Tariq Iqbal Bhutta ( Department of Paediatrics, Nishtar Medical College, Multan. )
Imran Iqbal ( Department of Paediatrics, Nishtar Medical College, Multan. )
Fifty children with bronchial asthma were studied. Male female ratio was 2:1 and age of onset was above 2 years in 70%. The disease presented as an acute attack in 74% cases. Commonest precipitating factors were exercise, cold air, cold drinks and rice. Symptoms were more prominent during the night and in winters in 56%. Chest deformity was noted in 24% and eosinophilia in 71%. PEFR was lower than 80% of predicted in 67%, spirometry showed obstructive pattern in all those tested. Disease was mild in 48%, moderate in 40% and severe in 12%. Severity of the disease was statistically unrelated to known risk factors. Expected weight of the patients was significantly affected by the severity of the disease but height remained unaffected (JPMA 38: 14 , 1988).
In developing countries, asthma is probably the most common chronic respiratory illness after tuberculosis1. It is both underdiagnosed and undertreated2. Compared with other diseases, mortality due to asthma is low but morbidity is significant3. Recurrent or persistent course of the disease interferes with the daily life of all the asth¬matic children to a variable extent. Acute symptoms incapacitate the child for a time and chronic ones lead to growth retardation and beha¬viour problems. The presence of a chronically ill child puts social, physiological and financial burden on the parents, siblings, other family members and the community. Hence a study was done on children with bronchial asthma to find its presentation,severity in relation to risk factors and to evaluate its effects on body growth.
MATERIAL AND METHOD
Indoor and outdoor patients seen during 9 months (June 85 — Marcn 86) at paediatric department of Nishtar Medical College Hospital, Multan were included in the study. The criteria for selection was either a personal observation of an acute attack (with breathlessness, wheeze and ronchi on auscultation of chest), or history of such attacks with ronchi at examination. In doubtful cases, exercise testing was performed to elicit bronchial hyperreactivity. 4 Those suffering from some other disease were extluded. A detailed questionnaire was used to record history obtained from mothers in every case, information was also obtained from children wherever possible. Questions included age of onset, frequency, severity, duration of acute attacks, precipitating factors, degree of restriction of daily activities and family history of atopic disease. Complete physical examination was performed with particular attention to presence of any chest deformity. Height and weight of the patients were recorded. Routine investigations of blood and X-Ray chest were performed in most of the cases, during the quiscent phase. Peak expiratory flow rate (Wright’s mini-flow meter: Airmed Corp.) was recorded in 33 patients who were able to cooperate in the manoeuvre. Lung function tests by a vitallograph were performed in eight patients when not in acute attack. Lability index4 was calculated in four patients. Other investigations, like allergy skin testing and IGE levels could not be done because of lack of adequate facilities. Statistical analysis was done using analysed Student’s ‘t’ test and chi-square test.
Fifty patients (34 males, 16 females) from different socio-economic group were studied. Ages of the patients ranged between 1½ years to 13 years; majority being above 5 years; ratio was 2.1 :l(Table-I).
Thirty six (72%) presented with acute episode of wheezing and four (8%) had history of wheezing at the time of admission. Nine (18%) had persistent cough or breathlessness and one was in status asthmaticus. In 15 (30%), asthma started before their second birthday and in 31 (62%) before their sixth birthday. Severity of acute attacks was graded into mild, moderate and severe on the basis of the treatment required to control it; namely, oral therapy, parenteral bronchochiators and hospita¬lisation. Afticks were mild in 26(52%), moderate in 19(38%) and severe in 5 (10%). The frequency of attacks was increasing since the onset in 19 (38%), decreasing in 2 (4%), while in 13(26%) it was unchanged. Common precipitating factors included cold air (70%), exercise (70%), dust (54%) and various foods (68%).Table I. In between the acute attacks, 2 1 (42%) had persistent cough and 5 (10%) had wheeze. Asthma interfered with daily routine in 45 (90%); and in 35 (70%) exercise was difficult or impaired. An examination in quiscent phase revealed ronchi on auscultation in 17 (34%) and chest deformity in 12 (24%) (Table II).
The disease was more troublesome during the night and in winter in 28 (56%). Six patients (12%) had symptoms more prominent during summer. Maximum cases (54%) were admitted’ in the three months of August, November and January. Twenty eight (56%) presented during winter months, and 22 (44%) during summer months (Table III).
Eosinophiia (more than 250 eosinophiia/ mm)3 was found in 71% patients. Chest roent¬genography revealed hilar prominence in 12%, increased bronchial markings in 94% and hyperin¬flation in 27%. Peak expiratory was less than 80% of Predicted in 22 (44%). All 8 showed decreased values of FVC; FEV1/FVC ratio, FMEF (forced mid-expiratory flow), PEF (peak expiratory flow) and MVV (maximum voluntary ventilation). Four patients tested for lability of airways by exercise testing were all found labile with a lability index of more than 30% (Table-V).
Severity of the disease was graded into mild, moderate and severe on the basis of Ellis classification5. In 24 (48%), disease was mild, in 20 (40%) moderate and in 6 (12%) severe. Severity of the disease was not influenced by age of onset or a with more severe disease not significant (Table VI).
Severe degree of asthma was associated with failure to gain weight (P <0.10) although height was history of atopy although male sex appears to be associated unaffected (P<0.l). Duration of symptoms was not related statistically to height and weight attained (Table VII).
