2. *A ,10 mon old male infant present with coryza ,
,cough , shortness of breath and poor feeding
*O/E he had :
Tachypnea and tachycardia
Hyperinflated chest
Intercostal and subcostal recession
Wheeze and crepitations
Pallor
*Chest X-ray showed:
Hyperinflation
Patchy collapse
6/12/2015
Does this child get Asthma Prof.Dr.Saad S Al
Ani Khorfakkan Hospital
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3. *E ,2 year old female child present with:
Recurrent chest infections
Not put much weight since she was born
Frothy cough especially at night
Shortness of breath and poor feeding
Bulky , greasy ,difficult -to-flush stools
Malnutrition
*O/E she had :
Failure to thrive
Wheeze and crepitations
*Chest X-ray showed:
Hyperinflation & Patchy lesions
6/12/2015
Does this child get Asthma Prof.Dr.Saad S Al
Ani Khorfakkan Hospital
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4. *L ,8 year old girl gives a 6- month history of a
progressive cough .
* In the past she had dry cough lasted several weeks
after each cold .
*A tentative diagnosis of asthma has been made and
stepping up anti-asthma therapy along with oral
antibiotics with eventual improvement of each
coughing episodes.
*She was hospitalized for acute pneumonia on
several occasions to give I.V. antibiotics
*Her present cough is productive of purulent
phlegm
6/12/2015
Does this child get Asthma Prof.Dr.Saad S Al
Ani Khorfakkan Hospital
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5. *N ,a 4 year old boy who has been referred by his
GP.
*He has suffered frequent wheezing episodes in
winter associated with cold
*He get day-to day symptoms of cough and he is
breathless with exercise
*Last month he was up all night wheezing after
having “pillow fight” with his sister
*His mother has hay fever ,and his older sister had
frequent wheezing in infancy with eczema
*He has mild eczema
6/12/2015
Does this child get Asthma Prof.Dr.Saad S Al
Ani Khorfakkan Hospital
5
8. *“Asthma is probably overdiagnosed by
a factor of 5 ”
Michael Seear ,MD
pediatrician, respirologist, and instructor with the University of
British Columbia Certificate in International Development, Vancouver
.
Miles Weinberger, MD
professor of pediatrics at the University of Iowa Children’s Hospital, Iowa City,
* Although asthma is at times
overdiagnosed ,it is also at times
underdiagnosed
9. * Preschool-aged children have the
highest hospitalization rate for
asthma, reporting that 5% to 10% of
all hospitalizations for US children
are for asthma
10. *Asthmatic aged younger than 5
years has twice the number of
hospitalizations as school-aged
asthmatics and 5 times the number
as teenaged asthmatics.
11. *“There are other studies that suggest that
patients are being overdiagnosed with
pneumonia, and very often when you look
at those studies, probably a lot of what’s
called pneumonia in young kids is actually
manifestations of asthma,”
Miles Weinberger
12. *
*A chronic respiratory disease,
often arising from allergies,
that is characterized by sudden
recurring attacks of :
Labored breathing
Chest constriction
Coughing
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13. *An estimated 25.9 million people,
including almost 7.1 million children,
have asthma
National Health Interview Survey (NHIS) Data, 2011
http://www.cdc.gov/asthma/nhis/2011/data.htm
15. *Asthma prevalence is higher among
persons with family income below the
poverty level
Akinbami, L., et al. Trends in Asthma Prevalence, Health Care Use, and Mortality
in the United States, 2001-2010 http://www.cdc.gov/nchs/data/databriefs/db94.pdf
16. *Asthma accounts for more than 15
million physician office and hospital
outpatient department visits
National Ambulatory Medical Care Survey: 2010 Summary Tables
http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf
And nearly 2 million emergency department
visits each year
National Hospital Ambulatory Medical Care Survey: 2010 Outpatient Department Summary
Tables http://www.cdc.gov/nchs/data/ahcd/nhamcs_outpatient/2010_opd_web_tables.pdf
National Hospital Ambulatory Medical Care Survey: 2010 Emergency Department Summary Tables
http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf
17. *An average of 1 out of every 10 school-
aged children have asthma
United States Environmental Protection Agency. Asthma Facts. March
2013. http://www.epa.gov/asthma/pdfs/asthma_fact_sheet_en.pdf.
18. *Asthma is the third-ranking cause of
hospitalization in children
United States Environmental Protection Agency. Asthma Facts. March
2013. http://www.epa.gov/asthma/pdfs/asthma_fact_sheet_en.pdf
19. *In 2009, 1 in 5 children with asthma
went to the emergency department
CDC. National Center for Environmental Health. Asthma’s Impact on
the Nation: Data from the CDC National Asthma Control Program.
