PROFILE OF PATIENTS PRESENTING WITH ASTHMA IN PEDIATRIC OPD OF KATHMANDU MEDICAL COLLEGE Affiliation

The study was a cross-sec onal study carried out at Kathmandu Medical College for dura on of six months. Pa ents were labeled as asthma as per the diagnosis guideline of Global Ini a ve for Asthma (GINA) 2016. A er the diagnosis of asthma, pa ent and their caregivers sat for a face to face interview and a detailed proforma was filled up. Data was then entered in SPSS 20 and descrip ve analysis was done to analyze the results.


Methodology
The study was a cross-sec onal study carried out at Kathmandu Medical College for dura on of six months.Pa ents were labeled as asthma as per the diagnosis guideline of Global Ini a ve for Asthma (GINA) 2016.A er the diagnosis of asthma, pa ent and their caregivers sat for a face to face interview and a detailed proforma was filled up.Data was then entered in SPSS 20 and descrip ve analysis was done to analyze the results.

Results
A total of 69 pa ents labeled with the diagnosis of asthma were enrolled during the study period.The mean age of the enrolled pa ents was 6.44(±3.36)years.Male outnumbered the females (17:8).The study showed 45(65.2%) of the pa ents had a physician diagnosed allergic rhini s while only around 5% had atopic derma s.Around 52.2% of the pa ents had a family history of atopy.Most of the pa ents (75.4%) enrolled in the study were labeled as mild persistent asthma followed by intermi ent asthma in 18.8% and moderate persistent asthma in 5.8%.

Conclusion
The study found asthma to be more prevalent in male popula on while mild persistent asthma was the most common severity present in the popula on.The most frequent risk factor for asthma found in the current study was physician diagnosed allergic rhini s.

INTRODUCTION
Asthma is a chronic inflammatory disorder.The Interna onal Consensus Report on the Diagnosis and Treatment of Asthma defines asthma as 'a chronic inflammatory disorder of the airways in which many cells play a role, including mast cells and eosinophils.In suscep ble individuals, this inflamma on causes symptoms that are usually associated with widespread but variable airflow obstruc on that is o en reversible, either spontaneously or with treatment, and causes an associated increase in airway responsiveness 1 to a variety of s muli'.It is characterized by 3 Rs, i.e. reversibility, rhythmicity and reac vity.Asthma is a disorder characterized by increase reac vity of the airway giving rise to inflamma on and bronchospasm.
The prevalence of asthma has been increasing worldwide.
Children comprise a major por on of asthma pa ent across the globe.In fact, asthma is the most common chronic 2 respiratory illness in children worldwide.The prevalence of asthma has been increasing in the developing countries while in the developed countries the prevalence is found to 3 be stable.Since the prevalence is higher in children and asthma is a chronic condi on, it causes considerable stress to the caregivers and parents of the diseased children.Moreover, for this same reason, it becomes truly important to study the factors affec ng the development and progression of this disease.
Mul ple studies have been carried out to assess different factors associated with development of asthma.Studies worldwide have shown prematurity, low birth weight, family history of asthma, passive smoking, history of allergic rhini s, atopic derma s, exposure to pets, cockroaches and mites etc to be associated with development of 4 asthma.Very few studies were found to have been done in Nepal regarding the risk factors and demographic profile of children with asthma.This study was conducted to assess the demographical profile as well as risk factors present in pa ents with asthma presen ng in Pediatric outpa ent department of Kathmandu Medical College.

