What's New in Pediatric Asthma

From An Intensive Review of Family Medicine, presented June 8-13, 2009, bythe Medical University of South Carolina, Charleston

C. Michael Bowman, MD, PhD, Professor of Pediatrics, Medical University of South Carolina, Charleston

Educational Objectives

The goal of this program is to improve management of asthma in children. After hearing and assimilating this pro­gram, the clinician will be better able to:

1.   List key elements of current asthma guidelines.

2.   Recognize signs of uncontrolled asthma.

3.   Assess asthma severity and control.

4.   Counsel families and patients about proper use of rescue and controller medications.

5.   Address environmental factors, such as tobacco smoke.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Bowman and the planning committee reported nothing to disclose.

Ackowledgements

Dr. Bowman was recorded in Kiawah Island, SC, at An Intensive Review of Family Medicine, presented June 8-13, 2009, by the Medical University of South Carolina, Charleston. The Audio-Digest Foundation thanks Dr. Bowman and the Medical University of South Carolina for their cooperation in the production of this program.

Introduction: “The State of Childhood Asthma, United States, 1980-2005” (www.cdc.gov/nchs/data/ad/ad381.pdf) useful refer­ence; incidence of asthma increasing; 22 million children in United States affected; »9% have current problems; 12.7% have had asthma; 5.2% have had attack in last year; incidence twice as high in groups of lower socioeco­nomic status; office visits increasing; emergency department (ED) visits and hospitalizations stable; mortality im­proving; asthma care  —  39% of patients report having care plans; 57% informed about peak flow rates; 52% considered environmental changes; costs  —  in 2005, nearly $20 billion spent ($6.2 billion on medications); loss of 75,000 child-years of school; in 1999, black children with asthma had 4.6-fold increase in risk for death (6.0-fold in 2004), compared to white children; important to recognize and to provide care

Guidelines for diagnosis and management of asthma: recent guidelines focus on severity and control (daily or weekly symptoms should be evaluated); consider seasonal flares, environmental exposures, and triggers; partner­ship and communication between patient, family, and providers important; Global Initiative for Asthma (GINA) guidelines recognize importance of asthma control; National Asthma Education and Prevention Program (NAEPP) guidelines  —  Expert Panel Report 3 (EPR-3); evidence-based; literature reviewed up to March 15, 2006; recognized as work in progress; key points outlined in each section; include data tables and recommendations; “online text­book” of asthma

Asthma “underworld”: underrecognition  —  families assume symptoms due to common cold; children who do not play hard often perceived as shy; undertreatment  —  due to satisfaction with use of albuterol (eg, “he just needs alb­uterol”); flares associated with returning to school after summer; underreferral  —  symptoms perceived as “not that serious”; due to satisfaction with results of prednisolone (eg, Orapred); daily use of controller medication for 5 yr results in less steroid burden to body than one 5-day burst of prednisone; families worry about use of steroids; need for Orapred often indicates asthma not in control

Recognizing asthma in children: challenging; signs  —wheezing; positive family history; severe bronchiolitis due to respiratory syncytial virus (RSV); cough variant (many children have chronic cough with no family history); history  —  prolonged (eg, 2 wk) common cold; exercise intolerance (ask parents about specific activities; ask child about, eg, running and need for rest); exposure to pollen, animals, or environmental tobacco smoke; ask parents about response to treatment (eg, albuterol, prednisone; cough due to reactive airway disease or asthma resolves with albuterol); key tipoffs  —  prolonged upper respiratory infections (URIs); exercise intolerance; weight issues (sug­gested that intake of fast food leading to greater inflammatory cytokines and mediators can result in greater expres­sion of asthma and obesity); excessive school absences; concerns expressed by school nurses or coaches; responsiveness to short-acting b-agonists or steroids; recurrent need for oral steroids (well-controlled child needs oral prednisone only 1-2 times per year)

Key concepts in guidelines: severity  —  initial assessment; consider risk for death and admission to hospital; classify asthma as mild, moderate, or severe; control  —  assess response to management; evaluate daily symptoms; deter­mine how often child needs rescue medication; impairment and risk  —  current status and history; evaluate need for medication adjustments, doses of controller medication (eg, fluticasone and salmeterol [Advair Diskus]), fre­quency of rescue medication, and how close child is to normal activity and daily life

