Diagnosis and Treatment of Asthma in Children

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Diagnosis and Treatment of Asthma in Children

• Loran Clement, M.D.

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Some Basic Facts About Asthma

• Asthma is very common
• Approximately 6-8 of children in the U.S. has
  asthma
• Prevalence 10-15 reported in some inner city
  populations

• Asthma is very expensive
• Direct and indirect costs for asthma - gt 15
  billion a year

• Asthma significantly impairs quality of life
• Leading cause of missed school days
• Interrupted or impaired sleep for child and
  family
• Children dont participate in physical activities
  

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The prevalence of asthma is increasing (1980
2000)
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In the United States, increases in the
prevalence, morbidity, and mortality of asthma
have been disproportionately great among

• Urban dwellers
• Populations of low socioeconomic status
• Ethnic minorities
• Children

Although a variety of factors may play a role,
the cause of this epidemic remains unknown
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Pathophysiology of Asthma
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What causes asthma?

• Susceptibility heavily influenced by genetic
  factors that produce atopy (at least 10-15 genes
  may be involved)
• Allergic sensitization a specific immune
  response occurs when a susceptible person is
  exposed to an antigen
• Symptoms occurs when a person with asthma is
  re-exposed to specific allergen(s) or other
  triggers

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Asthma Symptoms Result from Inflammation and
Bronchoconstriction
BRONCHIOLE
Reduced airway opening
Tightened muscle
Alveolus filled with trapped air
Thick Muscle Layer
Excess Mucus
Inflammation
Bronchoconstriction
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PATHOPHYSIOLOGY OF ASTHMA
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Lung function during early and late phases of
allergic response
BEFORE STIMULUS
LATE PHASE
EARLY PHASE
BRONCHOSPASM
INFLAMMATION
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Five Components ofAsthma Management

• 1. Diagnosis and Assessment of Activity
• 2. Pharmacologic Therapy
• 3. Control of Other Factors Contributing
• to Asthma Severity
• Establish an Educational Partnership
• Re-assessment and Re-education

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Diagnostic Criteria for Asthma

• History of episodic symptoms of airflow
  obstruction (especially at night, after exercise,
  or after breathing cold air)
• coughing
• chest tightness or pain
• dyspnea
• wheezing
• Airflow obstruction is at least partially
  reversible
• spirometry usually not very helpful in children
• Alternative diagnoses are excluded
• differentiating asthma from recurrent respiratory
  infections difficult during the first 3-6 years
  of life

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CLASSIFYING ASTHMA SEVERITY AND INITIATING
TREATMENT IN YOUTHS gt 12 YEARS AND ADULTS
EPR-3, p74, 344
Classification of Asthma Severity
Components of Severity
Persistent
Intermittent
Mild
Moderate
Severe
Symptoms
lt2 days/week
gt2 days/week not daily
Daily
Continuous
Impairment Normal FEV1/FVC 8-19 yr 85 20-39 yr
80 40-59 yr 75 60-80 yr 70
Nighttime Awakenings
gt1x/week not nightly
lt2x/month
3-4x/month
Often nightly
SABA use for sx control
lt2 days/week
gt2 days/week not daily
Daily
Several times daily
Interference with normal activity
none
Minor limitation
Some limitation
Extremely limited

• Normal FEV1 between exacerbations
• FEV1 gt 80
• FEV1/FVC normal

• FEV1 gt80
• FEV1/FVC normal

• FEV1 lt60
• FEV1/FVC reducedgt 5

• FEV1 gt60 butlt 80
• FEV1/FVC reduced 5

Lung Function
Exacerbations (consider frequency and severity)
0-2/year
gt 2 /year
Risk
Frequency and severity may vary over time for
patients in any category
Relative annual risk of excaerbations may be
related to FEV
Step 1
Step 2
Step 3
Step 4 or 5
Consider short course of oral steroids
Recommended Step for Initiating Treatment
In 2 -6 weeks, evaluate asthma control that is
achieved and adjust therapy accordingly
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Classification of Asthma Severity
ActivityUsing Readily Identifiable Features

