Classification of Asthma | Severity in Children

An Overview of Classification of Asthma: Asthma is Classified into many types based on various factors such as classification of asthma, classification of asthma severity, classification of asthma in adults & childrens, classification of asthma in pediatrics, Gina classification of asthma, classification of asthma attack, Difficulty to control asthma and classification of asthma drugs (Broncial drugs or asthmatic drugs).

What are the classification of Asthma?

1. Classification of Asthma

Asthma, as a chronic inflammatory disease, shows variations in its clinical manifestations and in the degree obstruction to air flow, so its severity can be modified over time in the same patient.

The Global Initiative for Asthma (GINA) established a practical classification system, considering clinical and functional aspects such as the frequency of day and night respiratory symptoms, as well as lung function;

their combination allows to establish the severity classifying asthma as intermittent and persistent (mild, moderate and severe).

Recently, it has been proposed classify asthma according to the degree of control as:

  • controlled,
  • partially controlled and
  • uncontrolled.

Based on following parameters asthma is classified into 4 types;

The parameters that used in this system are:

  • frequency of day and night
  • respiratory symptoms,
  • limitation of activities,
  • use of rescue medications,
  • determination of forced expiratory volume in 1 second (FEV1) or
  • peak expiratory flow (PEF) and the appearance of exacerbations.

What are the 4 Types of Asthma?

Mild intermittent asthma

Mild symptoms up to 2 days a week and up to 2 nights a month.

Symptoms

  • Coughing,
  • Wheezing or whistling when breathing,
  • Development of mucus in the airways,
  • Swollen airways.

Treatment

  • To Treat Mild intermittent asthma rescue inhaler is used.
  • No medications required due to occasianally occuring symptoms.
  • Medications is based on severity of asthma as prescribed by doctors.
  • For Exercise Induced Asthma: Rescue Inhaler is Provided.
  • For Allergy Triggering: Allergies medications are prescribed.

Mostly Seen in individual with

  • Family history of asthma,
  • Having allergies,
  • Being over-weight,
  • Smoking,
  • Exposure to chemicals,
  • Exposure to fumes or pollution,

Mild persistent asthma

Symptoms more than twice a week, but no more than once in a single day.

Symptoms

  • Wheezing/whistling while breathing,
  • Swollen airways,
  • Coughing,
  • Chest tightness or pain,
  • Production of excess mucus in the airways.

Treatment

  • Inhaled Corticosteroid low-dose medication prescribe by doctor
  • Rescue Inhaler and Allergic Medications
  • Oral Corticosteroids over 5 years of age.

Mostly Seen in individual with

  • Being over-weight,
  • Having family history of asthma
  • Allergies,
  • Exposure to smoke or smoking,
  • Exposure to chemicals at work,
  • Exposure to pollution and fumes,
Classification of Asthma Severity

Moderate persistent asthma

Symptoms once a day and more than 1 night a week.

Symptoms

  • Being over-weight,
  • Having family history of asthma
  • Allergies,
  • Exposure to smoke or smoking,
  • Exposure to chemicals at work,
  • Exposure to pollution and fumes,

Treatment

  • Slightly higher dose of Inhaled Corticosteroid as prescribed by doctors
  • Rescue Inhaler and allergy medications

Mostly Seen in individual with

Same as Mentioned above, all asthma shows related triggerings.

What classes of asthma are severe?

Severe persistent asthma

Symptoms throughout the day on most days and frequently at night.

Symptoms

Coughing, Wheezing or Whistling, Chest tightness and pain, Excess mucous production and Inflamation in airways.

Treatment

  • Higher Dose of Medications as campared to other types
  • Oral And Inhaled Corticosteriods
  • Rescue Inhaler and Medications

Mostly Seen in individual with

  • Person with respiratory illness like pneumonia
  • Mild asthma not treated on time
  • Family History
  • Over-Weight
  • Smoking
  • Exposure to chemicals and fumes

Patient participation in disease classification has also been considered through self-administration of the Asthma Control Questionnaire (ACT).

Patients with high risk of death are classified in the group of difficult-to-control asthma (ADC), requiring higher and lower criteria for define it, the common denominator being the lack of control of the disease, the use of high doses of steroids and an adequate previously established treatment.

Classifying asthma with any of these systems allows us to know its impact on life of the patient and consequently establish the recommended treatment scheme for each group of patients.

Classification of Asthma Drugs

Bronchial Asthma is characterised by hyper-excitation of tracheobronchial smooth muscle to a variety of stimuli which results in narrowing of airways and increase secretion of mucus plugging.

