Pediatric Asthma Miami-Dade County Public Schools Physical Education and Health Literacy.
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Transcript of Pediatric Asthma Miami-Dade County Public Schools Physical Education and Health Literacy.
Pediatric AsthmaPediatric Asthma
Miami-Dade County Public SchoolsMiami-Dade County Public Schools
Physical Education and Health LiteracyPhysical Education and Health Literacy
ObjectivesObjectives
Overview of asthmaOverview of asthma Review guidelines for asthma Review guidelines for asthma
treatment treatment Review other management strategies Review other management strategies
for asthmafor asthma
What is AsthmaWhat is Asthma Disease of chronic Disease of chronic
airway inflammationairway inflammation Characterized byCharacterized by
– Airway inflammationAirway inflammation– Airflow obstructionAirflow obstruction– Airway Airway
hyperresponsivenesshyperresponsiveness
http://health.allrefer.com/health/asthma-normal-versus-asthmatic-bronchiole.html
Cookson W. Nature 1999; 402S: B5-11
PathophysiologyPathophysiology Caused byCaused by
– Inflammation and Inflammation and edemaedema
– Bronchial smooth Bronchial smooth muscle spasm and muscle spasm and hypertrophyhypertrophy
– Mucous plugging Mucous plugging
Jenkins, HA, et al. Chest 2003; 124: 32-41.
http://www.pathguy.com/histo/087.htm
Asthma in ChildrenAsthma in Children
Asthma is the most common chronic Asthma is the most common chronic disorder of childhooddisorder of childhood
Over 9 million children under the age Over 9 million children under the age of 18 in the US have been diagnosed of 18 in the US have been diagnosed with asthma with asthma – The disparity between Black and white The disparity between Black and white
non-Hispanic children is increasingnon-Hispanic children is increasing Asthma morbidity and mortality is Asthma morbidity and mortality is
increasing as wellincreasing as well
The Burden of Asthma in The Burden of Asthma in ChildrenChildren
1 million US children <18 y/o experience 1 million US children <18 y/o experience some degree of disability due to asthma some degree of disability due to asthma – Disabling asthma disproportionately affects Disabling asthma disproportionately affects
Blacks and Hispanics, single-parents, lower SESBlacks and Hispanics, single-parents, lower SES Disabling asthma lead to ~3 weeks of Disabling asthma lead to ~3 weeks of
restrictive activity per year higher than restrictive activity per year higher than other chronic medical conditionsother chronic medical conditions– 9.7 school days/year 9.7 school days/year – ~9.2 physicians contacts/year~9.2 physicians contacts/year
Asthma EtiologyAsthma Etiology
Asthma is a complex traitAsthma is a complex trait– Heritable and environmental factors contribute Heritable and environmental factors contribute
to its pathogenesisto its pathogenesis Multiple interacting genesMultiple interacting genes
– At least 20 distinct chromosomal regions with At least 20 distinct chromosomal regions with linkage to asthma and asthma related traits linkage to asthma and asthma related traits have been identifiedhave been identified
Chromosome 5q – cytokine gene clusterChromosome 5q – cytokine gene cluster ADAM33ADAM33 – bronchial hyperresponsiveness – bronchial hyperresponsiveness PHF11PHF11 – total IgE – total IgE
Hygiene HypothesisHygiene Hypothesis
Rapid rise in atopy and asthma is Rapid rise in atopy and asthma is greatest in developed countries and greatest in developed countries and urban areasurban areas– Cannot be explained by change in Cannot be explained by change in
genetic background but is thought to be genetic background but is thought to be the result of complex interactions the result of complex interactions between genes and the environment between genes and the environment
HistoryHistory