Asthma care: assessment  —  initial and recurring; quantitative and subjective; pulmonary function tests (PFTs) help­ful; control environment and comorbidities  —  address environmental tobacco smoke (advise against smoking in­doors or in car; tobacco smoke from 1 cigarette lingers in room for 3 hr); manage allergens and triggers (eg, gastroesophageal [GE] reflux); form partnership with patient and family  —  education; follow-up; communica­tion; guidelines recommend follow-up every 3 mo; therapeutics  —  ensure patients and families know when and how to use medications and devices; many children have difficulty using “Diskus” inhalers; nurse or therapist should check for correct use; be aware of medication updates and new devices

Pediatric perspectives: age groups  —  0 to 4 yr of age; 5 to 11 yr; start PFTs at age 5 yr; ³12 yr of age; nebulizer treatment  —  for every centimeter tubing away from mouth or nose, 50% of medication dose lost; using mask im­portant (with nebulizer machines, mask does not need to be fitted tightly; with spacers, mask must be fitted tightly to activate valve); impairment  —child should be able to play every day; growth issues  —  starting inhaled steroids may reduce growth velocity by 1 cm during first 6 mo, but children catch up to predicted heights (based on parental heights); reassure families about low doses of steroids given by inhalation, compared to doses of oral prednisone; family education  —  crucial that family understands and retains information about medications

Initiating care: “get control, gain trust, and show you know what you’re doing”; start with medium-dose controller medications; determine severity and duration of asthma; consider activity in school; determine causes of sickness and how concerned family is; in children with nighttime cough and asthma, consider sinus disease, GE reflux, and environment in which child sleeps; ask whether symptoms more severe during day or at night; ask about past treat­ment and response; include education, assessment, follow-up, and written action plans (“can’t be done in 7 min”); assessment of techniques important

Elements of outpatient care: identify triggers; controller medications (may be helpful to compare medications to acne medications, eg, “we don’t want your lungs to break out next week”); inhaled steroids; leukotriene modifiers; combination therapy of inhaled steroids and long-acting b-agonists; rescue medications  —  determine how often needed; according to guidelines, albuterol 1 to 2 times weekly acceptable (1-2 times per month sign of adequate care); levalbuterol; dosage varies (depends on route of administration); if patient not doing well, 2 puffs of albuterol through small spacer (90 μg) may be inadequate, compared to albuterol through nebulizer (2.5 mg; 10-20 puffs roughly same as 1 nebulizer dose); “green zone” (ie, “feeling tight”; take 2 puffs of albuterol); “yellow zone” (ie, “things not going well”; take 6 puffs); “red zone” (ie, considering going to hospital; take 8-10 puffs every 20 min x 3); advise families that >2 puffs acceptable for symptom control; use spacers up through teenage years, then dry powder inhaler or metered-dose inhaler (MDI) alone; use of dry powder inhaler requires rapid inhalation, use of MDI requires long, slow inhalation with breath hold (children should be taught appropriate breathing maneuvers); assessment  —  peak flow monitoring helpful for determining whether exercise intolerance due to conditioning or to bronchospasm; PFTs; education, appropriate techniques, and follow-up every 3 mo important; written action plans; provide spacers when prescribing albuterol; physician (not family) should adjust therapy over time

Goals: “a cold is a cold”; eliminate environmental tobacco smoke; full activity tolerance; adequate sleep (consider GE reflux, sinus disease, obstructive sleep apnea, and environmental problems); no lung-related school absences; rare occurrence of symptoms; need for rescue medication <2 times per month; near normal PFTs; rare occurrence of flares; rare need for prednisone; no hospitalization; need for oral steroids £2 times per year; minimal medication side effects

Fluticasone: eg, Flovent Diskus, Advair Diskus; recommended to be used twice daily; when used once daily, benefit decreases to 10% of that from twice-daily use; thrush in mouth  —  main side effect of inhaled steroids; recommend rinsing or brushing teeth immediately after taking medication; medication doses do not have to be 12 hr apart

Adjustable outpatient care: follow-ups  —  evaluate function, flares, and pharmacy refills; determine severity of sick­ness; ask about school; assess drug techniques; suggest environmental control if necessary; patient satisfaction (provide quality of life forms); physician satisfaction; maintain follow-up every 3 mo; when to refer to asthma specialist  —need for back-up management; perplexing conditions; difficulties with family; need for PFTs or thera­pists to review device techniques with patient; questionable diagnoses

