I. Correctly distinguish between “childhood asthma” and “infant asthma”
In pediatrics, according to the physiological developmental characteristics of children, pediatric asthma between the ages of 3 and 14 is called “childhood asthma”, and the characteristics of childhood asthma are: ① Children in this age group can easily cooperate with doctors and parents. (2) Children in this age group have more mature organs, especially the trachea and bronchial smooth muscle. The application of drugs to dilate the trachea and bronchi, such as albuterol and aminophylline, can already play a good therapeutic role. ③As they grow older, the more contact they have with the outside world, the more likely they are to be stimulated by outside antigenic substances such as dust, pollen, feathers or eating foreign proteins such as shrimp, crab, fish and eggs or stimulated by smoke, paint, gasoline and perfume and develop asthma. ④ Pulmonary function tests are feasible to understand and track the progression of asthma and the effectiveness of treatment.
Similarly, pediatric asthma under 3 years of age is referred to as “infantile asthma” based on the physiological development of the pediatric population. Infantile asthma is difficult to treat, mainly because: (1) children do not cooperate with doctors and parents. The choice of asthma medication is difficult because the trachea and bronchial smooth muscle are not well developed, so the bronchodilators such as albuterol and aminophylline are basically ineffective. ③If asthma in this age group is not treated in time, bronchopneumonia and respiratory failure are likely to occur, or suffocation caused by weak cough, choking on milk and sputum blocking the airways, or even death. ④It is not possible to apply spirometry to track the severity of the disease and the effect of treatment. ⑤ Basically, they are caused by respiratory tract infections.
Why do asthma exacerbations often occur in the early morning and at night?
Many parents often tell their doctors that their children’s asthma attacks often worsen at night or after nap and when they wake up in the early morning, and the children often cannot sleep because of severe coughing and wheezing at night. This is mainly due to physiological changes in the body’s autonomic nerves (sympathetic and parasympathetic). At night, the sympathetic nerve is at its lowest excitability of the day due to the reduced release of cholinesterase, while the parasympathetic nerve (mainly the vagus nerve) is at its highest excitability of the day. We know that sympathetic excitation leads to bronchial smooth muscle diastole and airway dilation, and vice versa, contraction and airway narrowing. In contrast, parasympathetic excitation results in contraction of bronchial smooth muscles and an increase in sputum, and vice versa, in dilation and a decrease in sputum. As a result, children often show significant aggravation at night and early morning. In addition, the secretion of corticosteroid hormone by human adrenal glands is the lowest at 4-6 in the early morning, which reduces the permeability of cell membranes to asthma-causing inflammatory mediators, causing spasm of tracheal and bronchial smooth muscles, narrowing of airways and increase of sputum secretion, which is also a main reason for the aggravation of children’s coughing and wheezing at night and early morning.
Third, will wheezing definitely occur in pediatric asthma?
People know that cough and wheeze are the main symptoms of asthma, however, when cough is the only symptom of asthma without wheeze it is not recognized and thus the diagnosis of asthma is ignored. It is a misconception that people generally think that asthma is only asthma when wheeze is present. Chronic cough is a common problem encountered by parents and outpatients of pediatric patients. In fact, some of the children with undiagnosed chronic cough or diagnosed with bronchitis, recurrent upper respiratory tract infections, and mycoplasma infections are bronchial asthma. This is actually a specific type of pediatric asthma, clinically known as “cough variant asthma”. Since its introduction by Gvauser in 1972, cough variant asthma has been recognized as one of the most common diseases causing chronic cough in children.
IV. What happens if pediatric asthma is not treated properly
Pediatric asthma is a chronic disease, and the earlier it is treated, the better the outcome. In the early stage when the disease is mild, it is often not taken seriously by parents or not recognized by doctors when it is already a bronchial asthma disease and not given timely and appropriate treatment. The chronic inflammation that exists in the airways for a long time is not effectively controlled, which will cause the epithelial cells of the airway mucosa to fall off, fibrosis of the subepithelial tissue, hypertrophy of the smooth muscle cells and proliferation of the ring cells, and finally lead to irreversible narrowing and deformation of the airways, a process that often This process often takes several years. At this point, the child will develop emphysema, pulmonary heart disease, and eventually die of heart failure and respiratory failure. Some of them may develop into bronchiectasis, with the appearance of a short and thick neck and an enlarged barrel-shaped anterior and posterior thorax, medically known as “barrel chest”. After the age of 14, the disease develops into adult asthma, and the chance of a complete cure is lost. For this reason, not only the physician should know, but also the parents should know why the drugs are used, what drugs can be used for a long time, what drugs can be used temporarily, and what to do if the effect is not satisfactory.
