Interpretation of "Recommendations for the Standardized Diagnosis and Treatment of Children's Bronchial Asthma (2020 Edition)"
Asthma is the most common chronic respiratory disease in children. The domestic prevalence rate continues to increase, and the burden of disease is serious. In recent years, although great progress has been made in the diagnosis and treatment of childhood asthma in my country, the diagnosis rate and control rate are still not satisfactory.
In order to improve the level of pediatricians’ asthma diagnosis and standardized management, and enhance their awareness of early disease management, the Chinese Journal of Pediatrics, the Chinese Journal of Pediatrics, the Respiratory Group of the Pediatrics Branch of the Chinese Medical Association, and the Pediatrics Branch of the Chinese Medical Recommendations for standardized diagnosis and treatment of asthma (2020 edition).
At the 25th National Pediatrics Academic Conference of the Chinese Medical Association, Professor Hong Jianguo from Department of Pediatrics, First People's Hospital Affiliated to Shanghai Jiaotong University, , as the corresponding author of the article, explained the new version of asthma in detail. Related content of diagnosis and treatment recommendations. Professor
Hong pointed out that the prevalence rate of asthma in people aged 20 and above in my country has reached 4.2%, and the total number of patients has reached 45.7 million. The cumulative prevalence rate of asthma in urban children aged 0-14 has also reached 3.02%.
However, there are still about 30% of urban children with asthma in my country that have not been diagnosed in time, and nearly 20% of children with asthma have not been well controlled.
1. The risk factors of are complex, and the environmental pollution of
cannot be ignored!
The risk factors that affect the occurrence, development and severity of asthma in children are more complex, mainly including the following factors (see the table below).
Table 1. Risk factors related to childhood asthma
Professor Hong said that among the many risk factors, we must pay more attention to environmental pollutants, especially the multiple negative effects of PM2.5 on children’s respiratory health. Environmental pollutants can aggravate the symptoms of children with asthma and increase the risk of acute asthma attacks and hospitalization.
A double-blind crossover study on the effect of indoor air intervention on children with asthma. 43 cases of asthmatic patients aged 5 to 13 were included to observe the effect of using air purifiers in the bedroom (2 consecutive weeks). The results of the
study show that changes in personal PM2.5 exposure are associated with significant changes in airway resistance and inflammation in children with asthma. Through personal air quality management, reducing PM2.5 exposure is very important for improving airflow restriction, especially small airway airflow restriction.
2. Diagnostic evaluation
Clinical evaluation + reversible airflow limitation
The diagnosis of childhood asthma mainly relies on clinical manifestations and evidence of reversible airflow limitation, and excludes other diseases that may cause related symptoms. The clinical diagnosis process of asthma is as follows Shown.
Figure 1. Clinical practice diagnosis flow chart of bronchial asthma in children
3. Differential diagnosis
Various diseases that may cause cough/wheezing
Before making a diagnosis of childhood asthma, other diseases that can cause repeated coughing and/or wheezing must be excluded .
Table 2. Differential diagnosis of common children with recurrent cough and wheezing related diseases
Four, pulmonary function assessment
5 Major points to note
Lung ventilation function is an important method for the diagnosis of asthma, and also an important basis for assessing the level of asthma control and severity of the disease.
Children with asthma and lung function testing should pay attention to the following points:
1, testing timing, drug use, physical condition, operation process and testing (operation) technical specifications will affect the measurement results.
2. Judgment of sensitive evaluation indicators: According to clinical practice, Chinese children's data, and related guidelines, it is recommended to use FEV1
3. Peak flow meter examination cannot be used to replace lung ventilation function examination in children and adults.
4. Pulse oscillation detection is to indirectly reflect the ventilation function by calculating and analyzing the distribution of airflow resistance parameters at different oscillation frequencies. The measured value varies greatly. The actual clinical significance of the detection indicators should be accurately understood and evaluated.
5. The actual value of tidal ventilation function test in evaluating airflow limitation in children with asthma needs further study.
Five, refractory and severe asthma in children
Note coexisting diseases
Refractory asthma in children means that although they receiveThe combination of doses of ICS has not yet achieved well-controlled asthma. my country’s guidelines clearly point out that for children with difficult-to-control asthma, possible related influencing factors must be comprehensively analyzed. The assessment process for children with refractory asthma is shown in the figure below.
Figure 2. Evaluation process for refractory asthma in children
Extrapulmonary coexisting diseases are an important treatable feature in all asthma patients, especially refractory asthma. Coexisting diseases are very common in refractory asthma, and multiple diseases can coexist in the same patient.