• Days with Nights with
  PEF or FEV1 PEF
• Symptoms Symptoms (
  of normal) Variability
• Step 4
• Severe Continuous
  Frequent ? 60
  gt30
• Persistent
• Step 3
• Moderate Daily ? 5
  per month 60 80 gt30
• Persistent
• Step 2
• Mild 3 - 6 per week 3 - 4
  per month ? 80 20 - 30
• Persistent
• Step 1
• Mild ? 2 per week ? 2 a
  month ? 80 ? 20
• Intermittent

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Spirometry

• A medical test that measures the flow and
  volume of air entering and leaving the lungs as a
  function of time. (ATS, 1994)

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Spirometry - Measurements Based on FVC maneuver

• Forced Vital Capacity (FVC) Volume expired by a
  forced maximal expiration after maximal
  inhalation
• Forced Expiratory Volume in 1 second (FEV1)
  Volume of air forcefully expired in the first 1
  second
• Forced Expiratory Flow from 25-75 of Exhalation
  (FEF25-75) Average air flow rate during the
  middle half of the FVC maneuver reflects flow
  through the small airways
• FEV1/FVC ratio - the ratio of FEV1 to FVC
  (expressed as a percent)
• Peak expiratory flow rate (PEFR)

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Spirometry Interpretation FVC and FEV1

• Interpretation of predicted FVC
• 80-120 Normal
• 70-79 Mild reduction
• 50-69 Moderate reduction
• lt50 Severe reduction

• Interpretation of predicted FEV1
• gt75 Normal
• 60-75 Mild obstruction
• 50-59 Moderate obstruction
• lt50 Severe obstruction

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Spirometry Pre- and Post-bronchodilator

• Obtain a flow-volume loop
• Administer a bronchodilator
• Obtain a second flow-volume loop 15-20 minutes
  after bronchodilator administration
• Calculate percent change in FEV1 (or FEF 25-75)
• Obstruction is considered to be reversible if the
  change is 12 or greater
• Failure to demonstrate a change after
  bronchodilator does not exclude a reversible
  component of obstruction because airway
  inflammation that does not responsive to B2
  agonist may be present

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Pre-Post Bronchodilator
ATS recommends a positive response is gt 12
improvement in FEV1
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Special Considerations in Pediatric Patients

• Ability to perform spirometry dependent on
  developmental age of child, personality,
  cooperation, and interest of the child
• Best results in children gt6 years old
• Patients need a calm, relaxed environment and
  good coaching. Patience and experience is key.
• Younger children may require more than 3 tests

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Special Considerations in Pediatric Patients

• Must perform a maximal forced exhalation for at
  least 3 seconds
• Incentive screens on monitor often very helpful
  Blow out all your birthday candles.
• The best test is the one with the greatest sum
  of FEV1 and FVC
• Even with the best of environments and coaching,
  a child may not be able to perform spirometry (or
  may have normal spirometry despite having asthma)

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Spirometry Quality
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Five Components ofAsthma Management

• 1. Diagnosis and Assessment of Activity
• 2. Pharmacologic Therapy
• 3. Control of Other Factors Contributing
• to Asthma Severity
• Establish an Educational Partnership
• Re-assessment and Re-education

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Overview of Asthma Medications

• Quick Relievers
• Bronchodilators
• Short-acting inhaled beta2-agonists
• (Anticholinergics)
• Systemic Corticosteroids

• Long-Term Controllers
• Anti-inflammatory drugs
• Inhaled corticosteroids
• Leukotriene modifiers
• Long-acting b2-agonists

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Acute Asthma
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Treatment of acute asthma attack

• When asthma symptoms occur, inspire 2
  puffs of a beta2-agonist from a MDI or give an
  albuterol treatment with a nebulizer
• This can be repeated 20 minutes later if symptoms
  continue
• If symptoms persist, child should be seen by a
  health care provider and/or commence oral steroid
  therapy