20. *Boys are more likely to have asthma
than girls
United States Environmental Protection Agency. Asthma Facts. March
2013. http://www.epa.gov/asthma/pdfs/asthma_fact_sheet_en.pdf.
21. *
*The annual economic cost of asthma,
including direct medical costs from
hospital stays and indirect costs such as
lost school and work days, amount to
more than $56 billion annually
Centers for Disease Control and Prevention, (May 2011) Asthma in the
U.S. Vital Signs http://www.cdc.gov/vitalsigns/asthma/
22. Abstract:
About 334 million people worldwide suffer from asthma, and this figure may be an
underestimation. It is the most common chronic disease in children. Asthma is among
the top 20 chronic conditions for global ranking of disability-adjusted life years in children;
in the mid-childhood ages 5–14 years it is among the top 10 causes. Death rates from
asthma in children globally range from 0.0 to 0.7 per 100 000. There are striking global
variations in the prevalence of asthma symptoms (wheeze in the past 12 months) in
children, with up to 13-fold differences between countries. Although asthma symptoms
are more common in many high-income countries (HICs), some low- and middle-income
countries (LMICs) also have high levels of asthma symptom prevalence. The highest
prevalence of symptoms of severe asthma among children with wheeze in the past 12
months is found in LMICs and not HICs. From the 1990s to the 2000s, asthma
symptoms became more common in some high-prevalence centres in HICs; in many
cases, the prevalence stayed the same or even decreased. At the same time, many
LMICs with large populations showed increases in prevalence, suggesting that the
overall world burden is increasing, and that therefore global disparities in asthma
prevalence are decreasing. The costs of asthma, where they have been estimated, are
relatively high. The global burden of asthma in children, including costs, needs ongoing
monitoring using standardised methods.
Asthma is among the top 20 chronic conditions for global
ranking of disability-adjusted life years in children
In the mid-childhood ages 5–14 years it is among the top 10
causes
Int J Tuberc Lung Dis. 2014 Nov;18(11):1269-78. doi: 10.5588/ijtld.14.0170.
Global burden of asthma among children.
Asher I1, Pearce N2.
24. *Episodic
viral-
associated
wheezing
*Episodes are more frequent
in winter
*Almost always associated
with colds
*Usually completely
asymptomatic between
episodes
*Response to regular anti-
inflammatory therapy is
poor
6/12/2015
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Ani Khorfakkan Hospital
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25. *Classic
atopic
asthma
*An Atopic background
(allergies or eczema)
*Positive family history of atopy
and asthma
*Day-to-day symptoms
triggered with exercise or
occurring at night when no cold
*Response well to regular anti-
inflammatory asthma therapy
6/12/2015
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26. *Cough
variant
asthma
*Nocturnal and/or exercise –induced
cough when free from cold
*Wheezing may never been heard
*Personal of family history of other
atopic disorders
*Response rapidly to anti- asthma
therapy
*Symptoms relapse when therapy
withdrawn
6/12/2015
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28. Chronic inflammatory disease of the airways
Airways spasm and swelling
Obstruction to air flow
Wheezing or gasping for air
Resolves spontaneously
Responds to a wide range of treatments
*
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Khorfakkan Hospital
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29. *
*Continuing inflammation makes the airways
hyper-responsive to stimuli such as:
* Cold air
* Exercise
* Dust mites
* Pollutants in the air
* Stress
*Anxiety
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31. 6/12/2015
Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*
*Asthma is the most common chronic disease of
childhood in industrialized countries
*Boys are more likely than girls to have asthma
*Children with asthma have symptoms of:
Coughing
Wheezing
Shortness of breath or rapid breathing
Chest tightness
32. 6/12/2015
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Khorfakkan Hospital
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*Nighttime symptoms are common
*
*Physical examination may show evidence of other
atopic diseases such as eczema or allergic rhinitis
*Many childhood conditions can cause wheezing
and coughing of asthma
*Not all cough and wheeze is asthma
33. 6/12/2015
Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*
*Asthma can be aggravated by:
Rhinosinusitis
Gastroesophageal reflux
Nonsteroidal anti-inflammatory drugs
(especially aspirin)
34. 6/12/2015
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Khorfakkan Hospital
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*
*Presentation during acute episodes:
Tachypnea
Tachycardia
Cough
Wheezing
Prolonged expiratory phase
38. 6/12/2015
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Khorfakkan Hospital
38
is used to:
Monitor response to treatment
Assess degree of reversibility with therapeutic intervention
Measure the severity of an asthma exacerbation
*
*Children older than 5 years of age can perform
spirometry maneuvers.
