WHEEZING, SNEEZING, AND DIFFICULT BREATHING
From the American Academy of Family Physicians’ 2006 Scientific Assembly, Washington, DC
| ASTHMA IN CHILDREN AND ADOLESCENTS— Thomas G. Irons, MD, Professor of Pediatrics, Brody School of
Medicine, East Carolina University, Greenville, NC
|
| Assessment and monitoring: look for pattern of symptoms, history of recurrent episodes, and reversible airway obstruction;
rule out other conditions; easy breathing screening test—assess following occurrences within last 12 mo;
wheezing or whistling in chest; awakening at night with cough; wheezing, coughing, or shortness of breath with exercise
(and need to stop exercise); and whether cough persists when child has a cold; diagnosis of asthma—>3 episodes of
wheezing lasting >1 day and interfering with sleep, and parental asthma or documented atopic dermatitis, or 2 signs (eg,
physician-diagnosed allergic rhinitis apart from colds, wheezing apart from colds, peripheral blood eosinophilia with
other diagnoses ruled out)
|
| Severity of asthma: determine how often patient had problems with coughing, wheezing, shortness of breath, and tightness
in chest during day and night in past 2 wk; how often patient had to use rescue inhaler; ask about awakening in
morning or missing school due to symptoms; symptoms with exercise or play; ask about highest and lowest peak flow;
determine whether peak flow dropped below 80% of personal best; persistent—symptoms present >2 times per week or
patient awakens at night >2 times per month; intermittent—daytime symptoms present ≤2 times per week; mild—
daytime symptoms present >2 times per week but <1 time daily; moderate—daytime symptoms present daily; severe—
day- and night-time symptoms continual; patient categorized based on most severe feature
|
| Routine follow-up: required every 1 to 6 mo, depending on severity; spirometry every 1 to 2 yr (at minimum); peak
flow may not be true indicator of severity because patient can transiently produce substantial pressure with short tidal
volume (forced expiratory volume in 1 sec [FEV1 ] more accurate); ask about severity, self-management skills, medication
use, and care plan; when to refer—severe asthma; allergic rhinitis not controlled with medication; control cannot be
achieved with good case management and compliance; comorbidities
|
| Triggers: discuss exposure to tobacco smoke; assess and counsel patients about exercise-induced bronchospasm; common
triggers include infection, animal dander, dust mites, molds, pollen, cockroaches, weather change, strong odors,
fumes, chemicals, and smoke; trigger controls—discontinue smoking (tobacco) in house or car; bathe cat or keep outdoors;
wash stuffed animals (every few months) and place in dark plastic bag for 24 hr once weekly; cover pillows; comorbid
conditions—rhinitis; sinusitis; gastroesophageal reflux disease (GERD; no evidence that treatment of GERD
improves asthma); viral illness; provide influenza vaccine
|
| Treatment: inhaled antiinflammatory agents for persistent asthma (montelukast [Singulair] acceptable alternative); increase
when needed, decrease when possible; provide delivery devices; most patients benefit from use of spacer; recommend use of
peak-flow meters; severe asthma—high-dose inhaled steroids with long-acting β-agonist (possible increase in exacerbation
of severe disease and death rate in adults); oral steroids when needed; moderate persistent asthma—low- to medium-
dose inhaled steroid with long-acting β-agonist, or medium-dose inhaled steroid (preferred for children <5 yr of age); low-
to medium-dose inhaled steroid and leukotriene modifier or theophylline; rescue albuterol; mild persistent asthma—low-
dose inhaled steroid; leukotriene modifier or cromolyn; theophylline (fewer side effects at 5 µg/mL)
|
| Inhaled antiinflammatory agents: many studies show little or no effect of long-term use on growth or complications
(eg, cataracts); oral steroids should be used in exacerbations triggered by respiratory infection, regardless of severity; acceptable
to use high-dose inhaled steroids, but oral steroids superior for relapse at 48 hr and symptom scores 12 hr after
treatment; use of oral dexamethasone for exacerbations in office and in emergency department (ED) may be superior to
prednisone because only 2 doses needed, taste better, and compliance better
|
| Spacers: in young patient with properly fitted mask, spacer can be as effective as nebulizer; mometasone powder inhaler
avoids use of spacer (used once daily); salmeterol and fluticasone effective (maintenance medication [not to be used for
rescue]); monitor β-agonist use (re-evaluate patients who use >1 canister per month)
|
| Self-management plan: develop written plan; discuss with teachers; educate patients about how and why to take long-
term and quick-relief medication, correct technique for using devices (eg, inhaler, peak flow meter), peak flow monitoring,
and effort dependence; nurse-led community teamwork effective; comprehensive education and review of printed or