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ED Care

• Begin beta2-agonist treatment immediately
• Get short history (prior intubations or
  respiratory failure?), recent medication use,
  triggers
• Oxygen to maintain SaO2 gt90
• ABG in patients with suspected hypo-ventilation
  or with severe distress
• Ancillary studies (CBC, CXR) when indicated
• Corticosteroids (unless albuterol rapidly clears)
• Hospitalization if not clear after three
  treatments

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Danger Signs

• History of rapid or severe deterioration
• Severe symptoms at rest (accessory muscle use,
  chest retraction, difficulty speaking, cyanosis,
  agitation)
• FEV1 or PEF lt50 of personal best
• pCO2 gt42 mm Hg

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Hospital Management

• Inhaled beta2-agonist (and an anti-cholinergic?)
  by MDI or via nebulization. Albuterol can be
  given continuously, at regular intervals, or as
  needed
• Intravenous or oral corticosteroids
• Oxygen to achieve O2 saturation gt90
• Repeat assessment (symptom assessment, physical
  exam, PEF, O2 saturation, other tests as needed)
• For impending or actual respiratory failure,
  admit to ICU for intubation and mechanical
  ventilation

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Quick Reliever TherapyMDI spacer or
Nebulizer?

• The MDI spacer combination has been
  evaluated in acute asthma attacks in all age
  groups and all asthma severity ranges. When
  properly used, this combination has been shown to
  be at least as effective or better than use of a
  nebulizer in outpatient, inpatient, ED, and
  intensive care unit settings
• Therapeutic benefits commence sooner
• Medications given by MDI spacer are cheaper
• Administration of medication is easier
• Medications given by MDI and chamber have fewer
  side effects
• Administration of medications by MDI and chamber
  can be done anywhere

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Asthma Controller Therapy
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Multiple studies have shown that asthma is
Where do we stand in our efforts to control the
current asthma epidemic?

• under-diagnosed
• under-treated

• Multiple other studies have shown that
• disease activity can be controlled in the vast
  majority of asthmatic children if the disease is
  recognized and treated with anti-inflammatory
  medications

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CLASSIFYING ASTHMA SEVERITY AND INITIATING
TREATMENT IN YOUTHS gt 12 YEARS AND ADULTS
EPR-3, p74, 344
Classification of Asthma Severity
Components of Severity
Persistent
Intermittent
Mild
Moderate
Severe
Symptoms
lt2 days/week
gt2 days/week not daily
Daily
Continuous
Impairment Normal FEV1/FVC 8-19 yr 85 20-39 yr
80 40-59 yr 75 60-80 yr 70
Nighttime Awakenings
gt1x/week not nightly
lt2x/month
3-4x/month
Often nightly
SABA use for sx control
lt2 days/week
gt2 days/week not daily
Daily
Several times daily
Interference with normal activity
none
Minor limitation
Some limitation
Extremely limited

