Symptoms of bronchial asthma in children

In children, in most cases, there is an atopic form of bronchial asthma. Typical symptoms of bronchial asthma are manifested by asthma attacks, bronchial obstructive syndrome. The main causes of violation of patency of the bronchi are edema and hypersecretion, spasm of bronchial musculature.

For bronchospasm is more clinically characterized by dry paroxysmal cough, noisy breathing with difficulty exhaling, dry wheezing.

With the prevalence and hypersecretion in the bronchi, various wet rales are heard.

Characteristic is that during an attack of bronchial asthma, there is shortness of breath, a feeling of lack of air, wheezing, a paroxysmal cough with hard-to-extract spitting phlegm. Exhaling is difficult. There is swelling of the chest and suffocation in severe bronchial asthma. In children, especially the early age, bronchial asthma is often combined with atopic dermatitis or at an older age (in adolescents) with allergic rhinitis (seasonal or year-round).

Symptoms of bronchial asthma often appear or worsen at night and especially in the morning hours. A severe attack of bronchial asthma occurs with severe dyspnea with the participation of ancillary musculature. Characteristically unwillingness to lie. The child is sitting with his hands on his knees. Swelling of the cervical veins is observed. The skin is pale, there may be cyanosis of the nasolabial triangle and acrocyanosis. With percussion - tympanitis, whistling, buzzing rattles and various in all fields of the lungs.

Threatening state is a mute slight and sharp decrease in peak volumetric expiratory flow rate of less than 35%.

There is emphysema of the lungs. It is difficult to leave the sputum. Sputum is visually viscous, light, glassy. The heart sounds are muffled. Tachycardia. There may be an increase in liver size.

To assess the function of external respiration in bronchial asthma, the forced vital capacity of the lungs is determined, the volume of the forced expiration in the first second, the peak volumetric expiratory flow rate determined with the help of portable flowmeters. To assess the degree of disruption of the reactivity of the receptor apparatus of the bronchi, inhalation tests with histamine and acetylcholine are carried out.

In the period of remission in the absence of clinical signs of obstruction, it is necessary to perform a lung function test using spirometry or to study the flow-volume curve of the forced vital capacity of the lungs.

[1], [2], [3], [4], [5]

Clinical and functional criteria for diagnosing bronchial asthma

For each degree, certain changes in clinical and functional parameters are characteristic. It is important that the presence of at least one characteristic corresponding to a higher than the other signs of severity, makes it possible to identify the child in this category. It should be noted that the use of criteria for verification of the severity of asthma should only be in cases where the patient has never received anti-inflammatory medication or used antiasthmatic drugs more than 1 month ago. This approach to assessing the severity of the disease is used to address the issue of starting therapy and assessment of the severity of violations / limitations of life activity in medical and social expertise.

Classification of bronchial asthma by severity (GINA, 2006)

Characteristics	Degree of severity
	Intermittent	Persistent
	Light	Light	Medium	Heavy
Daytime Symptoms	<1 time per week	> 1 time per week, but <1 time per day	Daily	Daily
Night Symptoms	<2 times a month	> 2 times a month	> 1 time per week	Frequent Symptoms
Exacerbations	Short-term	Violate activity and sleep	Violate activity and sleep	Frequent exacerbations
FEV1 or PSV (from due)	> 80%	> 80%	60-80%	<60%
The variability of PSV or FEV1	<20%	<20-30%	> 30%	> 30%

[6], [7], [8], [9], [10], [11], [12],

Classification of bronchial asthma

Classification of bronchial asthma:

• on etiology;
• by severity and level of control;
• for the period of the disease.

[13], [14], [15], [16],

Classification of bronchial asthma in etiology

Distinguish allergic and non-allergic forms of the disease. At children in 90-95% of cases there is an allergic / atopic bronchial asthma. Non-allergic forms of asthma are referred to as non-allergic. The search for specific causal environmental factors is important for the designation of elimination activities and in certain situations (with clear evidence of the relationship between exposure of the allergen, symptoms of the disease and the IgE-dependent mechanism) - allergen-specific immunotherapy.

[17], [18], [19], [20],

Symptoms of bronchial asthma depending on severity

The classification of the severity of bronchial asthma presented in GINA (2006), primarily focused on the clinical and functional parameters of the disease, should take into account the number of daytime and nighttime symptoms per day / week, the frequency of short-acting beta2-adrenergics, the peak exhalation rate (PSV) or volume forced expiration in the first second (FEV1) and daily fluctuations of PSV (variability)]. However, it is possible to change the severity of bronchial asthma. In addition to the clinical and functional disorders characteristic of this pathology, the volume of current treatment is taken into account when classifying asthma. Degree of disease control, as well as its period.

Light bronchial asthma

The frequency of attacks is not more than 1 time per month. Attacks episodic, lungs, quickly disappearing. Nocturnal seizures are present or rare. No change in sleep, tolerability of physical activity. The child is active. The volume of the forced exhalation and the peak expiratory flow rate of 80% of the proper value and more. Daily fluctuations of bronchial obstruction not more than 20%.

In the remission period, there are no symptoms, normal FVD. The duration of the remission period is 3 months or more. The physical development of children is not broken. The attack is eliminated spontaneously or once by taking bronchodilators in inhalations, or ingestion.

Moderately severe bronchial asthma

Attacks 3-4 times a month. They flow with distinct violations of the FVD. Night attacks 2-3 times a week. Tolerance of exercise is reduced. The volume of the forced exhalation and the peak expiratory flow rate of 60-80% of the proper value. Daily fluctuations of bronchial obstruction 20-30%. Incomplete clinico-functional remission. The duration of remission periods is less than 3 months. The physical development of children is not broken. Attacks are stopped by bronchodilators (in inhalations and parenterally), according to the indications, glucocorticosteroids are administered parenterally.

