Asthma in Children

1. Asthma in Children October 29, 2002 Swedish Family Medicine Jorge Garcia, MD

2. Case 1: Naomi J.

3. CASE 1 • An 7-year old girl has just moved into town and presents to her doctor. She has history of wheezing and rhinitis and recurrent otitis media since infancy. Over the past 2 years her symptoms have worsened. She complains of coughing and SOB daily and claims to awaken at least once a week in the middle of the night by these symptoms.

4. Her family history consists of maternal asthma, and atopy in both parents. Physical exam finds inflamed nose, mild wheezing, otherwise unremarkable. The patient's mother states that her daughter was previously prescribed an albuterol puffer to use prn, which her daughter uses daily and requires monthly refills. The child is able to remain active. In the past year she has had 4 courses of prednisone.

5. According to the above information: How would you classify this patient's severity?Mild intermittent Mild persistent Moderate persistent Severe persistent

6. Diagnosis of Asthma Severity DiagnosisDays w/SxNights w/Sx PEF (Step)(% personal best) or FEV2 % predicted best) severe persistent(4) Continual Frequent <60 moderate persistent(3) Daily >5 / month 60-80 mild persistent(2) >2/wk 3 to 4 / month >80 mild intermittent(1)<2 /wk <2 per month >80

7. What makes you think this is ASTHMA?

8. SUSPECT ASTHMA WITH: • Intermittent wheezing, cough, dyspnea. • Increased rate of breathing. • Sx worse at night and in early morning. • Associated with triggers. • Onset before age 5. (80%)

9. What is your differential?

10. Wheezing can be caused by: • URIs • Rhinitis • Sinusitis • CF • Cardiac disease • GERD • Foreign body aspiration...

11. Workup?

12. New Asthma Dx: • Confirm with PFT • Consider Allergy testing if the child also has significant allergic rhinitis.

13. With the diagnosis of Asthma What are the findings on PFT?

14. PFT • Increase in forced expiratory volume in one second (FEV1) of 12 percent or more after bronchodilator therapy. • variable airflow obstruction (20 percent or more) with serial spirometry or peak expiratory flow (PEF). • Not reliable in kids <3-4.

15. CASE 1: Naomi J. • An 7-year old girl has just moved into town and presents to her doctor. She has history of wheezing and rhinitis and recurrent otitis and sinusitis since infancy. Over the past 2 years her symptoms have worsened. She complains of coughing and SOB daily and claims to awaken at least once a week in the middle of the night by these symptoms.

16. Her family history consists of maternal asthma, and atopy in both parents. Physical exam finds inflamed nose, mild wheezing, otherwise unremarkable. The patient's mother states that her daughter was previously prescribed an albuterol puffer to use prn, which her daughter uses daily and requires monthly refills, but the patient is able to remain active. In the past year she has had 4 courses of prednisone.

17. What more would you want to know about your patient?

18. Obtain a history to rule out triggers • What are some possible triggers of RAD?

19. Obtain a history to rule out triggers. • What are some possible triggers of RAD?

20. dust mites and mold spores, pollen animal dander, cockroaches, indoor and outdoor pollutants, irritants (e.g., tobacco smoke, smoke from wood-burning stoves or fireplaces, perfumes, cleaning agents), pharmacologic triggers (e.g., aspirin or other nonsteroidal anti-inflammatory drugs, beta blockers and sulfites), physical triggers (e.g., exercise, hyperventilation, cold air) physiologic factors (e.g., stress, gastroesophageal reflux, respiratory infection [viral, bacterial] and rhinitis). Kitchen sink.

21. What is the best way to treat her today? • ?

22. “Treatment of children with asthma should begin with the most aggressive therapy necessary to achieve control, followed by "stepping down" to the minimal therapy that will maintain control.”

23. Moderate Persistent Asthma (Step 3) • High dose corticosteroid inhaler daily. • Long acting daily bronchodilators. • Short acting bronchodilator for symptoms.

24. Asthma treatment by severity: • Step 1; mild, intermittent • days with symptoms: <2 times per week • nights with symptoms <2 per month • PEF>80% predicted.

25. Asthma treatment by severity:Step 1; mild, intermittent • No daily preventive meds needed: treat symptoms only. • Treatment should be required no more than 2/week. • Short acting beta-2 agonist: Albuterol MDI with face mask or spacer. • Cost: $30-50/ canister.