Symptoms: Dyspnoea, Wheezing, Coughing and may be limitations of activity.

It is of 2 types:

Classification of Asthma

Extrinsic asthma: It is mostly episodic, Less prone to status asthmaticus.

Intrinsic asthma: It tends to be perennial, status asthmaticus is more common.

Classification of Bronchial Asthma Drugs

1. Bronchodilators

  • A. β2 Sympathomimetics: Salbutamol, Terbutaline, Bambuterol, Salmeterol, Formoterol, Ephedrine.
  • B. Methylxanthines: theophylline (anhydrous), Aminophylline, Choline theophyllinate, Hydroxyethyl theophylline, theophylline ethanolate of piperazine, Doxophylline.
  • C. Anticholinergics: Ipratropium bromide, Tiotropium bromide.

2. Leukotriene Antagonists: Montelukast, Zafirlukast.

3. Mast Cell Stabilizers: Sodium cromoglycate, Ketotifen.

4. Corticosteroids

  • A. Systemic: Hydrocortisone, Prednisolone and Others
  • B. Inhalational: Beclomethasone dipropionate, Budesonide, Fluticasone propionate, Flunisolide, Ciclesonide.

5. Anti-IgE Antibody

  • Omalizumab

Classification of Asthma in Children

Definition

Asthma is defined as an inflammatory disorder of chronic respiratory tract, in which various cell types and elements are involved. Is chronic inflammation is associated with hyperresponsiveness bronchial, leading to recurrent episodes of wheezing, dyspnea, feeling of chest tightness and coughing, particularly at night and early morning, which are related to variable obstruction airflow, spontaneously reversibleor with treatment.

Causes

Childhood asthma causes are not fully understood, Some factors involved in childrens asthma involves:

  • Inherited tendency to develop allergies
  • Parents with asthma
  • Some types infections in airway at young age
  • Exposure to environmental factors, such as air pollution or cigarette smoke.
  • Viral infections like common cold
  • Exposure to air pollutants, like tobacco smoke
  • Weather changes or cold air
  • Allergies to pet dander, dust mites, pollen or mold
  • Physical activity

Common Asthma signs and symptoms in Children include:

  • Frequent coughing that worsens when child has a viral infection, occurs while your child is asleep or is triggered by exercise or cold air
  • A wheezing or whistling sound while breathing out
  • Shortness of breath
  • Chest tightness or congestion

Asthma in young age might also cause:

  • Difficulty in sleeping due to shortness of breath,
  • coughing or wheezing
  • Bouts of coughing or wheezing that get worse with a cold or the flu,
  • bronchitis after a respiratory infection,
  • Delayed recovery,
  • Difficulty in breathing during play or exercise,
  • Fatigue, because of poor sleep.

Asthma signs and symptoms may differ from child to child, and might get worsened or better over time. child shows cough or chest congestion symptoms.

Complications in Asthmatic Children

number of complications are seen in asthma, including:

  • Severe attacks of asthma that needs emergency treatment or hospital care
  • Permanent decrement in lung function
  • Missing school life or getting behind in school
  • fatigue and Poor sleep
  • Symptoms that intervene with sports, play, or other activities

Prevention of Asthma in Children

Careful planning and avoiding asthma triggers are the best ways to prevent asthma attacks.

Limit exposure to asthma triggers: Avoid contact with allergens and irritants that trigger asthma symptoms.

Encourage child to be active: Regular exercise can help lungs to work effectively as long as childs symptoms are under control.

Do not allow smoking near your child: Keep your child away from smoking, air pollution or any other smoke which can cause asthma trigger.

Keep heartburn under control: Severe heartburn or Acid reflux GERD (gastroesophageal reflux disease) might worsen asthma symptoms, treat them on time with proper medications.

Help maintain a healthy weight of your child: Neither over weight nor under weight keep your childs diet proper, over weight can trigger asthma.

See the doctor when necessary: Regularly check symptoms, do not ignore any symptoms mild asthma can be treated easily then severe ones.

Classification of Asthma Severity

Classifying the severity of asthma is vital to establish appropriate treatment. This will ideally be done with the patient free of treatment, otherwise, the severity can be estimated based on the minimum baseline treatment step necessary to keep the patient well controlled.

Once the diagnosis has been established, it is convenient to classify the severity in order to initiate the appropriate treatment. An incorrect classification may imply an inappropriate or insufficient prescription. Table IV reflects the classic classification of asthma according to severity.