Severe bronchial asthma

Attacks several times a week or daily. Attacks are severe, asthmatic conditions are possible. Night attacks almost daily. Significantly reduced the tolerance of physical exertion. The volume of the forced exhalation and the peak expiratory flow rate are less than 60%. Daily fluctuations of bronchial obstruction more than 30%. Incomplete clinical and functional remission (respiratory failure of varying severity). The duration of remission is 1-2 months. Perhaps backwardness and disharmony of physical development.

Attacks are stopped by the introduction of parenteral bronchospasmolytics in combination with glucocorticosteroids in a hospital, often in the intensive care unit.

Evaluation of the spectrum of sensitization and defect level of the receptor apparatus of smooth muscles of the bronchi is carried out only in the period of remission.

In the period of remission, scarification tests are performed to determine the spectrum of sensitization to dust, pollen and epidermal antigens or knock-off probes with suspected allergens. Observation and treatment of a patient during an exacerbation and remission is performed by a district pediatrician and a pulmonary physician. To clarify the cause-significant antigen, the setting of skin tests is carried out by a district allergist doctor. The allergist doctor solves the need for specific immunotherapy and conducts it. The physician-pulmonologist and functional diagnostics teaches sick children and their parents to conduct peakflowmetry and fixation of the results. Research in the diary of self-observation.

Classification for the period of the disease provides for two periods - exacerbation and remission.

Classification of bronchial asthma depending on the period of the disease

Exacerbation of bronchial asthma - episodes of increasing dyspnoea, coughing, wheezing, stuffiness in the chest or any combination of these clinical manifestations. It should be noted that the presence of symptoms in patients with asthma in accordance with the criteria is a manifestation of the disease, and not an exacerbation. So, for example, if the patient has daily symptoms, two nocturnal symptoms per week and FEV1 = 80%, the doctor states that the patient has moderate severity of asthma, since all of the above serves as criteria for this form of the disease (rather than exacerbation). In the case when the patient adds additional (in excess of existing) need for short-acting bronchodilators to existing symptoms, the number of day and night symptoms increases, pronounced dyspnea occurs, asthma exacerbation is established, which also needs to be classified according to severity.

Control of bronchial asthma - elimination of manifestations of the disease against the background of the current basic anti-inflammatory treatment of asthma. Total control (controlled asthma) is now determined by GINA experts as the primary goal of asthma treatment.

Remission of bronchial asthma - complete absence of symptoms of the disease on the background of the withdrawal of the basic anti-inflammatory treatment. So, for example, the appointment of an appropriate degree of severity of asthma pharmacotherapeutic regimen for some time leads to a decrease (possibly to complete disappearance) of clinical manifestations of the disease and restoration of the functional parameters of the lungs. Such a condition must be perceived as control of the disease. In the case if the function of the lungs remains unchanged, and there are no symptoms of bronchial asthma and after the withdrawal of treatment, remission is ascertained. It should be noted that in children in the puberty period, spontaneous remission of the disease sometimes occurs.

[21], [22], [23]

Determination of the level of control depending on the response to the treatment of bronchial asthma

Despite the paramount importance (for determining the severity of bronchial asthma) of clinical and functional parameters, as well as the volume of treatment, the cited classification of the disease does not reflect the response to ongoing treatment. So, the patient can consult a doctor with symptoms of asthma corresponding to an average severity, as a result, he will be diagnosed with moderate persistent asthma. However, in case of insufficient volume of pharmacotherapy for some time, clinical manifestations of the disease will correspond to severe persistent asthma. Taking into account this provision, GINA experts proposed to distinguish not only the degree of severity, but also the level of disease control in order to make a decision on changing the volume of current treatment.

Levels of control over bronchial asthma (GINA, 2006)

Characteristics	Controlled BA (all of the above)	Partially controlled asthma (any manifestation within 1 week)	Uncontrolled asthma
Daytime Symptoms	No (<2 episodes a week)	> 2 per week
Restrict activity	No	There are - any expression	The presence of three or more signs of partially controlled asthma during any week
Nocturnal symptoms / awakenings	No	There are - any expression
Need for emergency medicine	No (52 episodes a week)	> 2 per week
Indicators of the function of the lungs (PSV or FEV1)	Norm	> 80% of the due (or the best score for this patient)
Exacerbations	No	1 per year or more	Any week with exacerbation

[24], [25], [26],

Diagnosis of allergic and non-allergic asthma in children

It is accepted to distinguish between allergic and non-allergic forms of bronchial asthma, they are characterized by specific clinical and immunological signs. The term "allergic asthma" is used as the base for asthma mediated by immunological mechanisms. When there are indications of IgE-mediated mechanisms (sensitization to external allergens, elevated serum IgE), one speaks of IgE-mediated asthma. In most patients (typical atopics - children with a hereditary predisposition to high IgE production, with the first manifestation of manifestations at an early age), allergic symptoms can be attributed to atonic asthma. However, IgE-mediated asthma can not always be called "atopic". In some people who can not be characterized as atopics, they do not have sensitization (at an early age) to common allergens, the development of IgE-mediated allergy occurs later when high doses of allergens are exposed, often in combination with adjuvants such as tobacco smoke. In this regard, the term "allergic asthma" is broader in comparison with the term "atopic asthma". In the non-allergic variant, allergen-specific antibodies are not detected in the examination, low serum IgE is characteristic, there are no other evidence of involvement of immunological mechanisms in the pathogenesis of the disease.

[27], [28], [29], [30], [31], [32],