electronic materials; home visits for selected high-risk patients; home monitoring; explain difference between control and
rescue medications
|
| Literature topics: prolonged breast-feeding (>6 mo) may protect against development of asthma; asthma flares usually
related to infection; consider Chlamydia pneumoniae in patient with multiple flares during respiratory infection season;
sputum eosinophilia persists in patients with controlled asthma; 33% of hockey players have bronchial hyperresponsiveness
(associated with chronic exposure to cold air); study found health care providers overestimated degree of control of
asthma in children 33% of time; high-efficiency particulate air (HEPA) filters shown ineffective against cat allergy; conflicting
evidence about dust mite control (effective interventions include removing carpet and using pillow covers); monitoring
exhaled nitric oxide may become useful; planned-care intervention (nurse-mediated training of office staff and
physicians) more effective than peer leader education (eg, lecture given by pediatrician) or conventional management
alone; inhaled steroids given at school (vs home) improve outcomes only if child not exposed to secondhand smoke at
home; some evidence that levalbuterol (Xopenex) superior to albuterol in ED because of reduced side effects with repeated
dosing; ipratropium (Atrovent) rarely used in children; Atrovent inhaler contraindicated in presence of peanut or
soy allergy; symptoms of depression and anxiety in teenagers closely related to asthma (screen teenagers with asthma for
depression); peak flow not as effective as spirometry in classifying severity of asthma; high-dose inhaled fluticasone inferior
to oral prednisolone in acute exacerbations of mild or moderate asthma, with significant difference in 48-hr relapse
rate (0% in oral prednisolone group, 13% in inhaled fluticasone group) and symptoms at discharge; lung function inversely
related to carbon content of airway macrophages
|
| ALLERGIC RHINITIS —Harold H. Hedges III, MD, Associate Clinical Professor, Department of Family Medicine, University
of Arkansas School of Medicine, Little Rock
|
| Introduction: allergic rhinitis affects 20% to 40% of pediatric population; mean onset of allergies in children 8 to 10 yr
of age (70% develop at <20 yr of age); symptoms—rhinorrhea; rhinitis; disruption of sleep; fatigue; negative effects—
school or work absenteeism; cognitive impairment; fearfulness; poor social interaction; poor performance in school or
work; decreased self-esteem; depression; anxiety; shyness
|
| Distinguishing allergic from nonallergic rhinitis: based on patient history and physical examination; no objective
diagnostic test; helps determine specific cause of rhinitis; demonstrates allergy triggers (so can be avoided); aids in selection
of appropriate medication (eg, azelastine [antihistamine nasal spray] or nasal steroids for nonallergic rhinitis); reduces
cost of inappropriate medication; helps explain inefficacy of antihistamines or immunotherapy; 52% of patients present
with nonallergic rhinitis, 48% with allergic rhinitis; few studies done on mixed rhinitis; study of 16,000 patients found 7%
had pure allergic rhinitis, 10% had pure nonallergic rhinitis, and 82% had mixed rhinitis (diagnoses not based on objective
test); symptoms and signs of allergic rhinitis—rhinorrhea; nasal congestion; sneezing; watery itchy eyes; itchy nose;
postnasal drip; symptoms present before age 20 yr; positive family history; symptoms or exacerbations seasonal; symptoms
improve in air conditioning or filtered air; fatigue, sinusitis, otitis media, and asthma concomitant conditions; antihistamines
reduce symptoms; symptoms may be caused by exposure to animal; symptoms and signs of non-allergic
rhinitis—congestion; rhinorrhea; symptoms perennial; negative family history; symptoms present after age 20 yr; caused
by perfumes, potpourri, burning candles, tobacco smoke, chemical exposures, office machines, weather changes, automobile
exhaust, gasoline, paints, fumes; no significant response to exposure to animal; symptoms respond to decongestants
but not to antihistamines; mixed rhinitis—combination of symptoms of allergic and nonallergic rhinitis; diagnosis based
on objective evidence of allergy by skin testing or in vitro testing and positive history for nonallergic triggers; negative allergy
test best test for nonallergic rhinitis; objective evidence of allergic rhinitis—decrease in allergic symptoms with
oral antihistamines, intranasal antihistamines, or steroids; nasal cytology positive for eosinophils, positive allergy skin test,
or positive in vitro test results
|
| Triggers of allergic rhinitis and anaphylaxis: pollen from trees, grasses, and weeds; molds; animal dander; foods
(eg, peanuts, shellfish); hymenoptera; consider chronic rhinosinusitis in patient with asthma who does not improve with
usual treatment; if patient doing well on asthma treatment, allergy testing or immunotherapy not required; obstruction of