This classification assesses the frequency of symptoms and PF. The moderate or severe nature is determined by the frequency and intensity of the symptoms, persistent asthma being at least moderate in nature.

If it is not possible to study PF, it will be classified according to symptoms only. It is important to bear in mind that to classify the severity the patient must be without treatment, an unusual fact.

Otherwise, it can be estimated based on the minimum therapeutic step necessary to maintain good control.

Thus, the child who requires a step 5-6 will have severe asthma, the one who requires a step 3-4 moderate asthma, and the one who requires a step 1-2 mild asthma.

Asthma is variable over time, which makes it difficult to classify. Thus, young children usually have asthma only with viral infections, being able to have moderate / severe asthma in winter and be asymptomatic in spring and summer.

In 1997, the National Heart, Lung and Blood Institute (World Health Organization) published the second report of the expert group:

Classification of Asthma in pediatrics

Guidelines for the Diagnosis and asthma Treatment

1. The fundamental principle of this report comprised a tiered treatment approach according to the clinical severity of asthma considering three variables:

  • frequency of daytime respiratory symptoms,
  • frequency of respiratory symptoms nocturnal and,
  • pulmonary function status, the conjunction.

These characteristics allowed the definition of four categories of the disease:

  • intermittent asthma and
  • three degrees persistent asthma (mild, moderate and severe);

asthma has since been classified based on these variables with adaptations according to the characteristics of each population where asthma represents a health care problem.

Given the clinical utility resulting from this classification, practically every country

has developed its own guidelines for the diagnosis and treatment of asthma.

Gina classification of Asthma

Of all the published clinical guidelines, the one most used probably due to its dissemination in several languages and constantly updated, it is the guide of the Global Initiative for Asthma (GINA).

At its revision in 2008, emphasizes once again the importance of continuing to classify asthma according to severity, but above all the need to treat patients according to this one (Table 1).

Likewise, the International Union Against Tuberculosis and Respiratory Diseases, based in Paris, has established a classification by severity of asthma mainly aimed at its application in countries with scarce financial resources.

This classification is also based on clinical and functional aspects, the main difference is that the

functional monitoring is performed with a flow meter, based on its lower cost and greater accessibility in situations of economic limitation (Table 2).

Classifications of asthma are based on the pathophysiological characteristics of this condition.

It is a chronic disease, with varying degrees of inflammation, which functionally can be translated

in varying degrees of obstruction to air flow and manifestations clinics also of variable intensity.

This means that gravity is not a characteristic constant, but can change over time, therefore

that it is necessary to keep the patient in follow-up until it is clinically and functionally reassessed and thus reclassified.

The disease classification by severity is very useful in the initial evaluation of the patient for their therapeutic and prognostic implications.

In January 2004, the GINA Executive Committee recommended that the guide be revised and emphasize the management of asthma according to the degree of clinical control, rather than the severity classification and was in the 2006 revision,

when it presented the classification according to the degree of control, classifying the disease into three categories: controlled, partially controlled and uncontrolled.

In this classification, in addition to including the frequency of symptoms and function pulmonary, considers the frequency of exacerbations.

This classification also has therapeutic implications, since depending on the degree of control in which is found, the patient will receive a higher or lower dose of steroidal anti-inflammatory drug and will or will not require more than one controller medication.

This classification has not yet been clinically validated. and it must be taken into account that we can find patients with adequate treatment and present frequent exacerbations; on the other hand, there are patients who they have daily symptoms and no exacerbations.

The Spanish Guide for Asthma Management (GEMA), unites the concepts of gravity and control. Consider that at initial evaluation, if the patient is not receiving maintenance treatment should be considered as seriousand give treatment, and once the patient requires minimum doses of medications to control yourself are You can classify according to the degree of control.

Namely, when the patient is under treatment, it is always should be aimed at achieving and maintaining control by making adjustments during patient follow-up.

On the other hand, more recently it has joined the patient’s participation in classifying the disease.

In 2004 Nathan proposed the questionnaire to control the asthma (ACT). This questionnaire

designed by asthma physicians, initially made up of 22 questions, it was applied to 471 patients, obtaining good consistency in the result.

Finally, it was decided to reduce to only 5 questions in which the frequency of respiratory symptoms is explored, the limitation they cause in activities daily routine of the subject, the frequency of use of rescue bronchodilator and the patient’s perception degree of control of their disease (Figure 1).

Each question has 5 answer options, which they have a value and the sum total of the questions allows to quickly and easily know the level of asthma control (Figure 2).

This questionnaire seems to be useful depending on the speed of application, certainty and active participation of the patient.

