15  Asthma

Author

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Published

June 6, 2025

15.1 Introduction

Asthma is a chronic inflammatory disorder of the airways, characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation. It is one of the most common chronic diseases in children worldwide, including in Ghana. Effective management is essential in pediatric care, especially due to its impact on the quality of life, school attendance, and healthcare utilization.

Understanding asthma in children is crucial for early diagnosis, effective management, and the prevention of complications. This note outlines the epidemiology, pathophysiology, clinical features, diagnosis, differential diagnoses, management, and public health implications of childhood asthma, with a focus on the context of Ghanaian healthcare.

15.2 Epidemiology

Asthma affects an estimated 10-15% of children in Ghana, although its prevalence varies by region, urbanization, and environmental factors. Urban areas such as Accra and Kumasi report higher cases due to increased pollution, lifestyle changes, and indoor allergens.

Risk Factors:

  • Genetics: Family history of asthma or atopy (eczema, allergic rhinitis).
  • Environmental exposures: Dust, smoke (including biomass fuel), pollution, and cockroach or mould allergens.
  • Infections: Respiratory syncytial virus (RSV), influenza.
  • Socioeconomic status: Overcrowded housing, poor ventilation.
  • Early weaning or formula feeding.

15.3 Pathophysiology

Asthma is mainly an inflammatory disease that affects the airways. In children, this airway inflammation is often eosinophilic and results in:

  1. Airway Hyperresponsiveness: Increased sensitivity to triggers such as cold air, dust, or exercise.
  2. Bronchoconstriction: Constriction of bronchial smooth muscles causes narrowing of airways.
  3. Airway Remodelling (in chronic cases): Thickening of the basement membrane, increased mucus secretion, and smooth muscle hypertrophy.

These changes contribute to the classic symptoms: wheezing, cough, chest tightness, and shortness of breath.

15.4 Clinical Features

The presentation of asthma in children may vary based on age and severity. Key symptoms include:

  • Wheezing: High-pitched whistling sound, often during expiration.
  • Coughing: Worse at night, early morning, or after exercise.
  • Shortness of breath: This is especially noticeable during exertion or with infections.
  • Chest tightness or pain.

Patterns of Childhood Asthma:

  • Intermittent asthma: Symptoms occur less than twice a week.
  • Persistent asthma: Symptoms occur more frequently and may impact daily activities.
  • Exercise-induced asthma: Triggered by physical activity.
  • Nocturnal asthma: Symptoms worsen at night.
  • Viral-induced wheeze: Common in toddlers; often resolves with age.

In Ghana, children may also present late or with severe symptoms due to poor access to healthcare or misdiagnosis.

15.5 Diagnosis

Asthma is primarily a clinical diagnosis in children, especially those under 5 years of age.

1. History:

  • Recurrent episodes of cough, wheeze, and breathlessness.
  • Family or personal history of allergies.
  • Symptoms triggered by cold, dust, exercise, or smoke.

2. Physical Examination:

  • Wheezing on auscultation.
  • Use of accessory muscles in severe cases.
  • Hyperresonance on percussion in chronic cases.

3. Investigations:

  • Spirometry (in children >5 years): Shows reversible airway obstruction (FEV1/FVC ratio < 80%).
  • Peak Expiratory Flow Rate (PEFR): Helps monitor asthma control.
  • Chest X-ray: To exclude other conditions (e.g., foreign body, pneumonia).
  • Allergy testing: Useful in atopic children (skin prick or serum IgE)

Diagnostic Challenge in Ghana:

  • Limited access to spirometry in rural settings.
  • Reliance on clinical judgment.
  • Misdiagnosis as pneumonia or bronchitis is common.

15.6 Differential Diagnosis

  • Bronchiolitis: Common in infants; usually due to viral infections.
  • Foreign body aspiration: Sudden onset of wheeze with localized findings.
  • Pneumonia: Fever with cough; may have focal crepitations or consolidation.
  • Congenital anomalies: E.g., tracheomalacia or vascular rings.
  • Tuberculosis: Chronic cough, weight loss, and a history of contact.