osteomeatal complex (from, eg, broken nose, Down syndrome) can cause rhinitis
|
| Signs of allergic rhinitis in children: nasal symptoms; chronic fatigue; Morgan’s line (Dennie’s sign); nasal crease;
nasal voice; irritability; poor appetite
|
| Physical changes: allergic rhinitis—pale blue edematous turbinates; clear watery nasal discharge; crease from “nasal
salute”; adenoid facies; lymphoid hyperplasia; nonallergic rhinitis—less mucosal edema; nonspecific nasal discharge
(usually not “crystal clear”); crease from nasal salute; biopsies show normal mucosal pattern and cell structure; not typical
inflammatory phenomenon
|
| Treatment: immunotherapy helps allergic rhinitis, but not nonallergic rhinitis; nasal irrigation—removes triggers and
prevents changes that cause symptoms; Waterpik with nasal irrigator; ceramic Neti pots for saline; “hose in the nose”
(disposable enema bucket filled with 2 tsp of salt, 1 tsp of baking soda, and 1 qt of warm water; washes triggers off nasal
mucosa); nasal steroids—indicated in all types of rhinitis; better than antihistamines for true allergic rhinitis, but patients
often reluctant to use; no good supporting evidence for homeopathic therapy (eg, acupuncture, herbal remedies; patients
who appear to improve should not be discouraged); intranasal steroids, astelazine, and decongestants for
nonallergic rhinitis
|
| Treatment of rhinitis medicamentosa: eg, oxymetazoline (Afrin); topical steroids can be initiated bilaterally while
discontinuing decongestant in one nostril (after 7-10 days, stop and treat other nostril); 1-wk tapered steroid dose; evaluate
underlying cause of rhinitis
|
| Diseases associated with rhinitis: asthma (treating sinusitis helps control asthma); otitis media with effusion; upper
respiratory infections; polyposis
|
| Reasons to consider immunotherapy: drugs highly effective, but provide only symptomatic treatment; immunotherapy
alters natural course of disease; allergy treatment (including sublingual immunotherapy) in monosensitized children
prevents development of new sensitizations; allergy vaccination or sublingual immunotherapy may prevent onset of
asthma in patients with rhinoconjunctivitis
|
| Indications for allergy testing and immunotherapy: inadequate control of symptoms with avoidance and pharmacotherapy;
prolonged or recurrent symptoms; intolerable side effects from medication; desire for long-lasting control
without medication; to decrease possibility of developing other new sensitizations or asthma; contraindications—short
season (ie, patient can be treated with antihistamines for 4-8 wk or steroid injections that cover through spring or fall);
well controlled asthma; patients with cardiovascular disease; patients on β-blocking drugs or levobunolol (Betagan Liquifilm);
patients with severe uncontrolled asthma (FEV1 should be 70% of best effort [not predicted]); patients with severe
immunodeficiency disease; pregnancy—do not start immunotherapy in newly pregnant patients; if patient becomes
pregnant while on immunotherapy (at baseline or on maintenance dose), continue immunotherapy through pregnancy
|
| Allergy screening: use 6 to 10 allergens to determine presence of allergy; same allergens common in patients in same
geographic area; testing for allergies to most common tree, grass, and weed pollens, mold, house dust mites, and cats
identifies ≈90% of allergic patients; interpreting results—if all tests negative except for positive control (histamine),
patient has hypoactive skin (most likely due to antihistamine); discontinue antihistamine for 7 to 10 days and retest, or
perform in vitro testing (eg, radioallergosorbent testing [RAST]); if tests for grass, tree, or weed pollens or mold allergens
positive, test for all local allergens (36-46 additional allergens); if tests for house dust mite or cat only positive results,
no further testing required (counsel patient about avoidance; consider immunotherapy); advantages—
differentiates allergic patient from nonallergic patient; eliminates need for unnecessary testing; helps determine pharmacotherapy;
identifies allergens to avoid; cost-effective; reliable
|
| Objective allergy testing: nasal cytology—identifies patients with nonallergic rhinitis-eosinophilia syndrome
(NARES); useful for patients who present with allergy symptoms and negative allergy test results; individual skin prick
testing—Duotip-Test; Morrow Brown needle; GreerPick; multiple antigen applicators; Multi-Test; QUINTEST; before
testing, educate patients about type of testing and time involved in testing and immunotherapy programs; discuss potential
for local and systemic side effects, rare possibility of anaphylaxis, and risk for death from allergy vaccinations; document
and obtain consent
|
Educational Objectives
| The goal of this program is to educate the listener about asthma in children and adolescents and about allergic rhinitis. After
hearing and assimilating this program, the participant will be better able to:
|
 | 1. Classify severity of asthma in children.