Ladder of long-term care: 1) rescue medication only; 1 canister contains 120 puffs (use of 1 canister per month ex­cessive); 2) low-dose daily inhaled corticosteroid; 3) medium-dose inhaled corticosteroid, or low-dose inhaled cor­ticosteroid with long-acting b-agonist (eg, Advair Diskus, Symbicort); 4) medium-dose inhaled corticosteroid with long-acting b-agonist; most children who present to specialist at this level; need to increase level of care, based on assessment and symptoms; 5) high-dose inhaled corticosteroid with long-acting b-agonist; consultations; 6) addi­tion of oral steroids

Moist cough in asthma: signs of poor control (ie, airway inflammation, smooth muscle hypertrophy, thickened sub­mucosa, mucus gland hypertrophy) accentuated by flares, resulting in bronchospasm; patients who present to ED often hypoxic, with ventilation-perfusion (V/Q) mismatch (need for O₂ indicates inflammation; may appear as atel­ectasis on x-ray); indicates chronicity of inflammation without control; improves with airway clearance in acute setting; medication compliance questionable

Challenge of tobacco smoke: RSV infection 2 times more prevalent in asthma after intrauterine exposure to tobacco smoke; encourage no smoking in house or car; most parents view child's physician visit as “teachable moment” and accept discussion about changes that influence their child's health; important to provide support (eg, tobacco cessa­tion products, referral to support groups, or telephone support)

Conclusion: asthma chronic inflammatory airway disease; long-term compliance needed; newest guidelines thor­ough and emphasize control; care algorithm dynamic; more emphasis on role of early infections (eg, RSV); ongo­ing relationships with families and patients key to effective care; take-home messages  —  seek control (use controller medicines); anti-inflammatory therapies; use written action plans for home and school; patient education important; determine goals of family; avoid asthma underworld; challenge  —  children without access to primary health care continue to have uncontrolled asthma; consider teaming up with local school or ED with willingness to take on small number of patients who do not currently have care for asthma; talk to school nurses and coaches about concern for children with unrecognized asthma; consider providing education sessions

Questions and answers: Advair  —  Advair Diskus dosing, 1 puff bid; available in 3 strengths (all contain 50 μg of sal­meterol, and 100, 250, or 500 μg of fluticasone); labels color-coded (eg, green, yellow, or red) for strength; 2 puffs of Advair HFA match 1 puff of dry powder inhaler; which device to use depends on compliance and appropriate technique; spacer may be helpful in elderly patients; Advair Diskus approved for children ³5 yr of age; Advair HFA approved for children ³10 yr of age (appears safe in younger children); black box warning for long-acting b-agonists  —  study of adults with moderate to severe asthma resulted in excess deaths in patients who received salme­terol alone, compared to combination therapy; increased risk for death when long-acting b-agonist used alone

Suggested Reading

Bisgaard H et al: Budesonide/formoterol maintenance plus reliever therapy: a new strategy in pediatric asthma. Chest 130:1733, 2006; Cazzola M et al: Safety of long-acting beta2-agonists in the treatment of asthma. Ther Adv Respir Dis 1:35, 2007; Currie GP et al: Long-acting beta2-agonists in asthma: not so SMART?. Drug Saf 29:647, 2006; Horner CC et al: Diagnosis and management of asthma in preschool and school-age children: focus on the 2007 NAEPP Guide­lines. Curr Opin Pulm Med 15:52, 2009; James CV et al: Paying for quality care: implications for racial and ethnic health disparities in pediatric asthma. Pediatrics 123 Suppl 3:S205, 2009; Nichols B et al: Detection of undiagnosed and poorly controlled asthma in a hospital-based outpatient pediatric primary care clinic using a health risk assessment sys­tem. J Asthma 46:498, 2009; Szefler SJ: Advances in pediatric asthma in 2008: where do we go now?. J Allergy Clin Immunol 123:28, 2009; Tay ET et al: Nebulizer and spacer device maintenance in children with asthma. J Asthma 46:153, 2009; Wechsler ME et al: Case records of the Massachusetts General Hospital. Case 15-2007. A 20-year-old woman with asthma and cardiorespiratory arrest. N Engl J Med 356:2083, 2007; Weinberger M: Seventeen years of asthma guidelines: why hasn't the outcome improved for children? J Pediatr 154:786, 2009.