““These observations…could be explained if These observations…could be explained if allergic disease were prevented by infection in allergic disease were prevented by infection in early childhood, transmitted by unhygienic early childhood, transmitted by unhygienic contact with older siblings, or acquired contact with older siblings, or acquired prenatally…Over the past century declining prenatally…Over the past century declining family size, improved household amenities and family size, improved household amenities and higher standards of personal cleanliness have higher standards of personal cleanliness have reduced opportunities for cross-infection in reduced opportunities for cross-infection in young families. This may have result in more young families. This may have result in more widespread clinical expression of atopic widespread clinical expression of atopic disease.”disease.” David Strachan, BMJ, 1989 David Strachan, BMJ, 1989
Allergic Diseases and Autoimmune Allergic Diseases and Autoimmune Diseases are RisingDiseases are Rising
Bach JF, N Engl J Med 2002; 347: 911-920
Hygiene HypothesisHygiene Hypothesis Environmental Environmental
impact on asthmaimpact on asthma– Farm exposureFarm exposure– Day care/siblingsDay care/siblings– PetsPets– Early infectionsEarly infections
Etiological Factors – Gene and Etiological Factors – Gene and EnvironmentEnvironment
Wills-Karp M, et al. Nature Reviews Immunology; 2001; 1: 69-75
Diagnosing AsthmaDiagnosing Asthma
Clinical diagnosis supported by the Clinical diagnosis supported by the certain historical, physical and certain historical, physical and laboratory findingslaboratory findings– History of episodic symptoms of airflow History of episodic symptoms of airflow
obstructionobstruction– Physical: wheeze, hyperinflationPhysical: wheeze, hyperinflation– Laboratory: exhaled nitric oxide (eNO), Laboratory: exhaled nitric oxide (eNO),
spirometryspirometry Exclude other possibilitiesExclude other possibilities
Conditions Mimicking AsthmaConditions Mimicking Asthma
Obstruction of Obstruction of small airwayssmall airways– AspirationAspiration– Chronic lung Chronic lung
disease secondary disease secondary to prematurityto prematurity
– BronchiolitisBronchiolitis– Cystic FibrosisCystic Fibrosis
Obstruction of Obstruction of large airwayslarge airways– Foreign bodyForeign body– Congenital Congenital
malformationsmalformations– Cardiac diseaseCardiac disease– Endobronchial Endobronchial
tumorstumors– Extrabronchial Extrabronchial
obstructionobstruction– PsychogenicPsychogenic
Natural History of AsthmaNatural History of Asthma
Martinez, FD. J Allergy Clin Immunol 1999; 104: S169-74.
Diagnosing Asthma in Young Diagnosing Asthma in Young Children – Asthma Predictive IndexChildren – Asthma Predictive Index >> 4 episodes/yr of 4 episodes/yr of
wheezing lasting wheezing lasting more than 1 day more than 1 day affecting sleep in a affecting sleep in a child with one child with one MAJOR or two MAJOR or two MINOR criteriaMINOR criteria
Major criteriaMajor criteria– Parent or sibling Parent or sibling
with asthmawith asthma– Atopic dermatitisAtopic dermatitis– Aeroallergen Aeroallergen
sensitivitysensitivity Minor criteriaMinor criteria
– Food sensitivityFood sensitivity– Eosinophilia (Eosinophilia (>>4%)4%)– Wheezing apart Wheezing apart
from infectionfrom infection
Adapted from Castro-Rodriquez JA, et al. AJRCCM 2000; 162: 1403
Outcome of Childhood AsthmaOutcome of Childhood Asthma
Phelan PD, et al. J Allergy Clin Immnol 2002; 109: 189-94.
Asthma ClassificationAsthma ClassificationDays with Days with symptomssymptoms
Nights with Nights with symptoms symptoms
PEF or PEF or FEV1FEV1
PEF PEF VariabilityVariability
Mild Mild IntermittentIntermittent
<<2x/week2x/week <<22x/monthx/month >>80%80% <20%<20%
Mild Mild PersistentPersistent
3-6x/week3-6x/week >2x/month>2x/month >>80%80% 20-30%20-30%
Moderate Moderate PersistentPersistent
DailyDaily >1x/week>1x/week >60->60-<80%<80%
>30%>30%
Severe Severe PersistentPersistent
ContinuousContinuous FrequentFrequent <<60%60% >30%>30%
Adapted from Guidelines for the Diagnosis and Management of Asthma-Update on Selected Topics 2002. NIH Publication No. 02-5075.
Pa t
ient
Dea
ths
(%)
Pat
i ent
De a
ths
(%)
Asthma Mortality: Asthma Mortality: Mild Patients Are Also at RiskMild Patients Are Also at Risk
Robertson et al.Robertson et al. Pediatr Pulmonol. Pediatr Pulmonol. 1992;13:95-100.1992;13:95-100.
