S

Asthma in Children

Asthma is no longer considered synonymous with

bronchospasm or constriction. It is an

inflammatory disease in which bronchospasm

occurs secondary to airway inflammation

Andrew Hsi, MD, MPH

Departments of Family and Community Medicine and Pediatrics

9 October 2013

Objectives for Presentation

S Definition of asthma

S Diagnosis of asthma

S Mechanisms of wheezing and asthma

S Health disparities and asthma

S Inpatient care of kids with asthma

S Asthma guidelines and asthma action plans

S When to refer

S Asthma in the primary medical home

What is Asthma?

S Chronic disease of the airways that may cause S Wheezing S Breathlessness S Chest tightness S Nighttime or early morning coughing

S Episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.

S Even with normal breathing, a person has asthma

During an asthma episode:

•The lining of the airways swells and becomes more

inflamed

• Mucus clogs the airways.

• Muscles tighten around the airways.

•These changes narrow the airways until:

breathing becomes difficult and stressful

trying to breathe through a straw stuffed with

cotton.

Pathophysiology of Asthma

Pathology of Asthma

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma

Created and funded by NIH/NHLBI, 1995

Normal Asthma

Asthma involves

inflammation of

the airways

National Heart, Lung and Blood Institute

Making The Diagnosis;

Symptoms and History

S Wheezing

S High-pitched whistling sounds when breathing out, especially in

children

S (Lack of wheezing and normal findings on chest examination do

not exclude asthma.)

S History of any of the following:

S Cough, worse particularly at night

S Recurrent wheeze

S Recurrent difficulty in breathing

S Recurrent chest tightness

Environmental Factors for

Diagnosis of Asthma

S Symptoms occur or worsen in the presence of the following

S Exercise

S Viral infection

S Animals with fur or hair

S House-dust mites (in mattresses, pillows, upholstered furniture, carpets)

S Mold

S Smoke (tobacco, wood)

S Pollen

S Changes in weather

S Strong emotional expression (laughing or crying hard)

S Airborne chemicals or dusts

S Menstrual cycles

S Symptoms occur or worsen at night, awakening the patient

Wheezing Definitions by

NHLBI

S High-pitched whistling sound made while breathing

S Usually breathing out (expiration)

S Results from narrowed airways

S Often caused by constricted or partially blocked

airways, bronchioles

S May also originate in a larger airway

S The most common cause of recurrent wheezing is

asthma, but there are many other possible causes

of wheezing.

Videos of Wheezing

Case study of child with asthma home visitor; youtube.com/watch?v=QGAg2Ttnwcw

S 4 year old with asthma event in hospital; youtube.com/watch?v=GUkh1EGXvaE

S Sitting baby between breathing treatments; youtube.com/watch?v=OxDj_QaTk44

S Older kid wheezing; www.youtube.com/watch?v=sKi-QwHmB7I

S Baby wheezing; www.youtube.com/watch?v=ZS-PJ9jlpFw

S Sounds of severe asthma inpatient; youtube.com/watch?v=WtMKm9vl_IU

S Kid nebulizer; youtube.com/watch?v=WtMKm9vl_IU

S Teen story with asthma; youtube.com/watch?v=oSgl2hFyP-E

Common Causes of Wheezing

in Children and Infants

S Allergies

S Asthma or reactive airway disease

S Gastroesophageal reflux disease

S Infections

S Bronchiolitis

S Bronchitis

S Pneumonia

S Upper respiratory infection

S Obstructive sleep apnea

Uncommon Causes of Wheezing

S Bronchopulmonary dysplasia

S Foreign body aspiration

Rare Causes of Pediatric Wheezing

S Bronchiolitis obliterans

S Congenital vascular abnormalities

S Congestive heart failure

S Cystic fibrosis

S Immunodeficiency diseases

S Mediastinal masses

S Primary ciliary dyskinesia

S Tracheobronchial anomalies

S Tumor or malignancy

S Vocal cord dysfunction

Risk Factors for Developing Asthma

S Genetic characteristics

S Occupational exposures

S Environmental exposures

Prevalence of Asthma 1980-2007

Children and Adults

0

2

4

6

8

10

12

14

Pre

va

len

ce (

%)

Year

lifetime

current

12-month

Pink line = pediatric

Blue line = adult

0

2

4

6

8

10

12

14

16

18

Pre

va

len

ce

(%

)