Extrapulmonary comorbidities seem to have not received enough attention in refractory asthma, even experts. Therefore, the evaluation of refractory asthma should always conduct a comprehensive and detailed analysis and identification of these coexisting diseases, and give appropriate intervention.
Six. Treatment strategies
The goal of asthma treatment is not limited to controlling acute asthma attacks as soon as possible, but also preventing and reducing recurrent attacks, achieving and maintaining the best control state, choosing appropriate drugs for individualized treatment and avoiding or reducing the adverse effects of asthma treatment drugs influences.
1. In recent years, GINA has fine-tuned the upgrade strategy of childhood asthma control treatment:
stage upgrade treatment (at least 2~3 months): in most cases, the clinical effect of control treatment can be perceived after a few days of treatment, but it must be fully The effect takes 2 to 3 months.
Short-term escalation treatment (1~2 weeks): During the period of viral infection or seasonal allergen exposure, the maintenance ICS dose needs to be increased for 1 to 2 weeks.
Symptom-based daily adjustment: For children over 12 years of age who use ICS-formoterol for control and relief treatment, on the basis of daily maintenance treatment, adjust the additional dose in time as needed.
2. According to the current plan, the order of lowering the intensity of the treatment drugs is as follows:
Reduce the dosage of oral glucocorticoids until discontinuation. Reduce the dosage of high-dose ICS. Reduce the frequency of drug use until 1 single use per night is low Dosage of ICS or leukotriene receptor antagonist until discontinuation of follow-up observation. The clinical effect of
3, ICS control treatment has a certain lag, so follow-up must be carried out within 2 to 4 weeks after stopping the drug, and regular long-term follow-up.
follow-up includes symptom assessment, early recognition of wheezing-related symptoms and timely intervention. If the child has recurrence of symptoms, further treatment should be determined according to the intensity and frequency of the attacks.
For mild occasional symptoms, symptomatic treatment can be performed as needed, and long-term control drugs can be continued to be discontinued; for non-frequent general attacks, it can be restored to the long-term control treatment plan before stopping the drug; for severe and frequent attacks, the drug should be stopped The previous long-term control treatment plan should be upgraded (leapfrog) treatment.
The treatment process of childhood asthma is shown in the figure below.
Figure 3. Flow chart for the treatment of asthma in children
Seven, asthma treatment drugs
The drugs used to treat asthma are mainly divided into three categories: relievers, control drugs and additional drugs:
1) Relief drugs: is used to quickly relieve bronchospasm and improve symptoms , Commonly used are SABA, inhaled short-acting anticholinergic drugs, etc.
2) Control drugs: achieves the purpose of controlling asthma through anti-inflammatory effects. It requires daily medication and long-term use, mainly including ICS, LTRA, and ICS-long-acting β2 receptor agonist (LABA) compound preparations.
3) Additional drugs: is mainly biologics represented by anti-IgE monoclonal antibodies (omalizumab), long-acting anticholinergic drugs (LAMA) such as tiotropium bromide, etc., mainly used in refractory and severe asthma .
In recent years, great progress has been made in the research and development and clinical application of biologics. Omalizumab has achieved good curative effect in the clinical application of pediatrics in my country. The anti-interleukin 5 antibody (mepolizumab) has also It has been approved abroad for use in children with severe eosinophilic asthma 6 years and older.
8. Other intervention measures
Poor medication compliance is one of the important factors affecting the disease control of children with asthma. In this regard, Professor Hong pointed out that the establishment of a joint doctor-patient relationship, the introduction of an electronic monitoring system and drug delivery reminder system, and regular follow-up are all conducive to improving compliance.
School-based children's asthmaAsthma management plans (including self-management of children with asthma) can effectively reduce the frequency of emergency department visits, the frequency of hospitalizations, and the number of days of daily activities.
In addition to full-time medical workers, well-trained non-professional health workers (community health workers), nurses, and pharmacists participating in the asthma child management plan can also bring clinical and health economic benefits.
Finally, Professor Hong concluded that the current guidelines for the diagnosis and treatment of childhood asthma have played a positive role in the management of asthma, but the level of childhood asthma management in my country still needs to be further improved. It is hoped that this recommendation can provide useful reference value for the standardized and homogenized diagnosis and treatment of childhood asthma in my country.
References:
1. Recommendations for standardized diagnosis and treatment of bronchial asthma in children (2020 edition) [J]. Chinese Journal of Pediatrics, 2020,58(9):708-717. DOI:10.3760/cma.j.cn112140-20200604-00578.
This article is first published: Medical Pediatrics Channel
Report Expert: Professor Hong Jianguo from the First People's Hospital of Shanghai Jiaotong University
This article is organized: Medical NCCPS 2020 Reporting Group-Xiaobu
Editor: Li Xiaorong
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