40. 6/12/2015
Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
40
*
*Repeat chest radiographs are not needed with new
episodes unless:
There is fever (suggesting pneumonia)
Localized findings on physical examination
should be performed with:
The first episode of asthma
Recurrent episodes of undiagnosed cough or wheeze to exclude
anatomic abnormalities
41. 6/12/2015
Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*
*In vitro serum tests are generally:
Less sensitive in defining clinically pertinent
allergens
More expensive
Require several days for results compared to
several minutes for skin testing
Such as:
Radioallergosorbent test ( RAST)
Fluorescentenzyme immunoassay ( FEIA)
Enzymelinkedimmunosorbent assay (ELISA)
42. 6/12/2015
Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*
Positive skin tests results:
*Identifying immediate hypersensitivity to aeroallergens
*Correlate strongly with bronchial allergen provocative
challenges
Should be included in the evaluation of all children with persistent
asthma but not during an exacerbation of wheezing.
43. 6/12/2015
Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*
*The most common causes of wheezing
in children include:
Asthma
Allergies
Infections
Gastroesophageal reflux disease
Obstructive sleep apnea
44. 6/12/2015
Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*Less common causes include :
Congenital abnormalities
Foreign body aspiration
Cystic fibrosis
*
45. 6/12/2015
Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*
*Optimal medical treatment of asthma
includes several key components:
Environmental control
Pharmacologic therapy
Patient education, including
attainment of self-management skills
Steps to minimize allergen exposure
46. 6/12/2015
Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*
*Asthma medications can be divided into:
Long-term control medications
Quick-relief medications
48. 6/12/2015
Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*
Are:
*The most effective anti-inflammatory
medications for the treatment of chronic,
persistent asthma
*The preferred therapy when initiating
long term control therapy
49. 6/12/2015
Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*
*Early intervention with inhaled corticosteroids
reduces morbidity but does not alter the natural
history of asthma
50. 6/12/2015
Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*
*Regular use of inhaled corticosteroids reduces:
Airway hyperreactivity
The need for rescue bronchodilator therapy
Risk of hospitalization
Risk of death from asthma
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*
*Do not have clinically significant adverse
effects on:
Hypothalamic-pituitary-adrenal axis function
Glucose metabolism
Subcapsular cataracts or glaucoma
When used at low-to-medium doses in children
52. 6/12/2015
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Khorfakkan Hospital
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*
*Two classes of leukotriene modifiers include :
Leukotriene receptor antagonists
(zafirlukast and montelukast)
•Leukotriene synthesis inhibitors (zileuton)
53. 6/12/2015
Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*
*Usefulness of leukotriene :
Modifiers in mild asthma
•Attenuation of exercise-induced
bronchoconstriction
54. 6/12/2015
Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*
*Long-acting β2-agonists:
Formoterol and Salmeterol, have:
Twice-daily dosing
Relax airway smooth muscle for 12hours
*Do not have any significant anti-inflammatory
effects
55. 6/12/2015
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Khorfakkan Hospital
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*
*Is approved for use in children older than 5
years of age for:
Maintenance asthma therapy
Prevention of exercise-induced asthma
*It has a rapid onset of action similar to
albuterol (15 minutes).
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Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*
Is approved for children 4 years of age
or older
• Has an onset of 30 minutes
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Asthma Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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*
It is mildly to moderately effective as a
bronchodilator
•Is considered an alternative, add-on
treatment to low- and medium-dose inhaled
corticosteroids
58. 6/12/2015
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Khorfakkan Hospital
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*
Humanized anti-IgE monoclonal antibody
that prevents binding of IgE to high-affinity
receptors on basophils and mast cells
It is approved for moderate to severe allergic
asthma in children 12 years of age and older.
59. 6/12/2015
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Khorfakkan Hospital
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*
•Xolair is delivered by subcutaneous injection
every 2 to 4 weeks, depending on body
weight and pretreatment serum IgE level
60. 6/12/2015
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Khorfakkan Hospital
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*
Quick-Relief Medications
Short-Acting β2-
Agonists
Anticholinergic Agent Oral Corticosteroids
61. 6/12/2015
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Khorfakkan Hospital
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*
*Short-acting β2-agonists, such as albuterol,
levalbuterol, and pirbuterol, are:
Effective bronchodilators that exert their effect
within 5 to 10 min
They last for 4 to 6 hours.
*Is prescribed for acute symptoms and as
prophylaxis before allergen exposure and
exercise
62. 6/12/2015
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Khorfakkan Hospital
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*
*Ipratropium bromide is an anticholinergic
bronchodilator that:
Relieves bronchoconstriction
Decreases mucus hypersecretion
Counteracts cough-receptor irritability
*It seems to have an additive effect with β2-
agonists when used for acute asthma
exacerbations.
