Laura T. Mulreany, MD LTC, MC Pediatric Pulmonologist

1. Guidelines for the Diagnosis and Management of AsthmaNational Asthma Education and Prevention ProgramExpert Panel Report 3 Laura T. Mulreany, MD LTC, MC Pediatric Pulmonologist

2. OVERVIEW • Not a comprehensive review of childhood asthma • What we have learned since 2002 • Major changes in new NHLBI guidelines • Assessment and monitoring • Patient education • Control of factors contributing to severity • Pharmacologic treatment

3. ASTHMA KNOWLEDGE 2007

4. CHILDHOOD ASTHMA • Chronic inflammatory disorder • Recurrent episodes of potentially-reversible airflow obstruction • Key features: • Bronchoconstriction • Airway hyperresponsiveness • Airway edema

5. CHILDHOOD ASTHMA • Major advances in understanding • Role of inflammation • Gene-by-environmental interactions • Early, recognizable risk factors • Treatment and disease progression

6. INFLAMMATION • Many cell types and mediators • Different phenotypes may have specific patterns and require different treatments • Causes airflow limitation and enhanced hyperresponsiveness • Response to treatment may be slow or incomplete • Airway remodeling may result from abnormally-regulated repair • Loss of lung function or reduced lung growth

7. GENE-BY-ENVIRONMENT INNATE IMMUNITY Imbalance between Th1 and Th2 cytokine profiles HOST GENETICS Cytokine response profiles ALLERGENS House dust mite and cockroach exposure Early dog or cat exposure RESPIRATORY INFECTIONS RSV Parainfluenza virus ENVIRONMENT

8. GENE-BY-ENVIRONMENT INNATE IMMUNITY Imbalance between Th1 and Th2 cytokine profiles GENETICS Cytokine response profiles ? Obesity ? Pollution ALLERGENS House dust mite and cockroach exposure Early dog or cat exposure ? Anti-oxidants & O-3-FA RESPIRATORY INFECTIONS RSV Parainfluenza virus ? In utero tobacco

9. EARLY RISK FACTORS • Age at onset influences decrease in lung function growth • Early onset (before 3 y/o) associated with decreased lung function growth • Target for intervention - children under 3 • But majority of toddlers who wheeze do not develop asthma

10. ASTHMA PREDICTIVE INDEX • Children under 3 y/o with 4 or more wheezing episodes / year • Development of persistent asthma increased if: • One of following: • Parental asthma, atopic dermatitis, aeroallergen sensitization OR… • Two of following • Sensitization to foods, ≥4% eosinophilia, wheezing apart from colds

11. TREATMENT & PROGRESSION • Anti-inflammatory therapy does not prevent disease progression • Inhaled corticosteroids provide • Better control • Prevention of symptoms and exacerbations • But… • Symptoms and airway hyperresponsiveness worsen when treatment withdrawn

12. ASTHMA MANAGEMENT 2007

13. AFTER DIAGNOSIS… • Identify precipitating factors • Identify co-morbid conditions • Assess patient’s knowledge & skills for self-management • Classify asthma severity

14. ASTHMA MANAGEMENT • Four components • Assessment and monitoring • Education • Control of environmental factors & comorbidities • Pharmacologic therapy

15. MAJOR CHANGES IN EPR-3 • Severity and control • Impairment and risk • Step-wise approach to diagnosis and treatment • Education • Environmental control • Treatment of acute asthma

16. Severity Intrinsic intensity of disease Measured best before therapy May be inferred from least amount of tx needed for control Guides decisions about treatment Control Degree manifestations are minimized & goals met Measured at follow-up Guides adjustments in treatment Responsiveness - ease of achieving control SEVERITY AND CONTROL

17. RESPONSIVENESS • Ease of achieving control • Uncertainty in • Clinically-significant outcomes • Time needed to assess response • Resistance to therapy • High prevalence of co-morbidities

18. CLASSIFICATION OF ASTHMA SEVERITYCHILDREN 0-4 YEARS OF AGE

19. CLASSIFICATION OF ASTHMA SEVERITYCHILDREN 5-11 YEARS OF AGE

20. CLASSIFICATION OF ASTHMA SEVERITYCHILDREN >12 YEARS OF AGE and ADULTS

21. SPIROMETRY • Pre and post-bronchodilator testing • Measures often do not correlate with sxs • FEV1/FVC more sensitive measure of severity in children • FEV1 useful measure of risk of exacerbations

22. ASSIGNING SEVERITY – AFTER TX STARTED

23. Impairment Frequency and intensity of disease Symptoms Lung function Functional limitations Risk Likelihood of exacerbations, decline in lung function or reduced lung growth Risk of adverse effects from medications IMPAIRMENT AND RISK

24. RISK • Severity of disease does not necessarily correlate with intensity of exacerbations • Predictors • More frequent or intense exacerbations • Severe airflow obstruction • Reporting feeling in danger or frightened • Female, non-white • Non-use of ICS • Smoking • Psychosocial factors • Attitudes and beliefs about medications

