Indian Pediatrics - Editorial

Recommendations

Indian Pediatrics 1999; 36:157-165

Consensus Guidelines on Management of Childhood Asthma in India

Reprint requests: Dr. Lata Kumar, Professor and Head, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India.

Asthma is a common disease amongst children in India with prevalence estimated at 5-10%. A world wide increase in the prevalence of asthma is being reported with increase in wheeze at an alarming rate of 5% per year. From 1983 onwards an increase in asthma mortality and morbidity has been noticed globally(1). Several guidelines have been published since 1990 with the aim of improving management of asthma. However, a systematic analysis of guidelines till 1995 had brought out several controversial issues as well as gaps in knowledge(2). In May 1997, guidelines were published about management of asthma by an Expert Committee of the National Heart Lung and Blood Institute of USA where they tried to overcome many of the previous lapses(3). The need for similar guidelines has always been felt amongst the physicians managing children in India. It is felt that the guidelines originating in this country would have much more relevance to the ground situation and the status of health services. Thus, to set up the process of achieving consensus towards suitable guidelines, a Consensus Conference was held on April 17 and 18, 1998 at the Advanced Pediatric Center of the, Post Graduate Institute of Medical Education and Research, Chandigarh in which experts (Annexure I) who manage asthma patient and have published papers in this field, participated. These guidelines were also later endorsed by the Indian Academy of Pediatrics, Respiratory' Chapter. Recent evidence was accessed using' searches on Medline, Embase, Index Medicus and Excerpta Medica. Some of the contentious issues were resolved with the help of the Cochrane Library(4). Since the consumer of health care in India is not sufficiently literate, physicians have been assigned a lot of responsibility in decision making for the patients. The guidelines are required to be updated periodically and provide flexibility to individualize patients. Since in large areas in our country all the recommended modalities may not be available, suitable improvisations must be made.

Objectives of the Conference

1. To reach at a uniform treatment approach towards children with asthma keeping in mind the limitations of resources in the Indian context and to develop guidelines based on available evidence for the pediatricians.

2. To prepare a consensus document for management of children with asthma which would provide guidelines to a general pediatrician managing asthma in India.

Various components discussed included pathogenesis, definition, classification of severity, measure of assessment and monitoring, referral, control of factors contributing to asthma severity, pharmacological therapy and education of patient, family and health professionals regarding ashtma care.

Pathogenesis and Definition

Bronchial asthma is a chronic inflammatory disorder in which several cells and cellular elements are involved. In susceptible individuals this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness and cough, particularly at night and early morning. These episodes are associated with variable and widespread airway obstruction that is often reversible either spontaneously or with treatment. The inflammation also causes increase in bronchial hyper-' responsiveness to a variety of stimuli.

Diagnosis

A detailed medical history, careful physical examination and peak expiratory flow rate measurement to demonstrate obstruction with 'reversibility of variable airflow obstruction are needed for the definite diagnosis of asthma. To establish the diagnosis of asthma the clinician roust determine that: (i) Episodic symptoms of airflow obstruction ~ 3 episodes are present; (ii) Airflow obstruction is at least partially reversible; and (iii) Alternative diagnoses are excluded. Physicians who care for children with asthma should be expected to be well versed in peak expiratory flow monitoring. They should perform spirometry wherever possible.

Measures of Assessment and Monitoring

A child with asthma is to be monitored for clinical signs and symptoms of asthma with the help of asthma diary given to the patients/ parents and record of peak expiratory flow rate with a standardized peak flow meter (Table 1). PEFR must be monitored at the physician's office, asthma clinics (where spirometry should be available) and in the emergency room. Patients with chronic severe asthma must be encouraged and trained to monitor their PEFR at home once a day routinely and twice a day if the morning reading is abnormal, to determine their PEFR variability. Patient's personal best should be assessed and used subsequently. Spirometry has been kept optional and emphasis must be given to patients's quality of life. Emphasis must be on self management but physician supervision must still be the primary mode. Patients must be given a written crisis management plan where literate; otherwise verbal communication at each contact must continue.

