A chest radiograph should be performed with the first episode of asthma or with recurrent episodes of undiagnosed cough or wheeze to exclude anatomic abnormalities. Repeat chest radiographs are not needed with new episodes unless there is fever (suggesting pneumonia) or localized findings on physical examination.
Two novel forms of monitoring asthma and airway inflammation directly include exhaled nitric oxide analysis and quantitative analysis of expectorated sputum for eosinophilia.
Many childhood conditions can cause wheezing and coughingof asthma (Table 78-1) but not all cough and wheeze is asthma. Misdiagnosis delays correcting the underlying cause andexposes children to inappropriate asthma therapy (Table 78-2).
Allergic bronchopulmonary aspergillosis is a hypersensitivity type of reaction to antigens of the mold Aspergillus fumigatus. It occurs primarily in patients with steroid-dependent asthma and in patients with cystic fibrosis.
Optimal medical treatment of asthma includes several key components: environmental control, pharmacologic therapy, and patient education, including attainment of
C—Cystic fibrosis R—Respiratory tract infections A—Aspiration (swallowing dysfunction, gastroesophageal reflux, tracheoesophageal fistula, foreign body) D—Dyskinetic cilia L—Lung and airway malformations (laryngeal webs, laryngotracheomalacia, tracheal stenosis, vascular rings and slings) E—Edema (heart failure, congenital heart disease)
From Schidlow DV: Cough. In Schidlow DV, Smith DS, editors: A Practical Guide to Pediatric Disease, Philadelphia, 1994, Hanley & Belfus.
self-management skills. Because many children with asthma have coexisting allergies, steps to minimize allergen exposure should be taken (Table 78-3). For all children with asthma, exposures to tobacco and wood smoke and to persons with viral infections should be minimized. Influenza immunizations are indicated. Asthma medications can be divided into long-term control medications and quick-relief medications.
Inhaled corticosteroids are the most effective anti-inflammatory medications for the treatment of chronic, persistent asthma and are the preferred therapy when initiating longterm control therapy. Early intervention with inhaled corticosteroids reduces morbidity but does not alter the natural history of asthma. Regular use reduces airway hyperreactivity, the need for rescue bronchodilator therapy, risk of hospitalization, and risk of death from asthma. Inhaled corticosteroids are available as an inhalation aerosol, dry powder inhaler, and nebulizer solution.
The potential risks of inhaled corticosteroids are favorably balanced with their benefits. A reduction in growth velocity may occur with poorly controlled asthma or inhaled corticosteroids use. Low-to-medium dose inhaled corticosteroids may decrease growth velocity, although these effects are small (approximately 1 cm in the first year of treatment), generally not progressive, and may be reversible. Regularly scheduled height measurements should be monitored. Inhaled corticosteroids do not have clinically significant adverse effects on hypothalamic-pituitary-adrenal axis function, glucose metabolism, or subcapsular cataracts or glaucoma when used at low-to-medium doses in children. Rinsing the mouth after inhalation and using spacers help lessen the local adverse effects of dysphonia and candidiasis and decrease systemic absorption from the gastrointestinal tract. Inhaled corticosteroids should be titrated to the lowest dose needed to maintain control of a child’s asthma. For children with severe asthma, higher dose inhaled corticosteroids may be needed to minimize the oral corticosteroid dose, but other “add-on” therapy should be considered (see the following sections).