15.7 Management

1. Education and Self-Management

  • Educate caregivers and older children on:
    • Nature of asthma.
    • Avoidance of triggers.
    • Proper inhaler technique.
    • Recognition of early warning signs.
    • Importance of medication adherence

2. Pharmacologic Management

a. Reliever Medications:

  • Short-acting beta2-agonists (SABA): e.g., Salbutamol.
    • First-line for acute symptoms.
    • Delivered via metered-dose inhaler (MDI) with a spacer.

b. Controller Medications

  • Inhaled corticosteroids (ICS): e.g., Beclomethasone, Budesonide

    • First-line for persistent asthma.

  • Leukotriene receptor antagonists (LTRA): e.g., Montelukast.

    • Useful for allergic or exercise-induced asthma.

  • Long-acting beta2-agonists (LABA): Used in combination with ICS in older children with poor control.

c. Systemic corticosteroids:

  • Prednisolone for acute exacerbations (short course).

3. Non-Pharmacological Measures

  • Avoid known allergens (dust, cockroach, pet dander).
  • Reduce exposure to cigarette smoke and biomass fuel.
  • Immunization (including flu vaccine where available).
  • Treatment of comorbidities (e.g., allergic rhinitis).

15.8 Acute Exacerbations

Signs:

  • Rapid breathing, use of accessory muscles.
  • Inability to speak in full sentences.
  • Cyanosis or drowsiness (life-threatening).

Management:

  1. Assess severity (mild, moderate, severe, life-threatening).
  2. Oxygen therapy: Maintain SpO₂ > 92%.
  3. Nebulized SABA: e.g., Salbutamol every 20 minutes for 1 hour.
  4. Oral corticosteroids: Prednisolone 1–2 mg/kg/day for 3–5 days.
  5. Ipratropium bromide: In severe cases, combined with SABA.
  6. Magnesium sulphate IV: In very severe or unresponsive cases.
  7. Referral: If there is a poor response or worsening symptoms

15.9 Monitoring and Follow-up

  • Review asthma control every 1–3 months.
  • Monitor growth in children on long-term corticosteroids.
  • PEFR monitoring for older children.
  • Step-up or step-down therapy based on control.

15.10 Asthma Control Criteria (based on GINA):

  • Daytime symptoms ≤2 times/week.
  • No night waking.
  • No limitation of activity.
  • Minimal reliever use.
  • No exacerbations.

15.11 Challenges in the Ghanaian Context

  • Limited diagnostic tools: Lack of spirometry or PEFR in rural facilities.
  • Access to medication: Inhalers may be expensive or unavailable.
  • Cultural beliefs: Asthma is often attributed to spiritual causes.
  • Poor adherence Due to a lack of understanding or medication side effects.
  • Stigma: Especially among school children using inhalers.
  • Environmental triggers: Open burning, indoor smoke, and dust.

15.12 Public Health Interventions

  • Health education: Community sensitization on asthma and triggers.
  • School health programs: Identification and management of asthma in schools.
  • Policy support: Include essential asthma medications in the National Health Insurance Scheme (NHIS).
  • Training healthcare providers: On asthma diagnosis and management.

15.13 Conclusion

Asthma in children is a significant public health issue in Ghana. Early recognition, accurate diagnosis, and comprehensive management can greatly enhance outcomes. Medical students need to be prepared to address asthma in both urban and rural environments, understand the unique challenges in Ghana, and advocate for improved care across all levels of the healthcare system.

Key Takeaways for Medical Students:

  • Always consider asthma in a child with recurrent cough or wheeze.
  • A detailed history and clinical examination are often sufficient for diagnosis.
  • Use inhale corticosteroids for long-term control and SABAs for quick relief.
  • Educate families and monitor regularly.
  • Advocate for improved access to asthma care in Ghana.