Asthma is the most common chronic disease of childhood in industrialized countries, affecting nearly 7 million children younger than 18 years of age in the United States. The number of people with asthma continues to grow. One in 11 children (7 million) had asthma, and 1 in 12 (18.7 million) adults (totaling over 25 million or 8% of U.S. population) had asthma in 2010 compared to 1 in 14 people (about 20 million, or 7%) in 2001. One in 5 children went to the emergency department for an asthma-related visit in 2009. Women are more likely than men to have asthma, and boys are more likely than girls to have asthma.
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Children with asthma have symptoms of coughing, wheezing, shortness of breath or rapid breathing, and chest tightness. The history should elicit the frequency, severity, and factors that worsen the child’s symptoms as well as a family history of
Tracheal stenosis Toxic inhalation, including smoke
From Lemanske RF Jr, Green CG: Asthma in infancy and childhood. In Middleton E Jr, Reed CE, Ellis EF, et al, editors: Allergy: Principles and Practice, ed 5, St Louis, 1998, Mosby–Year Book, p 878.
asthma and allergy. Exacerbating factors include viral infections, exposure to allergens and irritants (e.g., smoke, strong odors, fumes), exercise, emotions, and change in weather/humidity. Nighttime symptoms are common. Rhinosinusitis, gastroesophageal reflux, and nonsteroidal anti-inflammatory drugs (especially aspirin) can aggravate asthma. Treatment of these conditions may lessen the frequency and severity of the asthma.
During acute episodes, tachypnea, tachycardia, cough, wheezing, and a prolonged expiratory phase may be present. Physical findings may be subtle. Classic wheezing may not be prominent if there is poor air movement from airway obstruction. As the attack progresses, cyanosis, diminished air movement, retractions, agitation, inability to speak, tripod sitting position, diaphoresis, and pulsus paradoxus (decrease in blood pressure of >15 mm Hg with inspiration) may be observed. Physical examination may show evidence of other atopic diseases such as eczema or allergic rhinitis.
Objective measurements of pulmonary function (spirometry) help establish the diagnosis and direct the treatment of asthma. Spirometry is used to monitor response to treatment, assess degree of reversibility with therapeutic intervention, and measure the severity of an asthma exacerbation. Children older than 5 years of age can perform spirometry maneuvers. Variability in predicted peak flow reference values make spirometry preferred to peak flow measures in the diagnosis of asthma. For younger children who cannot perform spirometry maneuvers or peak flow, a therapeutic trial of controller medications helps in the diagnosis of asthma.
Allergy skin testing should be included in the evaluation of all children with persistent asthma but not during an exacerbation of wheezing. Positive skin tests results, identifying immediate hypersensitivity to aeroallergens (e.g., as tree and grass pollens, and dust), correlate strongly with bronchial allergen provocative challenges. In vitro serum tests, such as radioallergosorbent test (also known as RAST), fluorescent enzyme immunoassay (also known as FEIA), or enzyme-linked immunosorbent assay, are generally less sensitive in defining clinically pertinent allergens, are more expensive, and require several days for results compared to several minutes for skin testing (see Table 77-4).