• Normal FEV1 between exacerbations
• FEV1 gt 80
• FEV1/FVC normal

• FEV1 gt80
• FEV1/FVC normal

• FEV1 lt60
• FEV1/FVC reducedgt 5

• FEV1 gt60 butlt 80
• FEV1/FVC reduced 5

Lung Function
Exacerbations (consider frequency and severity)
0-2/year
gt 2 /year
Risk
Frequency and severity may vary over time for
patients in any category
Relative annual risk of excaerbations may be
related to FEV
Step 1
Step 2
Step 3
Step 4 or 5
Consider short course of oral steroids
Recommended Step for Initiating Treatment
In 2 -6 weeks, evaluate asthma control that is
achieved and adjust therapy accordingly
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STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS gt
12 YEARS AND ADULTS
EPR-3, p333-343
Intermittent Asthma
Persistent Asthma Daily Medication Consult with
asthma specialist if step 4 or higher care is
required Consider consultation at step 3
Step up if needed (check adherence,
environmental control and comorbidities)
Step 6 Preferred High-dose ICS LABA
oral Corticosteroid AND Consider Olamizumab
for patients with allergies
Step 5 Preferred High dose ICS
LABA AND Consider Olamizumab for patients
with allergies
Step 4 Preferred Medium-dose ICSLABA Alternat
ive Medium-dose ICSeither LTRA, Theophlline Or
Zileutin
Assess Control
Step 3 Preferred Medium-dose ICS OR Low-dose
ICS either LABA, LTRA, Theophylline Or
Zileutin
Step 2 Preferred Low-dose ICS Alternative LTRA
Cromolyn Theophylline
Step down if possible (asthma well controlled for
3 months)
Step 1 Preferred SABA prn
Patient Education and Environmental Control at
Each Step
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ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
YOUTHS gt 12 YEARS OF AGE AND ADULTS
EPR-3, p77, 345
Classification of Asthma Control
Components of Control
Not Well Controlled
Very Poorly Controlled
Well Controlled
lt 2 days/week gt 2 days/week
Throughout the day
Symptoms
Nighttime awakenings
lt 2/month 1-3/week gt 4/week
Interference with normal activity
IMPAIRMENT
none
Some limitation
Extremely limited
lt 2 days/week gt 2 days/week
Several times/day
SABA use
gt 80 predicted/ personal best
60-80 predicted/ personal best
lt60 predicted/ personal best
FEV1or peak flow
Validated questionnaires ATAQ/ACT
0/gt 20 1-2/16-19
3-4/lt 15
Exacerbations
0- 1 per year
2 - 3 per year
gt 3 per year
Progressive loss of lung function
RISK
Evaluation requires long-term follow up care
Rx-related adverse effects
Consider in overall assessment of risk

• Consider oral steroids
• Step up 1-2 weeks and reevaluate in 2 weeks

• Maintain current step
• Consider step down if well controlled at least 3
  months

• Step up 1 step
• Reevaluate in 2 - 6 weeks

Recommended Action For Treatment
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Five Components ofAsthma Management

• 1. Diagnosis and Assessment of Activity
• 2. Pharmacologic Therapy
• 3. Control of Other Factors Contributing
• to Asthma Severity
• Establish an Educational Partnership
• Re-assessment and Re-education

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Control Other Factors That Can Influence Asthma
Severity

• Control exposure to asthma triggers (tobacco
  smoke, air pollution, known allergens)
• Control rhinitis
• Intranasal corticosteroids are most effective
• Recognize and treat chronic sinusitis

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Five Components ofAsthma Management

• 1. Diagnosis and Assessment of Activity
• 2. Pharmacologic Therapy
• 3. Control of Other Factors Contributing
• to Asthma Severity
• Establish an Educational Partnership
• Re-assessment and Re-education

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Key Educational Tasks in the Asthma Care
Partnership

• 1. Patient physician must agree on the
  treatment goals
• Doctors must know what is important to patients,
  and visa versa
• Control of asthma must be defined and explained

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Key Educational Tasks in the Asthma Care
Partnership

• 1. Patient physician must agree on the
  treatment goals
• Doctors must know what is important to patients,
  and visa versa
• Control of asthma must be defined and explained

• 2. Physician must teach the basic facts about
  asthma
• Contrast normal and asthmatic (hyperreactive,
  inflamed) airways
• Emphasize the importance of controlling
  inflammation

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Key Educational Tasks in the Asthma Care
Partnership

• 1. Patient physician must agree on the
  treatment goals
• Doctors must know what is important to patients,
  and visa versa
• Control of asthma must be defined and explained

• 2. Physician must teach the basic facts about
  asthma
• Contrast normal and asthmatic (hyperreactive,
  inflamed) airways
• Emphasize the importance of controlling
  inflammation

• 3. Teach the therapeutic roles of different
  medications
• Patients must learn that different inhalers are
  NOT interchangeable
• Long-term controllers have different effects than
  quick relievers

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Key Educational Tasks in the Asthma Care
Partnership

• 4. Identify factors that make asthma worse and
  agree on relevant environmental control measures
• Two recent studies showed that children
  participating in highly successful asthma
  management programs experienced dramatic
  improvement in all measures of disease activity
  UNLESS they were exposed to tobacco smoke in
  their home environment (i.e., it isnt that dusty
  teddy bears fault)

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Some potential triggers
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Key Educational Tasks in the Asthma Care
Partnership

• 4. Identify factors that make asthma worse and
  agree on relevant environmental control measures