25. RISK - CHILDREN 0-4 y/o

26. RISK - CHILDREN 5-11 y/o

27. RISK - YOUTHS ≥ 12 y/o and older

28. TREATMENT OF ASTHMA

29. GOALS OF THERAPY • Prevent chronic or troublesome sxs • Prevent / reduce severity of exacerbations • Require infrequent use of quick-relief meds • Maintain (near) “normal” lung function • Maintain normal activity levels • Optimal meds with minimal / no side effects • Meet pt expectations of & satisfaction with asthma care Identical for all levels of severity

30. MEDICAL MANAGEMENT • Most effective medications for long term control have anti-inflammatory effects • Inhaled corticosteroids (ICS) are most potent and consistently effective • Safe for use in children • Sensitivity and response to ICS may vary • In mild-moderate asthma, dose-response relationship flattens in low-medium dose range

31. MEDICAL MANAGEMENT • Long acting beta agonists (LABA) • Black box warning • Adjunct to ICS, not monotherapy • Consider if not controlled on low dose ICS (pts older than 4 y/o) • Leukotriene modifiers, methylxanthines • Alternatives, not preferred • Omalizumab • Consider in severe asthma

32. INITIATING THERAPY 0-4 y/o • Start long term controller for: • 4 or more wheezing episodes in past year (lasting > 1day and affecting sleep) AND risk factors • Symptomatic tx > 2 days/week for > 4 weeks • Second exacerbation req oral steroids in 6 mo • (may consider use only during periods of consistently documented risk)

33. STEP-WISE TREATMENT • Combine impairment and risk • Assign severity to most severe category

34. MANAGEMENT - 0-4 y/o Step 6 Preferred: High dose ICS + either LABA or Montelukast Oral systemic corticosteroid Step 5 Preferred: High dose ICS + Either LABA Or Montelukast Step 4 Preferred: Medium dose ICS + either LABA or Montelukast Step 3 Preferred: Medium dose ICS Step 2 Preferred: Low dose ICS Alternative: Cromolyn or Montelukast Step 1 Preferred : SABA prn

35. MANAGEMENT - 5-11 y/o Step 6 Preferred: High dose ICS+ LABA +Oral systemic steroids Alternative: High dose ICS + either LTRA Or theophylline + oral systemic corticosteroids Step 5 Preferred: High dose ICS + LABA Alternative: High dose ICS + Either LTRA or Theophylline Step 4 Preferred: Medium dose ICS + LABA Alternative: Medium dose ICS + either LTRA or theophylline Step 3 Preferred: EITHER Low dose ICS + Either LABA, LTRA, or Theophylline OR Medium dose ICS Step 2 Preferred: Low dose ICS Alternative: Cromolyn or LTRA or Nedocromil or Therophylline Step 1 Preferred : SABA prn

36. ASSESSMENT OF CONTROL • Clinician and patient assessments • Six components • Signs and symptoms • Pulmonary function • Quality of life • Exacerbations • Medications - adherence and side effects • Patient satisfaction, communication w/ provider (minimally invasive markers and pharmacogenetics under consideration)

37. CLASSIFICATION OF ASTHMA CONTROLCHILDREN 0-4 YEARS OF AGE

38. CLASSIFICATION OF ASTHMA CONTROLCHILDREN 5-11 YEARS OF AGE

39. CLASSIFICATION OF ASTHMA CONTROLCHILDREN >12 YEARS OF AGE and ADULTS Validated questionnaires also used in assessment of control

40. ASSESSING CONTROL & ADJUSTING THERAPY

41. SPECIALTY REFERRAL • Life-threatening exacerbation • Not meeting goals of therapy • Atypical signs/sxs • Complicating conditions • Additional testing • Additional education • Consideration for immunotherapy • Step 3 for child 0-4, or step 4 for older pts • > 2 oral steroid bursts/year • Environmental or occupational exposure concern

42. EDUCATION • Repetition and reinforcement • Self-management • Review of goals of tx • Written action plan • Environmental control • Management of co-morbidities • All points of care • Patient satisfaction, quality of life, cultural and ethnic considerations

43. HOME Action plan Monitor signs/sxs (Consider peak flows) Increase frequency of SABA Albuterol HFA 4-8 puffs q20min X 3, then every 1-4 hours Oral steroids 1-2 mg/kg for 3 to 10 days Doubling ICS not sufficient ED/HOSPITAL Supplemental O2 SABA for all Ipratropium in ED only Systemic steroids Consider adjuncts (magnesium, heliox) Does not recommend: methylxanthines, antibiotics, excessive hydration, chest PT, mucolytics, sedation TREATMENT OF ACUTE ASTHMA – new recommendations

44. DISCHARGE TO HOME • At ED or hospital D/C • Written discharge plan • Medications • SABA, oral steroids to complete course • Consider ICS for 1-2 months • Techniques –devices, self-monitoring • Follow-up • Referral for education, specialty care (if indicated)

45. QUESTIONS?