METHODOLOGY
Descrip ve, cross-sec onal study design was used to carry out the study.The data was collected at the Pediatrics outpa ent department of Kathmandu Medical College and Teaching Hospital for a dura on of six months between March 2017 and August 2017.Hence, the total sample size was 69 asthma pa ents.
Purposive sampling technique was used to collect data from asthma pa ents.Pa ents were labeled as asthma as per the diagnosis guidelines of Global Ini a ve for Asthma (GINA) 2016.The best peak expiratory flow (PEF) in children more than six years of age was recorded with the help of a peak flow meter.Increase of more than 20% PEF a er nebuliza on with salbutamol was regarded as consistent with the diagnosis of asthma.Due to difficulty in diagnosis of asthma in children less than five years, probability based diagnosis of asthma was made as per GINA guidelines.
Following the diagnosis of asthma, face to face interview was conducted with the parents/ caregivers of the asthma pa ents in the Pediatric OPD.Also, the pa ent was examined clinically and their height, weight, vital signs and peak flow rate were taken and a detailed proforma was filled up.Body mass index was later calculated from height and weight.In pa ents more than six years old, the PEF was taken again a er giving salbutamol nebuliza on as per GINA guidelines to confirm the diagnosis of asthma.The same instruments were used for all pa ents and the instruments were checked for proper calibra on each me before taking the measurements.The proforma was devised by the researcher himself with extensive literature review, inputs from colleagues of the department and experts in the area.The proforma consisted of demographic details of the pa ent, history of disease along with the probable risk factors and findings of the clinical examina on of the pa ents.It took around 15-20 minutes to interview each parent/ caregiver and take measurements in the child.The proforma was pretested and modifica ons were made as per need.
Ethical clearance to conduct this study was taken from the Ins tu onal Review Commi ee of Kathmandu Medical College.Prior to data collec on, wri en informed consent was taken from the parents/ caregivers of each respondent.The interview was conducted separately with each parent/ caregiver and they were given full right to withdraw from the study any me without fear or explana on.Confiden ality was maintained throughout the study and the obtained data was used for research purpose only.
Data was checked for completeness and accuracy a er collec on and before entry.It was edited, organized and coded using Sta s cal Package for Social Sciences (SPSS) version 20.The collected data was analyzed using descrip ve sta s cs like frequency, percentage, mean, median and standard devia on.

RESULTS
A total of 69 pa ents labeled with the diagnosis of asthma were enrolled during the study period.The pa ents ranged from 2 years of age to 13 years of age with a mean age of 6.44 ± 3.36 years.Males comprised of majority (68%) of pa ents.
There was a wide varia on in the dura on of symptoms from few days to years with median dura on of symptoms being 21 days.Cough was the most common symptoms followed by shortness of breath and noisy breathing (  Enrolled pa ents were born with a mean birth weight of 2.99±0.59kgand a median gesta onal age of 38 weeks.There were 5 preterm babies in the study while 13 babies were low birth weight.More than half (59.4%) of the deliveries were vaginal while the rest were caesarean sec on deliveries.Only around 29% of deliveries needed admission during infancy for any respiratory illness.
On ques oning for risk factors of asthma, it was found that 65.2% of the pa ents had a physician diagnosed allergic rhini s.However, only around 5% had a history sugges ve of atopic derma s.Around 52.2% of the pa ents had a family history of atopy.Similary, one fi h of the pa ents reported of passive smoking at home.Majority of the caregivers (56.5%) complained of mite and cockroach problems at home.Only 9 (13%) pa ents had a pet at home.An astounding 94% of caregivers reported having given some form of asthma medica ons viz.salbutamol and/or steroid to their children during episodes of cold.Apart from episodes of cold, almost 85% of pa ents had history of cough and shortness of breath (Table 1).

Table 1: Frequency of risk factors present in the pa ents
On anthropometric measurement of children, the mean weight of children was 22.59±9.38kg while mean height was 116.79 ± 16.39cm.Mean body mass index (BMI) 2 calculated was 15.97 ± 3.7 kg/m .Examina on of the pa ents revealed wheeze in 95.7% of the pa ents while crepita ons were no ced in only 3 (4.3%)pa ents.Prolonged expira on was a finding on ausculta on in 51 (73.9%) pa ents.Hypoxia was noted in only 4 (5.8%)pa ents.
Most of the pa ents (75.4%) enrolled in the study were labeled as mild persistent asthma followed by intermi ent asthma in 18.8% and moderate persistent asthma in 5.8% (Figure 2).

