Asthma management from a solo QTIP practice prospective

1. Mariana Ciobanu, MD,FAAP Carolina Pediatrics-Cheraw QTIP July 2012 Collaborative meeting Asthma management from a solo QTIP practice prospective

2. To better understand how to differentiate between infants who wheeze and go on to develop asthma and those who wheeze but do not go on to have asthma • To discuss management strategies for treating children with a high risk of developing asthma • To discuss possible prevention therapies for asthma in children four years old or younger Objectives

3. What is Asthma? • Disease of chronic inflammatory disorder of the airways • Characterized by • Airway inflammation • Airflow obstruction • Airway hyperresponsiveness Cookson W. Nature 1999; 402S: B5-11 http://health.allrefer.com/health/asthma-normal-versus-asthmatic-bronchiole.html

4. Subacute/Chronic Inflammation Early Asthmatic Response Late Asthmatic Response Normal Airway Inhaled trigger chemotactic factors cytokines Asthmatic Inflammation Recruitment and activation of inflammatory cells Neural & vascular effects Mast Cells Alveolar macrophages

5. Asthma is a complex trait • Heritable and environmental factors contribute to its pathogenesis. Viral infections appears have an expanding role as well. • Onset appears early in life and severity remains constant • Multiple interacting genes • At least 20 distinct chromosomal regions with linkage to asthma and asthma related traits have been identified: Chromosome 5q , ADAM33 , PHF11 What Causes Asthma?

6. Host factors • Genetic predisposition • Atopy • Airway hyperresponsiveness • Gender • Race/Ethnicity • Environmental factors • Indoor allergens • Outdoor allergens • Occupational sensitizer • Environmental factors (cont) • Tobacco smoke • Air pollution • Respiratory infections • Socioeconomic status • Family size • Diet and drugs • Obesity Potential Risk Factors1 1Masoli M, et al. The Global Burden of Asthma: Executive Summary of the GINA Dissemination Committee Report. Allergy 2004; 59: 469-78.

7. Clinical diagnosis supported by the certain historical, physical and laboratory findings • History of episodic symptoms of airflow obstruction (e.g.. breathlessness, wheezing, and COUGH)-response to therapy! • Physical: wheeze, hyperinflation • Laboratory: exhaled nitric oxide (eNO), spirometry • Exclude other possibilities Diagnosing Asthma-Not Easy

8. Asthma • Congenital Anomalies with airway impingement: Vascular rings, tracheobronchial obstruction, mediastinal mass • Bronchopulmonary dysplasia • Cystic fibrosis • Gastroesophageal reflux • Aspiration • Foreign Body Aspiration • Heart Failure • Sinusitis and allergic rhinitis • Bronchiolitis • Pertussis • Tuberculosis • Immune system Disorders Differential Diagnosis Wheezing

9. Group 1: Low Lung function: children improve within a few years and "outgrow" their asthma • Group 2: Non-Atopic, viral-induced asthma: also outgrow asthma after a somewhat longer period of time (nonatopic wheezing). • Group 3: Atopic Asthma: in contrast, children who will go on to develop persistent wheezing beyond infancy and early childhood usually have a family history of asthma and allergies and present with allergic symptoms very early in life (atopy-associated asthma). Wheezing in Infants

10. > 4 episodes/yr of wheezing lasting more than 1 day affecting sleep in a child with one MAJOR or two MINOR criteria • Major criteria • Parent with asthma • Physician diagnosed atopic dermatitis • Minor criteria • Physician diagnosed allergic rhinitis • Eosinophilia (>4%) • Wheezing apart from colds Diagnosing Asthma in Young Children – Asthma Predictive Index 1Adapted from Castro-Rodriquez JA, et al. AJRCCM 2000; 162: 1403

11. Identify precipitating factors (pets, ETS, mold second hand smoking exposure) • Identify comorbid conditions that may aggravate asthma (GERD, allergies etc) • Assess the patient/families knowledge and self management skills • Classify asthma severity using the Guidelines from the NHLBI (Expert Panel) Asthma Diagnosis Made

12. Use Impairment and Risk • Impairment • Symptoms: night time symptoms, reliever use (SABA), miss school/work, quality of life, ACT screen • Lung function- spirometry (FEV0.5), eNO • Risk • Recurrent exacerbations including ED visits and hospitalization (may be normal between events) • At times, hard to differential between impairment and risk Assessing Asthma Severity

13. Break down into intermittent, mild, moderate, or severe persistent asthma depending on symptoms of impairment and risk • Once classified, use the 6 steps depending on the severity to obtain asthma control with the lowest amount of medication • Controller medications (inhaled steroids) should be considered if >4 exacerbations/year, 2 episodes of oral steroids in 6 months, or use of SABA’s (albuterol) more then twice a week Classifying Asthma Severity in Children 0-4 Years of Age

14. Step 1: intermittent- use SABA prn • Step 2: mild persistent-use low dose ICS OR montelukast • Step 3: moderate persistent: moderate dose of ICS • Step 4: moderate persistent: moderate dose of ICS and add either montelukast or LABA • Step 5: severe persistent: high dose ICS and montelukast or LABA • Step 6: severe persistent: high dose ICS and montelukast or LABA plus oral steroids • Consult asthma specialist if step 3 or higher (consider at step 2) Steps of Therapy 0-4 Years

15. Goals of therapy • Prevent symptoms • Maintain (near) “normal” PF • Maintain normal activity • Prevent exacerbations & minimize ER visits/hospitalizations • Optimal drug tx, minimal problems • Patient/family satisfaction Asthma Management

16. Monitor carefully- every 3-6 months if stable, more often if not(1 wk f/u app after an acute episode) • If stable after 3 months, try to reduce therapy (usually by 25-50%) • Inhaled steroids are safe even in the young at mild to moderate doses with only a slight decrease in growth velocity. Higher doses have been shown to affect growth, cause cataracts and reduce bone density • Response to therapy is very important in this age group! Maintaining Control

17. Managing Asthma: Asthma Action Plan Develop with a physician Tailor to meet individual needs Educate patients and families about all aspects of plan Recognizing symptoms Medication benefits and side effects Proper use of inhalers and Peak Expiratory Flow (PEF) meters

18. 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.

19. Managing Asthma: Peak Expiratory Flow (PEF) Meters Allows patient to assess status of his/her asthma Persons who use peak flow meters should do so frequently Many physicians require for all severe patients

22. Control chronic and nocturnal symptoms • Maintain normal activity levels and exercise • Maintain near-normal pulmonary function • Prevent acute episodes of asthma • Minimize emergency department (ED)visits and hospitalizations • Avoid adverse effects of asthma medications Asthma: Goals of Treatment1 1Global Initiative for Asthma. GINA workshop report: global strategy for asthma management and prevention. Available at: http://www.ginasthma.org. Accessed October 13, 2006.

23. There has been remarkable progress in pharmacotherapy, education and environmental measures in treating asthma • However, no single action has been demonstrated to decrease the risk of developing asthma • Genetic and environmental influences-key! • Exposure to microbial products- Hygiene? • Low level of lung function present in preschoolers with asthma • Prevention will depend on factors influencing the development and progression of asthma Asthma Prevention