Classification of Asthma Severity

Asthma severity classification has been modified to mild intermittent, mild persistent, moderate 'persistent and severe persistent asthma (Table II)(2). The recommended classification for severity of asthma exacerbations is depicted in Table III. Since spirometry is not routinely available to pediatricians in this country, it was felt that more emphasis be placed on PEFR measurement especially at the physicians' office. Patient's personal best should be used as the standard but in its absence expected PEFR according to norms published on children in India may be used(5). It was also mentioned that a severe form of asthma requiring daily oral steroids or stronger treatments like immunosuppressants is extremely uncommon in Indian children and m9st of the children get controlled with inhaled medications.

TABLE I

Basic Steps for Using a Peak Flow Meter

Move the indicator to the bottom of the numbered scale.
Stand up.
Take a deep breath, filling your lungs completely.
Place the mouthpiece on your tongue and close your lips around it. Do not put your tongue inside the hole.
Blow out as hard as you can in a single blow.
Write down the number you get.
Repeat the above two steps two more times. Note the best of the three values for your record.

TABLE II

Classification of Asthma Severity

Grade	Symptoms	Night-time Symptoms	Lung Functions
Severe	Continual symptoms,	Frequent	PEFR < 60%
persistent	Limited physical activity,		predicted
(Step 4)	Frequent exacerbations
Moderate	Daily symptoms,	> 1 time/week	PEF >60% to <80%
persistent	Daily use of beta agonist.		predicted
(Step 3)	Exacerbations affecting activity≥2/week. lasting days
Mild	Symptoms >2/week	. >2 times/month	PEF≥80% predicted
persistent	but < 1/day,
(Step 2)	Exacerbation may affect activity
Mild	Symptoms 5.2/ week,	5.2 times/month	PEF≥80%
intermittent	Exacerbation brief,
(Step I)	Asymptomatic between exacerbations

The presence of one of the features is sufficient to place a patient in that category. A child should be assigned to the most severe category in which any feature occurs. An individual's classification may change over a period of time.

TABLE III

Classifying Severity of Asthma Exacerbations

Goals of Asthma Therapy

The goals of asthma therapy in a child are to:

Prevent chronic and troublesome symptoms.
Maintain near normal peak expiratory flow rate.
Maintain normal activity levels (including exercise and physical activity).
Prevent recurrent exacerbations of asthma and minimize the need for emergency room visits and hospitalization.
Provide optimal pharmacotherapy with minimal side-effects.
Meet patient's and family's expectations of satisfaction with asthma care.

Pharmacological Therapy

Pharmacological therapy is the corner- stone of therapy. It must be instituted with proper environmental control measures. Medications are classified into two broad categories, long term control medications or the preventives and quick relief medications or rescue medications. Long term control medications .are mostly anti-infIammatory compounds. Early intervention with inhaled steroids can improve asthma control and normalize lung function and preliminary studies show that it might prevent irreversible airway injury. These are to be administered with the help of a metered dose inhaler and a spacer (in patients who cannot afford the commercially available spacers, a home made spacer can be used). Another alternative available in India is a dry powder inhaler (transparent rotahaler).

Table IV

Stepwise Approach in Long Term Management of Children with Asthma

A step care approach is to be adopted for management of asthma starting at a higher level and then stepping down as control is established (Table IV). Figs. 1 & 2 depict management algorithms of asthma exacerbation in the home and emergency room settings, respectively.

Referral

Patients must be referred to a special clinic of asthma if any of the following problems arise:

1. Failure to meet the goals of therapy.

2. Atypical signs or symptoms or uncertain diagnosis.

3. Presence of complications.

4. Need for additional diagnostic testing like skin tests, pulmonary function tests, endoscopy, incremental growth assessment, etc.

5. Severe symptoms such as step 4 care (Table IV).

6. Non adherence to therapy.

7. Need for good asthma education.

8. Significant psychosocial or psychiatric problems.

Environmental Control and Prevention of Asthma

Allergen A voidance

Indoor Allergens

Cockroach, house dust mite, fungal spores, animals (pets) are the main source. Skin testing can be used for the diagnosis. The following control measures are suggested:

Cockroaches: Leave no food uncovered. Traps to catch cockroaches are better than antiroach chemicals.

House dust mite: Sun the beddings weekly. No carpets or stuffed, upholstered furniture in the house. The mattresses and pillows should be covered with impervious coverings. Proper mapping of the country needs to be done to see where house dust mite is an important allergen (expected in warm, humid climate).

Pets: Pets like dogs, cats or birds should not be kept by children with asthma. Cats are not a common pet in India. Reports on pets are very few in this country. If pets are already in the house, contact with the patient should be minimized; or they should be kept out of the living premises.