In the context of the classification of asthma, a particular group of patients deserves special attention, who its clinical characteristics, it has been categorized disease such as difficult-to-control asthma (ADC).

The main guidelines for studying the disease give it a special space for analysis, but in all of them

the common characteristics are the lack of control of the disease, the use of high doses of steroids and an adequate previously established treatment.

The Latin American Consensus of ADC defines it as insufficiently controlled asthma despite a therapeutic strategy appropriate, adjusted to the level of clinical severity, indicated by a specialist and lasting at least six months.

10 Major and minor criteria have been established to classify it, among the first the common denominator is the use of steroids (systemic or inhaled in doseshigh), and among the latter functional aspects and severity of the disease are established.

A simple and practical algorithm is the one proposed by the Latin American group (Algorithm 1).

The clinical relevance This classification is based, on the one hand, on the identification of a group of patients at high risk of death;

Criteria for defining difficult-to-control asthma according to the American Thoracic Society (ATS) and Society Spanish of Pulmonology and Thoracic Surgery (SEPAR).

Major criteria

  • Use of an oral corticosteroid continuously or for more than six months in the current year
  • Continued use of high-dose inhaled corticosteroids with a long-acting beta 2 agonist

Minor criteria

  • FEV1 <80% or PEF variability> 20%
  • Daily use of short-acting beta 2 agonists
  • Use of oral corticosteroid cycles more than three times in the previous year
  • One or more consultations in Emergency Services in the year previous
  • Having presented an episode of asthma with risk of death
  • Rapid deterioration of lung function by decreasing the treatment with a corticosteroidand on the other hand, that once classified these patients require specific drugs for their control,
  • for example omalizumab, among others.

From a practical point of view, the clinician should always classify the patient using the classification that he considers most useful and practical for his needs.

This guide recommends as a starting point, in the first visit, classify the patient by severity to establish the scheme of corresponding treatment and in subsequent visits classify the patient by the level of control (Figure 3)

REFERENCES

1. National Asthma Education and Prevention Program.Expert Panel Report

2: Guidelines for the diagnosis andmanagement of asthma. 1997 publication 97-4051.

3. Application of the different classifications in practice clinic.

  • Initial evaluation Follow-up
  • Mild persistent asthma
  • Moderate persistent asthma Treatment
  • Intermittent asthma
  • Persistent severe asthma
  • Controlled asthma
  • Uncontrolled asthma
  • Partially controlled asthma

Algorithm 1. Algorithm for the diagnosis of difficult-to-control asthma.

  • Latin American Consensus of Asthma 2008.
  • Suspicion of ADC
  • First stage
  • Second stage
  • Rule out other F-V pathologies,
  • VR, DLCO, RX, TC, ORL and pH Consider testing with oral steroids Education to ensure proper treatment,
  • Adherence to treatment,
  • ADC confirmation,
  • Additional treatment,
  • Tracing: NO/YES

GINA level 4-GINA level 5: Tolerates withdraw oral steroid No response With response No attachment to treatment

2. Mexican Institute of Social Security. Guide for the diagnosis, staging and treatment of asthma. 2000.

3. National Institutes of Health (NIH). Global Strategy for Asthma Management and Prevention (GINA) The GINA Report 2008. www.ginasthma.org

4. British Thoracic Society. British Guideline on the Management of asthma, A National Clinical Guideline 2008. www.brit-thoracic.org.uk.

5. National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol 2007; 120 (5 Suppl): S94-138.

6. Executive Committee. GEMA 2009. Spanish Guide for Asthma Management 2009. Available at: www.gemasma.com.

7. Aït-Khaled N, Enarson DA. Management of Asthma. TO Guide to the Essentials of Good Clinical Practice. Second Edition 2005, International Union Against Tuberculosis and Lung Disease 2005.

8. Teeter JG, Bleecker ER. Relationship between airway obstruction and respiratory symptoms in adult asthmatics. Chest 1998; 113 (2): 272-7.

9. Nathan RA, Sorkness CA, Kosinski M, Schatz M, Li JT, Marcus P, et al. Development of the Asthma Control Test: A survey for assessing asthma control. J Allergy Clin Immunol 2004; 113: 59-65.

10. Latin American Consensus on Difficult Asthma Control. 2008 update. Drugs of Today 2008; XX (Suppl X).

Conclusion:

So, this was all about Classification of Asthma, in this article we saw all the four classifications of astha such as classification of asthma drugs, classification of asthma in children or pediatrics, classification of asthma severity and guidelines of gina classification.

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