Symptoms of bronchial asthma in children

In most cases, children have an atopic form of bronchial asthma. Typical symptoms of bronchial asthma include asthma attacks and broncho-obstructive syndrome. The main causes of bronchial obstruction are edema and hypersecretion, and spasm of the bronchial muscles.

Bronchospasm is more clinically characterized by a dry paroxysmal cough, noisy breathing with difficulty exhaling, and dry wheezing.

With prevalence and hypersecretion in the bronchi, moist rales of various sizes are heard.

Characteristic is that during an attack of bronchial asthma there is shortness of breath, a feeling of lack of air, wheezing, paroxysmal cough with difficult to separate viscous sputum. Exhalation is difficult. There is swelling of the chest and suffocation in severe cases of bronchial asthma. In children, especially at an 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 intensify at night and especially in the morning. A severe attack of bronchial asthma occurs with pronounced dyspnea with the participation of accessory muscles. Reluctance to lie down is characteristic. The child sits, resting his hands on his knees. Swelling of the jugular veins is observed. The skin is pale, there may be cyanosis of the nasolabial triangle and acrocyanosis. Percussion reveals tympanitis, whistling, buzzing wheezing and wheezing of various calibers throughout the lung fields.

A threatening condition is a silent, mild, and sharp decrease in peak expiratory flow rate of less than 35%.

Emphysematous lungs are observed. Sputum discharge is difficult. The sputum is viscous, light, glassy. Heart sounds are muffled. Tachycardia. The liver may be enlarged.

To assess the function of external respiration in bronchial asthma, the forced vital capacity of the lungs, the volume of forced exhalation in the first second, and the peak volumetric speed of exhalation, determined using portable flowmeters, are determined. To assess the degree of impairment of the reactivity of the bronchial receptor apparatus, inhalation tests with histamine and acetylcholine are carried out.

During the period of remission, in the absence of clinical signs of obstruction, it is necessary to conduct a study of pulmonary function using spirometry or a study of the forced vital capacity flow-volume curve.

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Clinical and functional criteria for the diagnosis of bronchial asthma

Each degree is characterized by certain changes in clinical and functional parameters. It is important that the presence of at least one sign corresponding to a higher severity than the other signs allows us to assign the child to this category. It is worth noting that the criteria for verifying the severity of asthma should only be used in cases where the patient has never received anti-inflammatory treatment or has used anti-asthmatic drugs more than 1 month ago. This approach to assessing the severity of the disease is used to decide on the initial therapy and assess the severity of disorders/limitations of life activities during medical and social examination.

Classification of bronchial asthma by severity (GINA, 2006)

Characteristics	Severity
	Intermittent	Persistent
	Light	Light	Medium degree	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	Common symptoms
Exacerbations	Short-term	Disrupt activity and sleep	Disrupt activity and sleep	Frequent exacerbations
FEV1 or PSV (from predicted)	>80%	>80%	60-80%	<60%
Variability of PSV or FEV1	<20%	<20-30%	>30%	>30%

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Classification of bronchial asthma

Classifications of bronchial asthma:

• by etiology;
• by severity and level of control;
• according to the period of illness.

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Classification of bronchial asthma by etiology

Allergic and non-allergic forms of the disease are distinguished. In children, allergic/atopic bronchial asthma occurs in 90-95% of cases. Non-allergic asthma includes non-immune forms of asthma. The search for specific environmental causative factors is important for the appointment of elimination measures and, in certain situations (with clear evidence of a link between allergen exposure, disease symptoms and the IgE-dependent mechanism), allergen-specific immunotherapy.

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Symptoms of bronchial asthma depending on the severity

The classification of the severity of bronchial asthma presented in GINA (2006) is primarily focused on the clinical and functional parameters of the disease (the number of daytime and nighttime symptoms per day/week, the frequency of use of short-acting beta2-adrenergic agonists, the values of peak expiratory flow rate (PEF) or forced expiratory volume in the first second (FEV1) and daily fluctuations in PEF (variability) should be taken into account). However, the severity of bronchial asthma may change. In addition to the clinical and functional disorders characteristic of this pathology, the classification of asthma takes into account the volume of current treatment, the degree of disease control, and its period.

Mild bronchial asthma

Attack frequency is no more than once a month. Attacks are episodic, mild, and disappear quickly. Nocturnal attacks are absent or rare. Sleep and exercise tolerance are unchanged. The child is active. Forced expiratory volume and peak expiratory flow rate are 80% of the expected value or more. Daily fluctuations in bronchopatency are no more than 20%.

During the remission period, there are no symptoms, normal FVD. The duration of remission periods is 3 months or more. The physical development of children is not impaired. The attack is eliminated spontaneously or by a single dose of bronchodilators inhalation or oral administration.

Moderate bronchial asthma

Attacks 3-4 times a month. Occur with distinct impairments of respiratory function. Night attacks 2-3 times a week. Reduced tolerance to physical activity. Forced expiratory volume and peak expiratory flow rate are 60-80% of the expected value. Daily fluctuations in bronchopatency are 20-30%. Incomplete clinical and functional remission. The duration of remission periods is less than 3 months. The physical development of children is not impaired. Attacks are relieved with bronchodilators (by inhalation and parenterally), parenteral glucocorticosteroids are prescribed according to indications.

