WHEEZING, SNEEZING, AND DIFFICULT BREATHING
| ASTHMA IN CHILDREN AND ADOLESCENTS— Thomas G. Irons, MD, Professor of Pediatrics, Brody School
of Medicine, East Carolina University, Greenville, NC
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| 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)
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| 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
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| 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
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| 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; gastro-esophageal reflux disease (GERD; no evidence that treatment
of GERD improves asthma); viral illness; provide influenza vaccine
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| Treatment: inhaled anti-inflammatory 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)
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| Inhaled anti-inflammatory 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
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| 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 (reevaluate patients who use >1 canister per month)
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| 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
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| 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
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| ALLERGIC RHINITIS —Harold H. Hedges III, MD, Associate Clinical Professor, Department of Family Medicine,
University of Arkansas School of Medicine, Little Rock
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| 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
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| 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
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| 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
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| Signs of allergic rhinitis in children: nasal symptoms; chronic fatigue; Morgan’s line (Dennie’s sign); nasal
crease; nasal voice; irritability; poor appetite
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| 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
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| 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
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| 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
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| Diseases associated with rhinitis: asthma (treating sinusitis helps control asthma); otitis media with effusion; upper
respiratory infections; polyposis
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| 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
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| 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
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| 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
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| 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
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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.
Educational Objectives
| The goal of this program is to improve management of asthma in children and adolescents, as well as allergic rhinitis.
After hearing and assimilating this program, the participant will be better able to:
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 | 1. Classify severity of asthma in children.
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| 2. Select appropriate treatment for asthma, based on severity and clinical findings.
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| 3. Distinguish allergic rhinitis from nonallergic rhinitis.
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| 4. Select patients with allergies who may benefit from immunotherapy.
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| 5. Administer appropriate tests to identify and manage allergies.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members 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, 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.
Acknowledgements
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.
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