Moulds or indoor fungal spores: Prevent seepage of water through roofs or walls during the rainy season. Keep rooms well ventilated and allow sunlight in. Children with asthma should not be asked to take out winter clothing and help in sunning. Similarly they should avoid cleaning cupboards and drawers which have been closed for some time.

Outdoor Allergens

Seasonal exposure to pollens and fungi can be reduced by keeping the doors and windows closed from early I1!Orning till evening during the high pollen season. Air conditoning can be used. The filter of the air conditioner should be properly maintained.

Incase an allergen is found to contribute significantly to patient problem, he should be referred to a specialist for skin testing and if required, for immunotherapy, only if the child is not responding appropriately to pharmacotherapy and allergen is significantly contributing to disease.

Irritants or Chemicals

A void tobacco smoke, strong odors, fumes from various kinds of stoves/Chullah and using kerosene, wood or cow dung.

Breastfeeding

In high risk families (atopy on both sides or even one side) exclusive breastfeed should continue for 4-6 months and mother should avoid well known allergenic food in diet while the baby is exclusively breastfed.

Psychosocial Aspects of Asthma Management

Children with chronic illnesses are at an increased risk for developing psychological disturbances. Children with severe asthma are three times more likely to develop emotional/ behavioural problems as compared to healthy peers. It was decided at the meeting that the primary physician to the patient should be able to deliver the necessary preventive services like explaining the basic facts about the disease and try 10 improve the quality of life by optimum care. Mental health workers can provide important services to asthmatic children who have obvious psychological or behavioural problems, experience school difficulties and are non compliant with treatments.

Family therapy aimed at modifying family interaction problems and parent child relationships can help in improved management of asthma and also improve the overall quality of life. Hence, family therapy should be considered an adjunct to the conventional treatment in severe asthmatic children. It is important that psychologists be part of the multidisciplinary treating team in order to pro- vide comprehensive services to children with asthma.

Health Education

The experts stressed the need for health education not only in Asthma Clinic or Hospital but also on TV, Radio and other communication media. The attitudes and practices concerning this disease demonstrate a high degree of ignorance and misinformation. Written material containing information regarding basic facts of asthma should be made available to the patient and the parent while making the diagnosis. Special measures were recommended to be taken to educate the people about the harms of passive smoking.

Future Directions for Research

The data presented indicate gross inadequacy of information regarding basic facts of asthma to patients and their parents. Intervention in the form of written material significantly improves the knowledge, of these individuals. More studies need to be done to assess the knowledge attitudes and practices of these patients and specific materials developed to improve the baseline information and change attitudes towards inhalation therapy. Participants felt that there was a social stigma attached to the disease and parents of the patients were specially concerned about the in-halation therapy having potential for producing drug dependence. More data needs to be generated towards epidemiology of asthma in this country especially as to why the incidence of asthma is relatively less in India and the disease is less severe as compared to some of the western countries. The utility of yogic breathing exercises and role of Ayurved also needs to be evaluated.

ANNEXURE I - MEMBERS OF THE CONSENSUS GROUP

D. Behara, Anil Bhalla, Krishan Chugh, S.K. Gambhir, S.K. Jindal, S.K. Kabra, Lata Kumar (Convener), Keya Lahiri, Prabhjot Malhi, Uday Nadkarni (did not attend the Conference but participated in drafting the Consensus Guidelines), H. Paramesh, Sujeet Rajan, G.R. Sethi, Meenu Singh, Sunit C. Singhi.

Rapporteurs for the Sessions: R.M.P.L. Ramanathan, K.O. Singh Writing Group: Meenu Singh, Lata Kumar, R.M.P.L. Ramanathan.

References

1 Lewis S. ISAAC. A hypothesis generator for asthma? Lancet 1998; 351: 1220.

2. Meijer RJ, Kerstjens HAM, Postma OS. Comparison of guidelines and self management plans in asthma. Eur Respir J.1997; 10: 1163-1172.

3. Sly RM. New guidelines for - diagnosis and management of asthma. Ann Allergy Asthma Immunol1997; 78: 427-437.

4. The Cochrane Library: Update Software, Ox- ford, UK.

5. Parmar Y, Kumar L, Malik SK. Normal values of peak expiratory flow rate in healthy north Indian school children 6-16 years of age. Indian Pediatr 1977; 14: 591-594.