• 5. Teach patients when they should take rescue
  actions
• Develop and explain an appropriate Asthma Action
  Plan

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Use symptoms or peak flows to determine zone
ASTHMA ACTION/MEDICINE PLAN Date___________ Patien
t Name________________ PF________________________
Doctors Tel._______________
Green means Go Use preventative medicine Yellow
means Caution Start quick relief medicine
and increase the dose of preventative
medicine Red means Danger Give oral steroids
immediately Seek medical attention immediately
11/9/98
John Doe
123-456-789
323-226-5049 (Dr. Asthma)
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Personal Best Peak Flow__________
Green - Go (Use preventative medicine)
Medicine Amount
How often ________________________________________
__ __________________________________________ ____
______________________________________

• Easy normal breathing
• No limitations on activity
• No wheezing, coughing or
• shortness of breath
• Peak flows are above_____________

ICS 2 puffs Twice a day
Leukotriene inhib 1 tab Each
evening Albuterol 2 puffs Every
3-4 hrs as needed
240
Yellow Caution (Start quick relief medicine
and increase the dose of preventative medicine)
Medicine Amount
How often ________________________________________
__ __________________________________________ ____
______________________________________

• At first sign of a viral infection
• Wheezing, coughing or
• shortness of breath
• Waking up at night with
• asthma symptoms
• Peak flows are______to_______

ICS 4 puffs Twice a day
Leukotriene inhib 1 tab Each evening Albuterol
2 puffs 3-4 Times a day
240
150
Red - Danger (Give oral steroids immediately Seek
medical attention immediately)
Call 911 or go to the Emergency Room
Medicine Amount
How often ________________________________________
__ __________________________________________ ____
______________________________________

• Medicine is not helping
• Hard and fast breathing
• Ribs showing when breathing
• Cannot talk in complete sentences
• Cannot walk
• Nose flares open when breathing
• Peak flows are Below________________

Prednisone (20mg) 2 Tablets Once a day
Albuterol 2 puffs Every 1 to 3 hrs

ICS 4 puffs Twice a day Leukotriene
inhib 1 tab Each evening
150
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Peak Expiratory Flow (PEF) Meters
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Peak Flow Monitoring

• Simple, quantitative, reproducible measure of the
  existence and severity of airflow obstruction
  (correlates with FEV1)
• May be useful for monitoring pulmonary function,
  managing therapy, and detecting asthma
  exacerbations
• Suitable for patients gt 5 years old
• Can use patients personal best as the reference
  value over time

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Shortcomings of Peak Flow Monitoring

• Results are heavily dependent on patient effort
  and, thus, less reproducible than spirometry
• Appears to be inferior to symptom assessment for
  detecting asthma exacerbations (this may delay
  starting appropriate therapy by gt1 day)
• Compliance with performing test and recording
  results very poor (lt10 of patients comply)
• May distract patients from regular use of
  controller medications (one more thing to do)

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Conclusions

• Daily peak flow monitoring is rarely effective
  for monitoring asthma status in children and may
  delay appropriate changes in therapy

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Key Educational Tasks in the Asthma Care
Partnership

• 4. Identify factors that make asthma worse and
  agree on relevant environmental control measures

• 5. Teach patients when they should take rescue
  actions
• Develop and explain an appropriate Asthma Action
  Plan

• 6. Physician must teach the necessary skills
• Patients must be shown how to properly use
  inhalers, spacers, and, when applicable, peak
  flow monitors

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Medical Staffs Ability to Effectively
Demonstrate Proper Inhaler Techniques
RT
98
97
100
RN
82
78
MD
80
69
Mean DemonstrationScore ()
60
57
60
40
21
20
12
0
MDI
Turbuhaler
MDI AeroChamber
Plt0.0001 vs. RN and MD
Hanania et al. Chest. 1994105111-116.
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Five Components ofAsthma Management

• 1. Diagnosis and Assessment of Activity
• 2. Pharmacologic Therapy
• 3. Control of Other Factors Contributing
• to Asthma Severity
• Establish an Educational Partnership
• Re-assessment and Re-education

53
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