parent education should include instructions on how to use medications and devices (eg, spacers, nebulizers, MDIs). The patient's MDI technique should be assessed on every visit.

Discuss the management plan, which includes instructions about the use of medications, precautions with drug and/or device usage, monitoring symptoms and their severity (peak flow meter reading), and identifying potential adverse effects and necessary actions.

Write and discuss in detail a rescue plan for an acute episode. This plan should include instructions for identifying signs of an acute attack, using rescue medications, monitoring, and contacting the asthma care team.

Parents should understand that asthma is a chronic disorder with acute exacerbations; hence, continuity of management with active participation by the patient and/or parents and interaction with asthma care medical personnel is important.

Emphasize the importance of compliance with and adherence to treatment.

Incorporate the concept of expecting full control of symptoms, including nocturnal and exercise-induced symptoms, in the management plans and goals (for all but the most severely affected patients).

Avoid unnecessary restrictions in the lifestyle of the child or family. Expect the child to participate in recreational activities and sports and to attend school as usual.

                  ASPIRATION SYNDROME

 

One of the most common causes of BOS in infants - a syndrome of habitual microaspiration of liquid food associated with dysphagia, often in combination with gastro-oesophageal reflux. Up to 30% of all cases of recurrent cough in infants are associated with aspiration syndrome. Determination of the cause may be difficult. Anamnestic data helps in the diagnosis of aspiration. Usually in these children there are the history and neurological symptoms such as attack coughing that develops in the child during feeding, the appearance of dry or moist rales in the lungs after a meal. The diagnosis is confirmed after examining a patient in the hospital. 

FOREIGN BODIES IN  LUNGS, TRACHEA AND BRONCHIAL TUBES 

It is the acute obstruction of respiratory tracts as a result of aspiration of foreign bodies  of different nature(organic, inorganic, metallic)  in the respiratory tracts (larynx, trachea, bronchial tubes).  Depending on the location  foreign bodies are divided into balloting, valvular (valve) and obturacting. Mechanical obstructions   and laryngospasm  have the main role I pathogenesis.

Clinic. Polymorphic, depends on the level of localization of foreign body, its size and form, time of stay in respiratory tracts. At the hit of foreign body in a larynx on a complete health attack of strong cough arises up, dyspnea, asphyxia, hoarse of voice. The clinical sings change as a result of motion of body. A diagnosis is due to laryngoscopy. The foreign body of trachea predetermines an exhausting cough, characteristic noise of slamming as a result of its blow on trachea, dyspnea attack .In the case of invasive penetration of foreigh body pain in chest, blood phlegma occur. If there is aspiration of foreign body in main bronchus, symptoms are the same, as well as at the hit in a trachea. When it penetrates deeper, in the distal regions of respiratory tracts, a cough becomes weaker. Obturation atelectasis in the proper lobe with compensating emphysema of neighbouring lobe develops at the complete corking of bronchus. The incomplete corking valve stenosis and obturation emphysema occur. Collection of anamnesis is purposeful important in establishment of diagnosis. Roentgencontrastive foreign bodies, or indirect signs of aspiration of nonroentgencontrastive bodies (atelectasis, acute emphysema of segment, lobe or    lung), appear at roentgenologic research, the Holtskneht – Jacobson symptom is exposed: displacement of mediastenum at deep inhalation in a sick side and at deep exhalation – in healthy. Foreign body of trachea and bronchial tubes is diagnosed also by bronchoscopy.

Help on prehospital stage

1.                To try to delete the foreign body. To take a child for feet, to drop downward by a head (for a short time) and inflict a few blows on the back. The children of the first year of life are laid on abdomen and face on the forearm of doctor, here by forel and middle fingers a head and neck are fixed. A forearm together with a child is lowered downward on 60 O. By the rib of palm of right hand short blows are dealed between shoulder-blades. For  elders  children  the Heymlih method is used : on the epigastrial area of child, which lies on a side, a doctor lays  the palm of the left hand, by the fist of right hand deals 5-8 short blows under the corner of 45 O in direction of diaphragm, or child which suffered, is clasped from behind of back by  hands so that the right palm compresses in a fist was at level between umbilicus and sternum, and left palm – over it, four sharp blows are done in this position, sending them insite and upwards, causing an artificial cough.

2.                With an attempt to delete the review of mouth cavity foreign body by hands or pincers, at possibility with direct laryngoscopy.

3.                Immediate hospitalization to otolaryngology unit. During transporting there must be the promoted position, to quiet a child, oxygen therapy.