Much has been written about asthma in the world, however, few clinical studies have been done in Pakistan. Male to female distribution in the present study correlates with findings of others5,6. Age distribution at the time of presentation also correlates with other studies7. The disease was more common in upper socio-economic classes in one study although present findings correlate with those of Williams and Phelan9. , who describe it more common in lower socioeconomic groups. A significant percentage of patients of asthma presented with chronic cough which has been recognised as an important symptom of airway hyper-reactivity10. The percentage of patients with an onset of disease in first year of life is lower than that in other studies7,11,12 which might be due to uñderdiagnosis of the disease especially in early years2. The observed deterioration in the fre¬quency of acute attack is at variance with obser¬vation of others5. This may be explained on the basis of a hospital based study which contains more cases with severe, persistent disease. Out of various precipitating factors asso¬ciation of cold air and dust with asthma is well known13,14. In a significant proportion of patients (68%) various foods were blamed, most common being rice and cold drinks. Wilson15 also found cola drinks as precipitating acute asthma in Asian children. The insignificant role of eggs in our circumstances also correlates with his studies. In between acute attacks, majority of children complained of difficulty in exercise which correlates with other studies16. The complaint of nocturnal symptoms by all the patients studied has been well-explained by He¬tzel. 17 Most of the patients had aggravation of their attacks in winter and inflow of patients was highest during August, November and January. In this region, cold dry winds in Winter precipitate asthma. The frequency of admissions in August. can be explained on the basis of increased humi¬dity due to monsoon rains7. The presence of history of atopic diseases in other family members and/or the patient him¬self correlates with the largely atopic nature of childhood asthma3. The presence of eosinophiia in 71% of patients correlates with the findings of others7. The presence of increased bronchovascular markings on X-Ray chest has been described by others18. Hyperinflation seen in 27% is a measure of deranged physiology as is shown by the lung function tests. These findings correlate with those of others4. More severe asthma has been correlated with early age of onset19, a male sex3 and history of atopy12,20. In the present study, these findings did not reach statistical significance due to the small sample size. Severe degree of asthma also leads to growth retardation21. The present study showed that the severity of the disease sig¬nificantly affected the weight but not the height.
1. MacFarlane, J. The respiratory physician in a Third World district hospital. Br. Med. J., 1984; 289: 657.
2. Speight, N. The diagnosis and management of asthma in children. Practitioner, 1986; 230:549.
3. Siegel, S.C. and Rachelefsky, G.S. Asthma in infants and children. J. Allergy Clin. Immunol., 1985; 76 (Pt.1):1.
4. Jones, R.S. Asthma in children. London) Edward Arnold, l976;p.56.
5. Ellis, E.F. Asthma in childhood. J. Allergy Clin. Immunol., 1983;72:526.
6. Godfrey, S. Problems peculiar to the diagnosis and management of asthma in children. Br. Thoracic Tuberculosis Association Rev., 1974; 1.
7. Wakhiu, I. and Sharma, N.L. A clinical study of bronchial asthma in children. Indian Paediatr., 1974;11: 789.
8. Graham, P.J., Rutter, M.L., Yule, W. and Pless, J.B. Childhood asthma; a psychosomatic disorder? Some epidemiological considerations. Br.J. Preventive Social Med.) 1967;21 :78.
9. Williams, H.E. and Phelan, D. Asthma in respira¬tory illness in children. Oxford Blackwall, 1975, p.116.
10. Cloutier, M.M. and Longhlin, G.M. Chronic cough in children; a manifestation of airway hyperreactivity. Pediatrics, 1981; 67: 6.
11. Kumar, L., Patil, A.S. and Walia, B.N. Clinical profile of bronchial asthma in children living in and around Chandigarh. Indian Paediatr., 1974; 11:273.
12. Blair, H. Natural history of childhood asthma— 20 years foliowup. Arch. Dis. Child., 1977;52: 613.
13. Aquilina, A.T. Comparison of airway reactivity induced by histamine, methachoilne, and isoca¬pnic hyperventilation in normal and asthmatic subject. Thorax, 1983 ;38: 766.
14. McFadeen, E.R. Jr. Pathogenesis of asthma. J. Allergy Clin. Immunol., 1984; 73 : 413.
15. Wilson, N. Food related asthma; a difference between two eltmic groups. Arch. Dis. Child., 1985;60:861.
16. Silverman, M. and Anderson, S.D. Standard tion of exercise tests in asthmatic children. Arch. Dis. Child., 1972; 47: 882,
17. Hetzel, M.R. and Clark, T.J.H. Comparison of normal and asthmatic circadian rythms in peak expiratory flow rate. Thorax, 1980; 35:732.
18. Simon, G., Connolly, N., Littlejohns, D.W. and McAllen, M. Radiological abnormalities in children with asthma and their relation to the clinical findings and some respiratory function tests. Thorax, 1973;28 :115.
19. Williams, H. and McNicol, K.N. Prevalence, natural history, and relationship of wheezy bronchitis and asthma in children; an epidemo¬logical study. Br. Med.J., 1969; 4:321.
20. Johnstone, D.E. A study of the natural history of bronchial asthma in children. Am. J. Dis. Child., 1968;115 :213.
21. Falliers, C.J., Szentivanyi, J., McBride, M. and Bukantz, S.C. Growth rate of children with intractable asthma. Observations on the influence of the illness and its therapy with steroids. J. Aliergy,1961;32 :420.