DISCUSSION
Asthma has been the most common chronic respiratory illness in children worldwide.Mul ple studies have been carried out worldwide to elucidate different risk factors for development of asthma.
Studies across the globe have reported that asthma is more prevalent in younger children as compared to older children.The mean age of children in this study was 6.64 years.This was similar to the results in other studies as [5][6][7] well.Similar study carried out by Jain et al has also reported the age group 6-9 years as the most prevalent age group for 7,8 asthma.However, in a study done in Kathmandu valley, the mean age of the pa ent was found to be much higher at Regarding gender specificity of the disease, there have been conflic ng results.This study showed 68% of the pa ents to be boys.Similar to this finding, mul ple studies have 5-7,10 reported male predominance.
In contrast, few studies have also shown female preponderance for development of 11,12 asthma.However, there are studies which have found no 4,8,13 significant gender difference in development of asthma.
Cough and shortness of breath have been found to be the most common presenta on of asthma in the present study.Although cough is a very common symptom of asthma, wheezing has been underreported in this study as compared 2 to other studies.
Prematurity has been strongly linked with development of asthma in later life.In this study, only 5 of the pa ents were born preterm.This is in contrast to studies which have shown significant associa on of preterm and low birth 14,15 weight babies with asthma.With be er neonatal care and improved survival of preterm neonates, perhaps in due course of me we may find higher number of preterm babies later developing asthma.
Atopy has been a known risk factor for development of asthma.In this study as well, atopic condi ons like allergic rhini s was found to be present in a significant number of asthma c pa ents.Similar results have been published 16 from other parts of the world as well.However, there are studies repor ng to the contrary where no significant associa on was no ced between asthma and allergic 13 rhini s.
Family history of atopy has been noted in majority of 7,8,16 pa ents in concordance with studies elsewhere as well.Pokharel et al however noted no significant differences in 17 prevalence of asthma with regards to family history of atopy.
Passive smoking was found in one fi h of the pa ents enrolled.This figure may be lower than compared to other studies which have shown significant associa on between 5,16,17,18 passive smoking and asthma.
Wheezing was the most consistent finding in pa ents enrolled in the study.This supports the finding elsewhere 8,19,20 repor ng wheezing as hallmark of asthma.
In this study, most of the pa ents were found to have taken asthma medica ons in the past year which was consistent pa ents taking these asthma medica ons may be due to easy availabilty of these drugs over the counter in pharmacies around the country and a lack of felt need of the parents to consult a doctor for a simple ailment like cough.
Most of the children with asthma had mild persistent asthma followed by intermi ent and moderate persistent asthma.Similar findings were reported in previous studies.This study did not report a single case of severe asthma during the study period.However, Hessen et al reported prevalence of severe asthma to be 7.3% in school going children of 18 Kathmandu in 2003.This finding may be due to availability of be er care now as compared to 15 years ago, thus minimizing the advancement of the disease to severe asthma.

CONCLUSION
This study tries to elucidate some of the well documented risk factors in the Nepalese se ng.The study found asthma to be more prevalent in male popula on while mild persistent asthma was the most common severity present in the popula on.The most frequent risk factor for asthma found in the current study was physician diagnosed allergic rhini s.However some seem to be not so prevalent.

RECOMMENDATIONS
The rising number of cases of childhood asthma makes a detailed study on possible risk factors for the disease an urgent need.Also, a higher sample size and longer data collec on period can be used in upcoming studies.Inferen al sta s cs can be used to find out the associa on risk factors with the development of asthma.The study has tried to elucidate the risk factors described in the western literature.Perhaps study of local risk factors like indoor air pollu on, overcrowding, etc need to be further evaluated.

LIMITATIONS OF THE STUDY
The study design, samples limited to only one ins tute and dura on of study poses some amount of limita on.Also, as a cross-sec onal study with descrip ve sta s cs alone, it is not able to draw hard conclusions about the cause for development of the disease. Figure.1).

Figure 1 :
Figure 1 : Frequency of presen ng symptoms of the pa ents (n = 69)