Patient AssessmentPatient Assessment
00
1010
2020
3030
SevereSevere ModerateModerate MildMild
4040
"Rules of Two" is a trademark of "Rules of Two" is a trademark of the Baylor Health Care Systemthe Baylor Health Care System
Rules of TwoRules of TwoTMTM
Use of a quick-relief inhaler more Use of a quick-relief inhaler more than: than: 2 times per week2 times per week
Awaken at night due to asthma Awaken at night due to asthma symptoms more than: symptoms more than: 2 times per 2 times per monthmonth
Refill of a quick-relief inhaler Refill of a quick-relief inhaler prescription more than: prescription more than: 2 times per 2 times per yearyear
Rel
ativ
e R
isk
of
Rel
ativ
e R
isk
of
Hos
pita
liza
tion
Hos
pita
liza
tion
88
77
66
55
44
33
22
11
00
Prescriptions per Person-YearPrescriptions per Person-Year
NoneNone 1-21-2 2-32-3 3-53-5 5-85-8 8+8+0-10-1
ßß22-agonists-agonists
TotalTotal
Age 0-17Age 0-17
TotalTotal
Age 0-17Age 0-17
Inhaled SteroidsInhaled Steroids
Breaking the “Rules of TwoBreaking the “Rules of TwoTMTM” Results in ” Results in Asthma MorbidityAsthma Morbidity
Adapted from Donahue et al. Adapted from Donahue et al. JAMA.JAMA. 1997;277:887-891. 1997;277:887-891.
Goals of TreatmentGoals of Treatment
SLEEPSLEEP LEARNLEARN PLAYPLAY
Key Components of Asthma Key Components of Asthma TherapyTherapy
Assessment and monitoringAssessment and monitoring Pharmacologic therapyPharmacologic therapy ““Trigger” controlTrigger” control Patient educationPatient education
Adapted from NAEPP Practical Guide for the Diagnosis and Management of Asthma. 1997 NIH Pub 97-4053.
Pharmacologic TreatmentPharmacologic Treatment““Controller”Controller”
Long-term ControlLong-term Control““Rescue”Rescue”
Short-actingShort-acting
Mild Mild IntermittentIntermittent
NoneNone ΒΒ22-agonist-agonist
Mild Mild PersistentPersistent
Preferred: low dose inhaled Preferred: low dose inhaled corticosteroid (ICS)corticosteroid (ICS)
ΒΒ22-agonist-agonist
Moderate Moderate PersistentPersistent
Preferred: low-medium dose ICS Preferred: low-medium dose ICS and long-acting and long-acting ΒΒ22-agonist-agonist
ΒΒ22-agonist-agonist
Severe Severe PersistentPersistent
Preferred: low-medium dose ICS Preferred: low-medium dose ICS and long-acting and long-acting ΒΒ22-agonist and -agonist and oral corticosteroids if neededoral corticosteroids if needed
ΒΒ22-agonist-agonist
Adapted from Guidelines for the Diagnosis and Management of Asthma-Update on Selected Topics 2002. NIH Publication No. 02-5075.
Inhaled CorticosteroidsInhaled Corticosteroids Preferred treatment alone or in Preferred treatment alone or in
combination for all persistent categories of combination for all persistent categories of asthmaasthma
Safe when use is monitoredSafe when use is monitored Reduces asthma symptoms, bronchial Reduces asthma symptoms, bronchial
hyperreactivity, exacerbations and hyperreactivity, exacerbations and hospitalizations, need for rescue hospitalizations, need for rescue medicationsmedications
Improves pulmonary function, quality of Improves pulmonary function, quality of lifelife
May prevent airway remodelingMay prevent airway remodeling
PharmacogeneticsPharmacogenetics
Study of the role of genetic Study of the role of genetic determinants in the variable determinants in the variable response to therapy response to therapy
The future of asthma treatmentThe future of asthma treatment
Other Management IssuesOther Management Issues
Environmental controlEnvironmental control– ““Safe” roomSafe” room
Diet Diet – Infant feedingInfant feeding– SodiumSodium– Fatty acidsFatty acids– AntioxidantsAntioxidants
Is Environmental Control Helpful?Is Environmental Control Helpful?
Single allergen Single allergen reduction not effectivereduction not effective
“…Treatment by means of allergen avoidance requires the definition of what patients are allergic to, and additional measures beyond the use of mattress covers and education” Thomas Platts-Mills
http://health.allrefer.com/health/asthma-common-asthma-triggers.html
Tailored Environmental Intervention Tailored Environmental Intervention
Morgan et al, 2004Morgan et al, 2004 Randomized, controlled trial of Randomized, controlled trial of
environmental interventionenvironmental intervention Intervention resulted inIntervention resulted in
– Reduction in asthma symptoms, disruption in Reduction in asthma symptoms, disruption in caretakers plans, caretaker’s and child’s sleep, caretakers plans, caretaker’s and child’s sleep, asthma-related visits to the ER or clinicasthma-related visits to the ER or clinic
– Reduction in asthma symptoms were Reduction in asthma symptoms were correlated to reduction in allergenscorrelated to reduction in allergens
No difference in reduction of allergens in No difference in reduction of allergens in homes with carpets or without carpetshomes with carpets or without carpets
Tailored Environmental Control Tailored Environmental Control Reduces Asthma SymptomsReduces Asthma Symptoms
Morgan WJ, et al. N Engl J Med 2004; 351: 1068-80.