|
| 2. Select appropriate treatment for asthma, based on severity and clinical findings.
|
| 3. Distinguish allergic rhinitis from nonallergic rhinitis.
|
| 4. Select patients with allergies who may benefit from immunotherapy.
|
| 5. Administer appropriate tests to identify and manage allergies.
|
Discussed on This Program
Albuterol (salbutamol sulphate in United Kingdom) [several trade names]
Azelastine HCl [Astelin, Optivar]
Cromolyn sodium [several trade names]
Dexamethasone [several trade names]
Fluticasone propionate [several trade names]
Fluticasone propionate/salmeterol [Advair Diskus]
Influenza virus vaccine [Fluarix, FluMist, Fluvirin, Fluzone]
Ipratropium bromide [Atrovent]
Levalbuterol HCl [Xopenex, Xopenex HFA]
Levobunolol hydrochloride [AKBeta, Betagan Liquifilm]
Mometasone furoate [Elocon, Asmanex Twisthaler]
Montelukast sodium [Singulair]
Oxymetazoline HCl [several trade names]
Prednisolone [several trade names]
Prednisone [several trade names]
Theophylline [several trade names]
Suggested Reading
Amirav I et al: Aerosol therapy with valved holding chambers in young children: importance of the facemask seal. Pediatrics
108:389, 2001; Dell S et al: Breastfeeding and asthma in young children: findings from a population-based
study. Arch Pediatr Adolesc Med 155:1261, 2001; Dykewicz MS et al: Diagnosis and management of rhinitis: complete
guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy
of Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol 81:478, 1998; Halterman JS et al: Benefits of a
school-based asthma treatment program in the absence of secondhand smoke exposure: results of a randomized clinical
trial. Arch Pediatr Adolesc Med 158:460, 2004; Johnstone DE: Immunotherapy in children: past, present, and future.
(Part I). Ann Allergy 46:1, 1981; Lozano P et al: A multisite randomized trial of the effects of physician education and
organizational change in chronic-asthma care: health outcomes of the Pediatric Asthma Care Patient Outcomes Research
Team II Study. Arch Pediatr Adolesc Med 158:875, 2004; Moller C et al: Pollen immunotherapy reduces the development
of asthma in children with seasonal rhinoconjunctivitis (the PAT-study). J Allergy Clin Immunol 109:251, 2002;
Passalacqua G et al: Long-lasting clinical efficacy of allergen specific immunotherapy. Allergy 57:275, 2002;
Qureshi F et al: Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma. J Pediatr
139:20, 2001; Smith AD et al: Use of exhaled nitric oxide measurements to guide treatment in chronic asthma. N
Engl J Med 352:2163, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed:
Dr. Hedges is on the Speakers’ Bureau and has received honoraria from Antigen Laboratory. Dr. Hedges also provides
testing materials to Lincoln Diagnostics for hands-on testing courses.
Drs. Irons and Hedges spoke in Washington, DC, at the 2006 Scientific Assembly, presented September 27 to October 1,
2006, by the American Academy of Family Physicians (AAFP). The Audio-Digest Foundation thanks the speakers and the
AAFP for their cooperation in the production of this program.
|