Year

Prevalence by Race and

Ethnicity 1997-2008

▲ Black NH

White NH

Hispanic

Attack Rate

Lifetime

Current disease

Asthma and Health Disparities

S Prevalence in children 8700 per 100,000

S Only ADHD at 9000 per 100,000 has higher prevalence

S By race and ethnicity

S 12.7% in non-Hispanic black children

S 19.2% in Puerto Rican children

S 8.0% in non-Hispanic white children

S Outcomes significantly disparate compared to white children

S Non-Hispanic black children were 2.6 times more likely to have an emergency department visit,

S 2.0 times more likely to be admitted to the hospital, and

S Almost 5.0 times more likely to die of asthma

Risk Factors for Developing Asthma:

Genetic Characteristics

Atopy

S Predisposition to develop IgE to exposure to

environmental allergens

S Can be measured in the blood

S Includes clinical conditions

S Allergic rhinitis,

S Asthma, and

S Eczema

S Clinical triad for allergic reactivity

Risk Factors for Developing Asthma:

Environmental Exposure

Clearing the Air:

Asthma and Indoor Air Exposures

http://www.iom.edu (Publications)

Institute of Medicine, 2000

Committee on the Assessment of Asthma and Indoor Air

Review of current evidence about indoor air exposures and asthma

Clearing the Air:

Categories for Associations of Various Elements

1. Sufficient evidence of a causal relationship

2. Sufficient evidence of an association

3. Limited or suggested evidence of an association

4. Inadequate or insufficient evidence to determine whether an association exists

5. Limited or suggestive evidence of no association

Clearing the Air:

Indoor Air Exposures & Asthma Development

Biological Agents

S Sufficient evidence of causal

relationship

S House dust mite

S Sufficient evidence of association

S None found

S Limited or suggestive evidence of

association

S Cockroach (among pre-school

aged children)

S Respiratory syncytial virus

(RSV))

Chemical Agents

S Sufficient evidence of causal relationship

S None found

S Sufficient evidence of association

S Environmental Tobacco Smoke (among pre-school aged children)

S Limited or suggestive evidence of association

S None found

Clearing the Air:

Indoor Air Exposures & Asthma Exacerbation

Biological Agents

S Sufficient evidence of causal

relationship

S Cat

S Cockroach

S House dust mite

S Sufficient evidence of an association

S Dog

S Fungus/Molds

S Rhinovirus

S Limited or suggestive evidence of

association

S Domestic birds

S Chlamydia and Mycoplasma

pneumonia

S RSV

Chemical Agents

S Sufficient evidence of causal relationship

S Environmental tobacco smoke (among pre-school aged children)

S Sufficient evidence of association

S NO2, NOX (high levels)

S Limited or suggestive evidence of association

S Environmental Tobacco Smoke (among school-aged, older children, and adults)

S Formaldehyde

S Fragrances

Current State of Guidelines

S 4 major guidelines for management of asthma in young

children

S EPR3 of the National Asthma Education Program (NAEPP)

S PRACTALL Consensus Report by the European Academy of

Asthma and Allergy in 2008

S Evidence Based Approach by European Respiratory Society

task force, published in the European Respiratory Journal in

2008 and

S Global Initiative (GINA) for diagnosis and management of

asthma in children <5 in 2009 (www.ginasthma.org)

EPR3 (see references)

S National Asthma Education and Prevention Program (NAEPP)

S Expert Panel Report 3 [EPR3]

S Shifted focus of efforts to:

S Ongoing assessment of disease control with

S Goal of improving the management of asthma over time

S Context in current clinical practice

S Many patients overestimate their level of disease control

S Physicians have a tendency to underestimate the prevalence of asthma symptoms and to overestimate the degree to which their patients’ asthma is controlled

Classification of Asthma

SBased on severity of disease

SSymptom presentation

SSeverity is the intrinsic intensity of disease

How to Classify Asthma Severity

S BEFORE therapy is started

S Classify according to clinical features

S Includes domains of current impairment and

future risk

S Helps guide clinical decisions on appropriate

medication selection

Domains for Classification

S Impairment

S Frequency and intensity of symptoms

S Functional limitations the patient is experiencing

S Future Risk

S Likelihood of;

S Asthma exacerbations,

S Decreased lung growth and development in kids,

S Progressive decline in lung function, or

S Medication adverse effects

Guidelines and Asthma

Classification

S Severity of asthma guides intervention

S Step wise approach to medication use

S Guide for increasing medications and monitoring progress

S Guide for referral for pulmonary testing and consultant

S Not guide for inpatient management

Stepped Approach to Meds

Step 2:

Preferred Daily

Inhaled

Corticosteroid

(ICS) (low dose)

and SABA as

needed

Step 3:

Preferred:

Low-dose

ICS + Long Acting

Beta Agonist (LABA)

OR

Medium-dose ICS

Alternative:

Low-dose ICS +

Leukotriene Receptor

Antagonists (LTRA),

theophylline, or

zileuton

Step 4:

Preferred:

Medium-dose

ICS + LABA

Alternative:

Medium-dose

ICS + LTRA,

theophylline, or

zileuton

Intermittent Mild

Persistent

Severe

Persistent Moderate

Persistent

Highest Medication Levels

Step 5:

Preferred:

high-dose

ICS + LABA

AND

Consider

omalizumab for

patients with

allergies

Step 6:

Preferred:

high-dose

ICS + LABA+

oral

corticosteroid

AND

Consider

omalizumab for

patients with

allergies

Severe Persistent

Videos for Inhaler and

Nebulizer Use

S Instructions for spacer;

youtube.com/watch?v=ma_cmlU9DxU

S Nebulizer demonstration with little girl;

youtube.com/watch?v=KCALJSjGZNc

S Kid in hospital bed nebulizer;

youtube.com/watch?v=e60ewaY8OhU&list=PL1E435A84

54F79937&index=3

Intermittent Asthma

S • Impairment

S Intermittent symptoms ≤ 2 times/week

S Nighttime symptoms ≤ 2 times/month

S Short acting β2 agonist (SABA) use ≤ 2 days/week

S No interference with normal activity

S Forced expiratory volume in one second (FEV1) > 80%

predicted

S Normal lung function between exacerbations

S Risk

S One or fewer exacerbations per year

Mild Persistent Asthma

S Impairment

S Symptoms > 2 days/week but not daily

S Nighttime symptoms 3-4 times/month

S SABA use is > 2 days/week but not > 1x/day

S Minor interference with daily activities

S FEV1 > 80% predicted

S Risk

S 2 or more exacerbations/year

Moderate Persistent Asthma

S Impairment

S Daily symptoms

S Nighttime symptoms > 1 time/week but not

every night

S Daily use of SABA required

S Some limitation of usual activities

S FEV1 > 60%, but < 80% predicted value

S Risk

S 2 or more exacerbations/year

Severe Persistent Asthma

S Impairment

S Symptoms throughout the day

S Nighttime asthma symptoms often 7x/week

S SABA use several times per day

S Physical activity extremely limited by asthma

symptoms

S FEV1 < 60% predicted

S Risk

S 2 or more exacerbations/year

Managing Asthma:

Asthma Management Goals

S Achieve and maintain control of symptoms

S Maintain normal activity levels, including exercise

S Maintain pulmonary function as close to normal levels as possible

S Prevent asthma exacerbations

S Avoid adverse effects from asthma medications

S Theoretical; no inhibition of lung growth and development

S Prevent asthma mortality

Managing Asthma:

Asthma Action Plan

S Develop with a physician

S Tailor to meet individual needs

S Educate patients and families about all aspects of plan

S Recognizing symptoms

S Medication benefits and side effects

S Proper use of inhalers and Peak Expiratory Flow (PEF) meters

Managing Asthma:

Sample Asthma Action Plan

Describes medicines

to use and actions to

take

National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the

Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.

Case History: Emergent Patient

Management

S Kid on nebulizer before transport to hospital;

youtube.com/watch?v=yX3bRFg_J6E

S Kid inpatient with asthma;

youtube.com/watch?v=oSgl2hFyP-E

S Kid with attack after hospital neb;

youtube.com/watch?v=EY8U6JDuIZk

Managing Asthma:

Indications of a Severe Attack

S Breathless at rest

S Hunched forward

S Speaks in words rather than complete

sentences

S Agitated

S Peak flow rate less than 60% of normal

Inpatient Asthma Management

S Admission for children who

S Require beta 2-agonist therapy more often than Q2-3 hours,

S Have not improved after dose of systemic glucocorticoids, or

S Require supplemental oxygen

S Other considerations

S A history of rapid progression of severity in past exacerbations

S Poor adherence with outpatient medication regimen

S Inadequate access to medical care

S Poor social support system at home

Therapies Initiated

S Oxygen administered

S Systemic steroids

S Albuterol nebulized (5 mg is a reasonable dose to start)