Air Filters and AsthmaAir Filters and Asthma
McDonald E, et al. Chest 2002; 1535-42.
Diet and AsthmaDiet and Asthma
High sodium diet may result High sodium diet may result in adverse effects on airway in adverse effects on airway reactivity in patients with reactivity in patients with asthmaasthma– No recommendation to No recommendation to
implement low salt dietsimplement low salt diets Potassium and Magnesium Potassium and Magnesium
effect unclear effect unclear Tartazine exclusion not Tartazine exclusion not
helpful except perhaps those helpful except perhaps those with proven sensitivitywith proven sensitivity
Diet and AsthmaDiet and Asthma Breast feedingBreast feeding
– Exclusive breast feeding > 4 monthsExclusive breast feeding > 4 months Protective against recurrent wheezeProtective against recurrent wheeze Higher odds of asthma in children who Higher odds of asthma in children who
are atopic and have a mother with are atopic and have a mother with asthmaasthma
Maternal avoidance diets during Maternal avoidance diets during pregnancy does not affect pregnancy does not affect incidence of asthmaincidence of asthma
Utilization of protein hydrolyzed Utilization of protein hydrolyzed formulas have not been shown to formulas have not been shown to reduce incidence of asthmareduce incidence of asthma
Probiotics supplementation has Probiotics supplementation has demonstrated decrease in atopy, demonstrated decrease in atopy, but asthma is unknownbut asthma is unknown
Diet and AsthmaDiet and Asthma Polyunsaturated fatty acidsPolyunsaturated fatty acids
– Omega 3’s vs. Omega 6’sOmega 3’s vs. Omega 6’s Omega 6 fatty acids, present in animal fat, Omega 6 fatty acids, present in animal fat,
metabolized to arachidonic acid generating potent metabolized to arachidonic acid generating potent inflammatory mediators and broncho-constricting inflammatory mediators and broncho-constricting agentsagents
Omega 3 fatty acids, found particularly in fatty fish Omega 3 fatty acids, found particularly in fatty fish are metabolized to eicosapentaenoic acid (EPA) and are metabolized to eicosapentaenoic acid (EPA) and docosahexaenoic aciddocosahexaenoic acid
– May competitively inhibit the use of arachidonic acid as May competitively inhibit the use of arachidonic acid as a substrate for the production of pro-inflammatory a substrate for the production of pro-inflammatory mediators such as prostaglandins and leukotrienesmediators such as prostaglandins and leukotrienes
– Theoretical benefit to lung function, but not Theoretical benefit to lung function, but not conclusively proven in studiesconclusively proven in studies
Trans fatty acids associated with prevalence of Trans fatty acids associated with prevalence of asthma, allergic conjunctivitis, and atopic asthma, allergic conjunctivitis, and atopic eczemaeczema
Diet and AsthmaDiet and Asthma
AntioxidantsAntioxidants– Epidemiological evidence Epidemiological evidence
suggests that antioxidants have a suggests that antioxidants have a role in asthmarole in asthma
– Randomized trialsRandomized trials No current role for Vitamin C in the No current role for Vitamin C in the
treatment of asthmatreatment of asthma Vitamin E supplementation provides Vitamin E supplementation provides
no additional benefit to standard no additional benefit to standard treatment of asthmatreatment of asthma
No substantiated role for No substantiated role for ΒΒ-carotene -carotene supplementation in asthmasupplementation in asthma
Asthma EducationAsthma Education
Self management education Self management education associated with:associated with:– Improvements in airflowImprovements in airflow– Improvements in self-efficacy scalesImprovements in self-efficacy scales– Reductions in school absenceReductions in school absence– Reduction in days of restricted activityReduction in days of restricted activity– Reduction in emergency room visitsReduction in emergency room visits
SummarySummary
Asthma is a disease of chronic airway Asthma is a disease of chronic airway inflammation; thus, inhaled inflammation; thus, inhaled corticosteroids is the preferred corticosteroids is the preferred pharmacologic therapypharmacologic therapy
Persistent asthma (those who break Persistent asthma (those who break the “rules of two”) need a controller the “rules of two”) need a controller medicationmedication
Children with asthma should all be Children with asthma should all be able to sleep, learn, and playable to sleep, learn, and play