4.                At ineffective of previous measures and impossibility of rapid hospitalization, there is the risk of death from an asphyxia. So conicotomia or tracheostomy is executed. Method of conicotomia: head of patient is maximally  backwards, feel an interval between thyroid that cricoid cartilages and with scalpel or another cutting object cut a skin, and then conical ligamentum   in transversal position. In the opening hole tracheostomic, intubation or another tube, which is in hands, are placed in order to provide access of air in a trachea.

Method of tracheostomy: bolster under the shoulders (not under a neck!) of patient. A head is maximally background. The little turn of head causes the displacement of trachea and cut her over not on a middle line and the wound of esophagus. Local anaesthesia. Vertical cut of skin from a cricoid cartilage by length of 4-5 cm. If a neck is short transversal cut is used by length of 5-6 cm at level of 2-3 rings of trachea. After dissection skins and fascia execute the subsequent baring of trachea only by a dull way. Move away the isthmus of thyroid downward and do overhead tracheostomy. Before section a trachea is sewed by silk which serves as a holder. Interval between cartilages is cutting by scalpel   higher than a holder, canulla is entered in trachea.

Chronic foreign body producing bronchiectasis in a 2-year-old boy. He had a history of choking on "something" while playing outdoors. A productive cough, recurrent pneumonia, and finger clubbing developed over the next 9 months. Chest film (<IT+>A<IT->) shows right lower lobe infiltrate. Bronchogram (<IT+>B<IT->) shows nonfilling of anterior basilar segment (<IT+>arrow<IT->) of right lung. The resected segment (<IT+>C<IT->) contained a bronchiectatic cavity (<IT+>arrow<IT->) with an aspirated grasshead (<IT+>D<IT->). Recovery was complete after operation and included resolution of severe clubbing. (From Hilman BC (ed): Pediatric Respiratory Disease. Philadelphia, WB Saunders, 1993, p 519.)

 

Help on  hospital stage

1.                If foreign body is in a larynx - laryngoscopy must be done to its delete.

2.                At finding of foreign body in a trachea or bronchial tubes – quickly

                     tracheobronchoscopy with anesthesia.

3.                Antibiotics of wide spectrum of action.

                            ANOTHER PATHOLOGY THAT CAUSES BOS

                A large group of diseases that occur with the manifestations of BOS, are hereditary metabolic.

            Hereditary deficiency α1-antitrypsin (α1-protease inhibitor) is a relatively rare disorder, inherited by autosomal recessive type. The earliest complaint is shortness of breath that occurs without cough and sputum, which, however, may join later. Percussion, auscultation and radiological findings are typical of pulmonary emphysema: swelling of the chest, bandbox sound over the lungs, weak breathing, increased pneumatization of pulmonary pattern. At α1-antitrypsin deficiency obstruction occurs due to loss of elasticity, and not as a result of bronchospasm. The diagnosis of α1-antitrypsin deficiency is confirmed by decrease of its content in the blood (normal 20-30 IU / ml), phenotype, genetic examination of relatives of the patient.

              Clinical manifestations of BOS at congenital malformations of the heart and blood vessels have certain similarity with acute obstructive bronchitis. The main mechanism for the development of BOS is a compression or occlusion of bronchial obstruction. The main in diagnosis is clinical and instrumental examination of the cardiovascular system with obligatory echocardiography.

             Recently, problem of relevant spread of tuberculosis among children becomes actual, which may be masked as obstructive bronchitis. In such case will be a long-term symptoms of intoxication, a history of frequent respiratory infections.

At X-ray of the chest thqre will be marked narrowing of the lumen of the bronchi, areas of atelectasis, emphysema, the presence of fistula with separation of caseous mass. For the correct diagnosis the utmost importance has tuberculin diagnostics, as well as identification of the causative agent in the washing waters.

             Often, BOS may be detected in diseases of the central and peripheral nervous system. In children with birth trauma, CNS impairment, hypertension-hydrocephalic syndrome, with severe malformations of the brain may be disrupted coordination of swallowing and sucking, which may result in aspiration of food (mostly liquid) with the development of BOS. At myopathy (amyotrophy Verdniga-Hoffmann disease, Oppenheim's) dysphagia associated with paresis of the swallowing muscles occurs with subsequent development of aspiration bronchitis. Swallowing disorders in these diseases are wavelike nature: the periods of improvement are replaced by increasing aspiration, mainly in the background of ARVI. Increased respiration and a direct effect of viral infection on the neuro-muscular system may contribute to violations of swallowing, dyskinesia of bronchial tree with the development of pronounced bronhoconstriction.

Thus, the differential diagnosis of bronchial obstruction syndrome in children is an extremely important issue. The tactics to the patient, differential treatment measures, which in turn determines the outcome of the disease depends on the timely establishment of the causes of bronchial obstruction.