S Neb treatment every 20-30 minutes for initial stabilization

S Planning for discharge at admission

S Assess patient's and family's understanding of asthma

S signs and symptoms,

S Triggers,

S Medications,

S Assess understanding of use of equipment for medications

Albuterol Treatments

S Continuously or intermittently; albuterol, salbutamol

S Via nebulizer or metered dose-inhaler (MDI) with spacer)

S Moderate exacerbations treated every 1 to 3 hours

S Doses commonly given; works better with patient sitting up

S 2.5 mg for weight < 30 kg

S 5 mg > 30 kg

S 4 to 8 puffs by metered dose inhaler with mask and spacer

S Young children using mask may not get full dose

S Repeat assessment frequently, every 20 minutes

Frequent Assessments

S Respiratory rate; refer to age norms

S Accessory muscle use; suprasternal, subcostal

S Air exchange; amplitude of inspiratory sounds

S Wheezing; more attention to inspiration

S Inspiratory to expiratory ratio; want <1:3

S Pulse oximetry; saturation above 85%

S Monitor pulse rate for side effects

Continuous SABA

S No improvement after several hours

S Needing treatments more than every 3 hours

S Dosing at

S 0.5 mg/kg per hour for children

S 10-15 mg per hour for adults (clinical decision for adolescents)

S ICU transfer for failure to respond: increasing fatigue,

increasing work of breathing, carbon dioxide retention by

blood gas level, or worsening hypoxemia

Continuous Assessment

S Switch to every 2 to 3 hour nebs with improved signs

S Daily labs; K, Mg, Phosphate

S Decreases reported on continuous treatment

S Significant for patients with concurrent CV disease, diuretic use

S Frequent assessment clinically

S Can patient carry on a conversation?

Steroid Treatment

S Relative contraindications: active herpes, varicella, hypersensitivity

S Medication choices; oral better than IV if child can swallow

S Prednisone, prednisolone, methylprednisolone

S 1 mg/kg every 12 hours for a total of five days

S 7-10 days for persons with past severe exacerbations

S Prednisolone liquid 15mg/5 mL tastes better to kids

S Inhaled not as effective in kids

Use of Oxygen

S Pulse oximetry or blood gas

S Not risk of CO2 retention in kids generally

S Humidified by mask or nasal cannula

S Either method maximum delivery about 40%

S Albuterol treatments may cause O2 sat drops initially

S Increased blood flow to poorly ventilated areas of lungs, bases

S Regional atalectasis from obstructed airways

S Goal to keep sats above 94% (90% at altitude?)

Other Medications

S Ipratropium bromide not recommended as standard therapy

S Theophyllines IV reserved for status asthmaticus

S Leukotriene Receptor Antagonists (LTRA)

S Not studied in hospitalized treatment

S Can hold doses until patient discharged

S Mag Sulfate; reserved for ICU management

S Antibiotics; not standard therapy

Working to Discharge

S Pulmonary consult; probably standard here

S Discharge planner to review financial status

S Asthma symptoms mild; clinical or by score system

S No oxygen need

S Treatments can be given at home, frequency of treatments

S Family has medication and knows how to use

S SABA; albuterol nebs or inhaler 4-6 puffs every 4 to 6 hours

S Oral steroids if hasn’t completed course inpatient

S Follow up scheduled in 2 to 5 days; preferable continuity of care

Asthma Action Plan

S Elements of plan

S Daily medications and the time(s) of day they are to be taken.

S Rescue medication

S Description of the symptoms for which they should be taken

S Frequency of use

S The phone number to call for questions.

S List of triggers that may exacerbate their asthma to avoid

S Primary care follow up and appointment

Referral to Specialist

S Pulmonary or Allergy Immunology

S Considered for any patient

S Asthma is difficult to control,

S Patients without good control on ICS and long acting beta agonist

S Considered for therapy with omalizumab

S Allergy testing for environmental of food triggers

S Desensitization therapy?

Asthma in Med Home

S Clinical quality measure

S UH Pediatric clinic model

S Diagnosis of asthma from chart review (medication)

S Use of Asthma Control Questions

S Assesses function in daily life including sleep interruption

S Frequency of medication use

S Score > 20 represents good control

S Should be given to family at every visit

Cycle for Management

S Assess and monitor asthma control

S Review medication use and techniques and adherence

S Review environmental trigger exposure

S Assess side effects

S Adjust medications; refill, step up, or decrease

S Review asthma action plan, revise as needed

S Schedule next appointment

S Continuity, continuity, continuity; hard to do in “med home”

What Are These?

S

Thank you

ahsi@salud.unm.edu