63. 6/12/2015
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Khorfakkan Hospital
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*
* Short bursts of oral corticosteroids (3 to 10
days) are administered to children with
acute exacerbations
*The initial starting dose is 1 to 2 mg/kg/day of
prednisone followed by 1 mg/kg/day over the
next 2 to 5 days
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Khorfakkan Hospital
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*
*Prolonged use of oral corticosteroids
Can result in systemic adverse effects such as:
Hypothalamic- pituitary-adrenal suppression
Cushingoid features
Weight gain
Hypertension
Diabetes
Cataracts& glaucoma
Osteoporosis
•Growth suppression
65. 6/12/2015
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Khorfakkan Hospital
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*Status asthmaticus
*Is an acute exacerbation of asthma that
does not respond adequately to therapeutic
measures and may require hospitalization
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Khorfakkan Hospital
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*
Significant respiratory distress
Dyspnea
Wheezing
Cough
•Decrease in peak expiratory flow rate
(PEFR)
67. 6/12/2015
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Khorfakkan Hospital
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*
*During severe episodes of wheezing, pulse
oximetry is helpful in monitoring
oxygenation
68. 6/12/2015
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Khorfakkan Hospital
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*
*In status asthmaticus, arterial blood gases
may be necessary for measurement of
ventilation
70. 6/12/2015
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Khorfakkan Hospital
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*
*For children younger than 3 years of age who
are at risk for asthma include:
• Eczema
• Parental asthma
or
• Two of the following:
1.Allergic rhinitis
2.Wheezing with a cold
3.Eosinophilia of greater than 4%
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Khorfakkan Hospital
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*Successful education
*Involves:
Teaching basic asthma facts
Explaining the role of medications,
Teaching environmental control measures
• Improving patient skills in the use of
spacer devices for metered dose inhalers and
peak flow monitoring
72. *Underdiagnosis and undertreatment of asthma in children: a tertiary hospital's
experience
Ioanna Vasilopoulou*, Irene Papakonstantopoulou, Katerina Salavoura, Nikoletta
Laliotou,Athanasios Kaditis and Vasiliki Gemou-Engesaeth
Methods
We studied 82 children (age 2-15y) that were referred to our clinic during 2013-2014 and their history and/or physical
examination revealed a clinical suspicion of asthma, according to GINA. Children were evaluated by personal/family
history, physical examination, skin prick tests to common allergens, total/specific IgE levels. Lung function tests were
carried out where possible. Chest X-ray and sweat test were performed if needed. Children were divided into three
groups: children with asthma diagnosed for first time, children with asthma whose symptoms were uncontrolled and
children with severe/persistent asthma.
Results
32/82 children were diagnosed with asthma for the first time in our Unit and had never received treatment before
despite pediatric follow up. 12/32 came for a reason other than asthma, such as Food Allergy (3), Urticaria (2), Drug
allergy (1), Eczema (1), Allergic Rhinitis (1) and hospitalization due to foreign body aspiration (1). Of the 37/82 children
who already had a diagnosis of asthma, 31 had poorly controlled symptoms despite treatment. Reasons for
uncontrolled asthma in 21/31 were low doses of Inhaled Corticosteroids or intermittent use, 7/31 had improper inhaler
technique and 3/31 had poor adherence to treatment. 9/82 children were referred for severe asthma; 4/9 had improper
inhalation technique. Non-adherence to treatment and co-morbid conditions also contributed to persistent symptoms.
Patients were treated individually. After 6 months, symptoms were well controlled in 67 children. 3 children were well
controlled at the 3 months follow up while 7 children's follow up is pending. 1 child did not return, 1 child followed
alternative therapies and 3 were not compliant to our advice.
Conclusions
Asthma in children is still often underdiagnosed. For correct diagnosis/treatment a detailed clinical history is mandatory
and lung function tests should be performed in children with associated comorbidities such as AR. Studies have shown
that one demonstration of the inhaler technique is not enough. It is essential to educate clinicians, patients and parents
and to promote compliance.
Conclusions
Asthma in children is still often underdiagnosed. For correct
diagnosis/treatment a detailed clinical history is mandatory and lung
function tests should be performed in children with associated
comorbidities such as AR. Studies have shown that one
demonstration of the inhaler technique is not enough. It is essential to
educate clinicians, patients and parents and to promote compliance
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Khorfakkan Hospital
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*
* www.uic.edu
* www.scienceopen.com
* faculty.washington.edu
* http://www.aafp.org