Severe bronchial asthma

Attacks several times a week or daily. Attacks are severe, asthmatic conditions are possible. Night attacks almost daily. Tolerance to physical activity is significantly reduced. Forced expiratory volume and peak expiratory flow rate are less than 60%. Daily fluctuations in bronchopatency are more than 30%. Incomplete clinical and functional remission (respiratory failure of varying severity). Duration of remission is 1-2 months. Delay and disharmony of physical development are possible.

Attacks are stopped by parenteral administration of bronchodilators in combination with glucocorticosteroids in a hospital setting, often in the intensive care unit.

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

During the remission period, it is recommended to perform scarification tests to determine the spectrum of sensitization to dust, pollen and epidermal antigens or prick tests with suspected allergens. The patient is observed and treated during the period of exacerbation and remission by the local pediatrician and pulmonologist. To clarify the causative antigen, skin tests are performed by the district allergist. The allergist decides on the need for specific immunotherapy and performs it. The pulmonologist and functional diagnostics doctor teaches sick children and their parents how to perform peak flowmetry and record the results of the study in a self-observation diary.

Classification by 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 shortness of breath, cough, wheezing, chest congestion or any combination of the listed clinical manifestations. It is worth noting that the presence of symptoms in patients with asthma in accordance with the criteria is a manifestation of the disease, not an exacerbation. For example, if a patient has daily symptoms, two night symptoms per week and FEV1 = 80%, the doctor states that the patient has moderate asthma, since all of the above serve as criteria for this form of the disease (and not an exacerbation). In the case when the patient has an additional (over and above the existing) need for short-acting bronchodilators in addition to the existing symptoms, the number of daytime and nighttime symptoms increases, severe shortness of breath occurs, an exacerbation of asthma is stated, which must also be classified by severity.

Control of bronchial asthma - elimination of disease manifestations against the background of current basic anti-inflammatory treatment of asthma. Complete control (controlled asthma) is today defined by GINA experts as the main goal of asthma treatment.

Remission of bronchial asthma is a complete absence of symptoms of the disease against the background of the cancellation of basic anti-inflammatory treatment. For example, the prescription of a pharmacotherapeutic regimen corresponding to the severity of asthma for some time leads to a decrease (possibly to a complete disappearance) of clinical manifestations of the disease and restoration of functional parameters of the lungs. This condition should be perceived as control over the disease. If the lung function remains unchanged, and there are no symptoms of bronchial asthma even after the cancellation of treatment, remission is stated. It should be noted that spontaneous remission of the disease sometimes occurs in children during puberty.

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

Despite the primary importance (for determining the severity of bronchial asthma) of clinical and functional parameters, as well as the volume of treatment, the given classification of the disease does not reflect the response to the treatment. Thus, a patient may consult a doctor with asthma symptoms corresponding to a moderate severity, as a result of which he will be diagnosed with moderate persistent bronchial asthma. However, in the case of insufficient drug therapy for some time, the clinical manifestations of the disease will correspond to severe persistent asthma. Taking this into account, when deciding on changing the volume of current treatment, GINA experts proposed to distinguish not only the severity, but also the level of disease control.

Levels of Asthma Control (GINA, 2006)

Characteristics	Controlled asthma (all of the above)	Partially controlled asthma (any manifestation within 1 week)	Uncontrolled asthma
Daytime symptoms	No (<2 episodes per week)	>2 per week
Activity limitation	No	Yes - any severity	Presence of three or more signs of partially controlled asthma in any week
Night symptoms/awakenings	No	Yes - any severity
Need for emergency medications	No (52 episodes per week)	>2 per week
Lung function tests (FEV1 or PEF)	Norm	>80% of predicted (or best for the patient)
Exacerbations	No	1 per year or more	Any week with exacerbation

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Diagnosis of allergic and non-allergic asthma in children

It is common to distinguish between allergic and non-allergic forms of bronchial asthma, which are characterized by specific clinical and immunological signs. The term "allergic asthma" is used as a basic term for asthma mediated by immunological mechanisms. When there are indications of IgE-mediated mechanisms (sensitization to environmental allergens, elevated serum IgE levels), they speak of IgE-mediated asthma. In most patients (typical atopics - children with a hereditary predisposition to high IgE production, with the first manifestation of symptoms at an early age), allergic symptoms can be attributed to atopic asthma. However, IgE-mediated asthma cannot always be called "atopic". Some people who cannot be described as atopic do not have sensitization (at an early age) to common allergens, and IgE-mediated allergy develops later with exposure to high doses of allergens, often in combination with adjuvants such as tobacco smoke. For this reason, the term "allergic asthma" is broader than the term "atopic asthma". In the non-allergic variant, allergen-specific antibodies are not detected during examination, serum IgE levels are low, and there is no other evidence of the involvement of immunological mechanisms in the pathogenesis of the disease.

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