For example, the child often xx, female, 10 years old, from the age of 3 years old appeared cough and wheeze, more than 10 times a year to dozens of episodes, sometimes several times a month, the beginning of each attack after the “cold”, and then gradually each attack with the “cold” relationship is not obvious The child was never seen by a specialist because his mother was a nurse, and every coughing and asthma attack was treated by his mother with her own medication, which was discontinued when there was slight relief, and never used during the remission period. Not long ago the child’s cough and asthma attacked again, his mother still self-treatment for 2 days did not work, and his condition worsened, when he was admitted to the hospital, he was already in severe asthma, asthma persistent state, combined with respiratory failure and heart failure, and was discharged after more than 20 days of hospitalization by vigorous resuscitation. The mother learned a very profound lesson and has been cooperating with the specialist for systematic treatment since then, and has not had another attack for more than one year. Through this incident, medical staff and parents should realize how important it is to treat children with asthma appropriately and reasonably.
V. What diseases are easily confused with pediatric asthma?
Pediatric asthma can be easily confused with some respiratory diseases in clinical practice, which may cause difficulties in diagnosis and delay the diagnosis and misdiagnosis. In pediatrics, it should be distinguished from the following diseases:
(1) Asthmatic bronchitis: this disease is common in infants and young children, mostly accompanied by fever, and blood tests often show an increase in leukocytes and neutrophils, but not in eosinophils.
(2) Capillary bronchitis: This disease is mostly seen in small infants under 6 months of age, mostly due to respiratory syncytial virus infection, with significant breath-holding and moaning, and a large number of fine wet sounds can be heard in the lungs in addition to croup. Inflammatory lesions in the lungs may be detected on chest X-ray.
(3) Bronchial lymph node tuberculosis:Due to the enlarged lymph nodes, there may be intractable cough and asthma-like dyspnea due to compression of the bronchi, but there is no sudden onset and cessation of asthma. The diagnosis can be helped by asking about the history of BCG vaccination and further X-ray chest radiographs and tuberculin and other more advanced tests.
(4) Bronchial foreign body: A history of foreign body aspiration or sudden violent choking can often be inquired about. If one side of the bronchus is blocked, wheezing sounds and other clinical signs are limited to the affected side. In asthma, the signs are the same on both sides, and the lung lobes or segments with blocked bronchi are seen on X-ray chest radiographs as pulmonary atelectasis or emphysema. Bronchoscopy may be performed if necessary.
(5) Mycoplasma pneumonia or bronchiectasis: The incidence of this disease has been increasing year by year in recent years. It is characterized by a severe dry cough, often lasting several weeks or months, with fever, and inflammatory lung lesions on X-ray chest. Treatment with erythromycin is effective.
In addition to the above common diseases, in infants it should be distinguished from aspiration syndrome, cystic fibrosis of the pancreas, bronchial and pulmonary developmental abnormalities, vascular malformations, cardiac disorders, mediastinal masses, and other diseases. In children, it should also be distinguished from chronic pharyngitis, tonsillitis, sinusitis, allergic rhinitis, bronchiectasis, eosinophilia, etc.
VI. Treatment goals of pediatric asthma
The cure of pediatric asthma is difficult, but if accurate diagnosis and reasonable treatment are mastered, and if attention is paid to prevention and treatment, it is possible to fight for a chance of cure in adolescence. The treatment goals of pediatric asthma are:
(1) Satisfactory symptom control with small doses of medication to achieve symptom relief and improve quality of life.
(2) The number and severity of acute attacks can be reduced to prevent complications such as emphysema, pulmonary heart disease, bronchiectasis, respiratory failure, heart failure, etc.
(3) The improvement of lung function is obvious.
(4) Educate the patient and family about asthma, especially prevention and treatment of attacks, and give self-treatment for mild attacks at home.
(5) Let the sick child go to school as much as possible.
(6) Do not restrict physical activity.
(7) Ensure that the child’s physical and mental development is normal to avoid adverse reactions during treatment.
VII. What are the first-line, second-line and third-line drugs for the treatment of pediatric asthma
Before the 1980s, aminophylline, epinephrine, isoproterenol, theophylline (teatropine, eugenol) were often used as the first choice for the treatment of pediatric asthma, with overemphasis on the side effects of hormones, and their use was generally not advocated when the condition was not very critical. After the 1990s, as the understanding of the mechanism of asthma has been deepened, a great leap has been made in treatment. Epinephrine and isoprenaline have been eliminated because of their serious cardiac side effects, often resulting in death by fragmentation, increased blood pressure, and serious heart rhythm disturbances, which have increased mortality. Aminophylline also because of its side effects, especially intravenous injection of cardiac side effects, oral individual differences, the amount of poisoning and treatment is not easy to grasp, the clinical effect of the drug is not ideal, especially the drug can only carry out symptom control, can not treat the cause of the disease, now is not as the first choice.
The persistent airway inflammatory response and airway hyperresponsiveness are now recognized as the cause of asthma development. With the successive introduction of corticosteroid aerosols and β2 agonists and a large number of clinical use, it has been proven that: as symptom control, β2 agonists are the best drugs to dilate the bronchial fly to relieve asthma symptoms. These drugs include: albuterol, albuterol, albuterol or albuterol, borneol (terbutaline), and more recently, long-acting agents such as Schlitzel (salmeterol), albuterol (procatheol) and allopurin, which have been used as second-line drugs for the treatment of asthma.