26. Step one: One inhaler...

27. Asthma treatment by severity:Step 2; mild, persistent • Days with symptoms >2 times per week • Nights with symptoms: >2 per month but less than 5 times/month. • percent predicted PEF >80%.

28. Asthma treatment by severity:Step 2; mild, persistent • Daily anti-inflammatory medications: • Cromolyn (Intal) inhaler $47.00 Nedocromil (Tilade) inhaler $36.00 • or Low- to medium dose inhaled corticosteroid [range of prices: Budesonide (Pulmicort Turbuhaler DPI), 200 µg per puff $19.00 to Fluticasone (Flovent), 44 µg per puff $47.00 (13-g canister)]

29. Asthma treatment by severity:Step 2; mild, persistent • Short-acting bronchodilatoras needed for symptoms. Intensity of treatment depends on severity of exacerbation: • Inhaled short-acting beta2 agonist by nebulizer or spacer/holding chamber and face maskor Oral beta2 agonist.

30. Step two: Two inhalers...

31. Treatment of Asthma by severity: Moderate Persistent Asthma (Step 3) • Day time symptoms:Daily • Night time symptoms>5 times per month • PEF >60 to <80%

32. Treatment of Asthma by severity: Moderate Persistent Asthma (Step 3) • High dose corticosteroid inhaler daily. • Long acting daily bronchodilators. • Short acting bronchodilator for symptoms.

33. Step 3: Rx with…?

34. Step 3: 3 inhalers...

35. High dose corticosteroid inhaler daily. • Beclomethasone (Vanceril DS MDI), 84 µg per puff $42.00 • Fluticasone (Flovent 220 µg per puff $95.50 • Reduce to lower dose once symptoms controlled.

36. Long acting daily bronchodilators. • Salmeterol (Serevent MDI) $42.00 (Serevent Diskus DPI) $43.50 • Short acting bronchodilators for rescue only: Albuterol.

37. Step 4: Severe and persistent Sx • Days with symptoms: Continual • nights with symptoms: Frequent • PEF <60% predicted.

38. Treatment of step 4?

39. Usually add oral pred to Step 3 medications. Treatment can be variable in step 4.

40. Step 4; severe, persistent • Daily anti-inflammatory medications: • High-dose inhaled corticosteroid with spacer/ holding chamber and face maskand • If needed, add systemiccorticosteroids (0.25 to 2 mg per kg per day) and reduce to lowest daily or alternate-day dosage that stabilizes symptoms.

41. What is the role of Antileukotrienes ? • “In patients with chronic asthma who are symptomatic while receiving moderate-to-high doses of inhaled beclomethasone, the addition of 2 to 4 times the licensed dose of antileukotriene (AL) agents reduces the rate of exacerbations that require systemic corticosteroids. Insufficient evidence exists that AL confers benefit over doubling the dose of corticosteroids or that it has an inhaled corticosteroid-sparing effect.” • Cochrane Database Syst Rev. 2002;(1):CD003133

42. What is the role of Antileukotrienes ? • They are new drugs, and expensive. • The doses that seem to work are higher than marketed recommendations. • They may help in Step 3 and 4, to reduce exacerbations, and reduce need to increase dose of inhaled steroids. • No worrisome side effects…yet.

43. Home severity monitoring may help keep kids out of the hospital. • First, determine their “Personal Best” • Ask them to check PF a few times each day, for two weeks, when asthma in good control.

44. Write out the PF Color Zones • PF <50% Red Zone • PF 50-80% Yellow Zone • PF> 80%: Green Zone

45. Green Zone: PF > 80% of personal best. • No symptoms at all. • Good Control. • Continue taking regular medications.

46. Yellow Zone: PF 50%-80% • CAUTION! Need rescue meds: • Use short acting Beta-2 agonist (Albuterol MDI or nebulizer). • Consider increasing dose of medication. • Monitor PF more frequently.

47. Red Zone: PF < 50% • Use Short Acting beta-2 Agonist: Albuterol. • Call doctor’s office, or seek medical attention.

48. Kids die of Asthma. Mortality rate increasing.

49. Who is at risk of dying of asthma? • Severe disease: 1-2% of these kids will die of asthma. • Hx: prior hospitalization, steroid need. • Symptoms triggered by foods. • Self weaning, esp. off steroids. • Lack of parental care. • Poor, African-American, boys.

50. However…in large study of asthma deaths: • 33% had mild asthma. • 34% had no prior hospitalization. • A minority of patients (15-30%) die suddenly, within two hours of onset of dyspnea.