Management of bronchial asthma in children.

Asthma affects 5-10% of children in developed countries. Despite the new insights into the diagnosis and management of asthma, the morbidity and mortality have shown an increase over the last decade. This is largely attributed to the delay in recognising the severity of the illness and prompt alterations in therapeutic regimen. There is no data available on the incidence of asthma in Pakistani children. However, 4% of all the children with acute respiratory tract illness, attending the outpatient department of Children Hospital, Pakistan Institute of Medical Sciences (PIMS) suffer fmm asthma. It is presumed that this figure more or less reflects the overall trend in the country, but obviously needs more substantiating evidence. Over the last decade, our understanding of the pathogenesis of asthma has undergone important changes. The concept of asthma as an inflammatory disease of the airway has gained considerable support. The association between allergy and asthma has also become increasingly clear. Moreover, asthma management has undergone drastic changes with the advent of inhaled betaagonists and steroids. As a result, the use of conventional drugs like theophylline has declined considerably. There is increasing emphasis on the shared management with patient and the family. Home management currently forms the cornerstone of asthma management as more and more children are regulating their own dosages according to their disease severity. Simple inexpensive peak-flow meters, metered dose inhalers and spacer devices have brought the management of asthma to the doorstep. The ambulatory management has very clearly shifted the emphasis fmm the treatment of acute attacks to the achievement of normal activity levels, including strenuous physical exercise. There is greater focus on discouraging the dependence on the physician and to minimize the number of hospital visits for exacerbations. Whereas most of the developed countries have been able to streamline their asthma management and have evolved standard management protocols, there seems to be little uniformity in asthma management practices in most of the developing countries including Pakistan. The national ARI programme of the Ministry of Health lays the emphasis on treating young children with acute respiratory tract infections. especially pneumonia with appropriate antibiotics. However, a number of children with ART may have a wheeze. The W.H.O. guidelines recommend that children with or without pneumonia, presenting with first episode of wheeze should be given a rapid acting bronchodilator and referred to a hospital if there is accompanying distress. In the absence of accompanying respiratory distress, oral salbutamol for five days is recommended. Similarly, all children having recurrent wheeze should be given oral salbutamol, whether or not their wheezing episode is accompanied by fast breathing. Though very useful, these are only general guidelines forthe management of children with asthma. There is aneedto clearly outline a more comprehensive protocol for the management of children with asthma. We reviewed the literature to evolve such a guideline for paediatricians and general practitioners involved in the care of children suffering from asthma, with the hope that a more uniform practice will eventually emerge among the health personnel involved in the management of this chronic problem.