These drugs have been used as second-line drugs in the treatment of asthma. As etiologic treatment, inhaled corticosteroids, sodium cromoglycate and nedolimus are now included as first-line drugs.
How to choose drugs for pediatric asthma attacks
When a pediatric asthma attack occurs, the first thing to determine is whether the attack is mild, moderate or severe, and whether it is combined with complications or infections.
Mild attacks: inhaled corticosteroids and intermittent inhaled and/or oral β2 agonists such as salbutamol (albuterol, albuterol), terbutaline (Bolycanib, albuterol), and oral aminophylline can also be given. When younger than l years old, oral replacement or combined with ipratropium inhalation can be used.
Moderate episodes: β2 agonists and/or oral aminophylline should be inhaled or administered orally. If there are nocturnal episodes of coughing, switch to slow-release beta2 agonists or aminophyllines, plus long-term inhalation of sodium cromoglycate or hormones.
Severe attacks:prompt medical attention should be sought, firstly intravenous medication should be given intravenously, high doses of hormones and β2 receptor stimulants should be given intravenously, when the symptoms are controlled and the condition improves, the treatment can be changed to oral β2 receptor agonists or aminophylline analogues or inhaled β2 receptor agonists, and continuous treatment with hormones-beclomethasone propionate (Bicodone, Bicodone, Andersin) by inhalation, inhaled hormones for more than six months to Gradually stop using them for several years.
In case of persistent asthma or severe asthma, oral hormone can be used instead of or in addition to hormone inhalation, and the dose should be reduced or taken every other day if possible. In case of intermittent severe attacks, short courses of hormones (3-7 days) should be given orally or intravenously, together with oral, intravenous or nebulized β2-receptor stimulants, or with aminophylline drugs.
Complications such as respiratory failure, heart failure, acid-base balance or electrolyte disturbance may aggravate asthma. In this case, appropriate treatment should be given actively. In case of co-infection, anti-infection treatment should be actively given.
Why salbutamol and aminophylline are not suitable for children under 2 years old with asthma
This is related to the growth and developmental characteristics of children at this age. We know that albuterol and aminophylline are used to calm asthma by relaxing tracheal and bronchial smooth muscles, and in children under 2 years old, the development of tracheal and bronchial submucosal smooth muscles is still immature, and there are only some intermittent muscle fiber bundles, and the contraction or relaxation of these muscle fiber bundles has little effect on the inner diameter of the airway. The smooth muscle under the trachea and bronchial mucosa of children over 2 years old is more mature and close to that of adults, and those intermittent bundles of muscle fibers are continuous with each other to form a more complete smooth muscle layer. At this time, its contraction or relaxation will directly affect the narrowing and expansion of the airway. Thus, albuterol and aminophylline analogs have a good calming effect for children over 2 years of age and are not appropriate for children under 2 years of age. If they are administered blindly to children of this age, they will not only fail to calm asthma, but also lead to serious toxic side effects.
Non-specific immunotherapy for pediatric asthma includes which
Non-specific immunotherapy is gaining attention because of its safety, high efficacy, ease of application, abundant drug sources and short course of treatment. There are many such therapies, and the ones commonly used clinically are introduced as follows:
1, corticosteroids: this is currently recognized as the most effective drugs to prevent and control asthma. Including systemic prednisone, dexamethasone, hydrocortisone. Local airway inhalation of beclomethasone propionate.
2.Cellular immunomodulators:
(1) thymosin (peptide): is a multi-skin immune active substance extracted from calf, pig or human embryonic thymus cells.
(2) transfer factor: is a small molecule non-antigenic substances extracted from human leukocytes that can be ultrafiltered.
(3) levomilva: has immunomodulatory effect.
3.Non-specific immune enhancers.
(1) BCG vaccine injection.
(2) Expired measles vaccine.
(3) expired polio vaccine enamel pills.
(4) Interferon.
(5) Card slow Shu solution (405 syrup).
(6) Placental lipopolysaccharide.
(7) Asthma vaccine; the most commonly used triple vaccine. Subcutaneous injection can be started before the good season, but it is rarely used now because of the long time and poor effect.
4.Anti-allergic drugs:
(1) Sodium cromoglycate aerosol.
(2) Ketotifen.
(3) histamine globulin: less used because of the tendency to allergic reactions and bleeding.
(4) Isoprostanes (fenagan).
(5) Immunosuppressants: In addition to hormones, these drugs include cyclophosphamide, cyclosporine and tretinoin. Because of the poor efficacy, clinical rarely used, not repeated.
6, Chinese medicine. Chinese medicine to strengthen the lungs, spleen and kidneys, with small side effects, good efficacy and other advantages, worthy of application.
7, other:
(1) Vitamin B6: can improve the symptoms of asthma.
(2) Vitamin K: has the effect of directly relaxing smooth muscle.
(3) Dinoprost (prostaglandin’s) aerosol: can relax the bronchial smooth muscle, but the effect only lasts for one hour.
(4) Phentolamine aerosol: rarely used, its therapeutic value needs further evaluation.