S
Asthma in Children
Asthma is no longer considered synonymous with
bronchospasm or constriction. It is an
inflammatory disease in which bronchospasm
occurs secondary to airway inflammation
Andrew Hsi, MD, MPH
Departments of Family and Community Medicine and Pediatrics
9 October 2013
Objectives for Presentation
S Definition of asthma
S Diagnosis of asthma
S Mechanisms of wheezing and asthma
S Health disparities and asthma
S Inpatient care of kids with asthma
S Asthma guidelines and asthma action plans
S When to refer
S Asthma in the primary medical home
What is Asthma?
S Chronic disease of the airways that may cause S Wheezing S Breathlessness S Chest tightness S Nighttime or early morning coughing
S Episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.
S Even with normal breathing, a person has asthma
During an asthma episode:
•The lining of the airways swells and becomes more
inflamed
• Mucus clogs the airways.
• Muscles tighten around the airways.
•These changes narrow the airways until:
breathing becomes difficult and stressful
trying to breathe through a straw stuffed with
cotton.
Pathophysiology of Asthma
Pathology of Asthma
Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma
Created and funded by NIH/NHLBI, 1995
Normal Asthma
Asthma involves
inflammation of
the airways
National Heart, Lung and Blood Institute
Making The Diagnosis;
Symptoms and History
S Wheezing
S High-pitched whistling sounds when breathing out, especially in
children
S (Lack of wheezing and normal findings on chest examination do
not exclude asthma.)
S History of any of the following:
S Cough, worse particularly at night
S Recurrent wheeze
S Recurrent difficulty in breathing
S Recurrent chest tightness
Environmental Factors for
Diagnosis of Asthma
S Symptoms occur or worsen in the presence of the following
S Exercise
S Viral infection
S Animals with fur or hair
S House-dust mites (in mattresses, pillows, upholstered furniture, carpets)
S Mold
S Smoke (tobacco, wood)
S Pollen
S Changes in weather
S Strong emotional expression (laughing or crying hard)
S Airborne chemicals or dusts
S Menstrual cycles
S Symptoms occur or worsen at night, awakening the patient
Wheezing Definitions by
NHLBI
S High-pitched whistling sound made while breathing
S Usually breathing out (expiration)
S Results from narrowed airways
S Often caused by constricted or partially blocked
airways, bronchioles
S May also originate in a larger airway
S The most common cause of recurrent wheezing is
asthma, but there are many other possible causes
of wheezing.
Videos of Wheezing
Case study of child with asthma home visitor; youtube.com/watch?v=QGAg2Ttnwcw
S 4 year old with asthma event in hospital; youtube.com/watch?v=GUkh1EGXvaE
S Sitting baby between breathing treatments; youtube.com/watch?v=OxDj_QaTk44
S Older kid wheezing; www.youtube.com/watch?v=sKi-QwHmB7I
S Baby wheezing; www.youtube.com/watch?v=ZS-PJ9jlpFw
S Sounds of severe asthma inpatient; youtube.com/watch?v=WtMKm9vl_IU
S Kid nebulizer; youtube.com/watch?v=WtMKm9vl_IU
S Teen story with asthma; youtube.com/watch?v=oSgl2hFyP-E
Common Causes of Wheezing
in Children and Infants
S Allergies
S Asthma or reactive airway disease
S Gastroesophageal reflux disease
S Infections
S Bronchiolitis
S Bronchitis
S Pneumonia
S Upper respiratory infection
S Obstructive sleep apnea
Uncommon Causes of Wheezing
S Bronchopulmonary dysplasia
S Foreign body aspiration
Rare Causes of Pediatric Wheezing
S Bronchiolitis obliterans
S Congenital vascular abnormalities
S Congestive heart failure
S Cystic fibrosis
S Immunodeficiency diseases
S Mediastinal masses
S Primary ciliary dyskinesia
S Tracheobronchial anomalies
S Tumor or malignancy
S Vocal cord dysfunction
Risk Factors for Developing Asthma
S Genetic characteristics
S Occupational exposures
S Environmental exposures
Prevalence of Asthma 1980-2007
Children and Adults
0
2
4
6
8
10
12
14
Pre
va
len
ce (
%)
Year
lifetime
current
12-month
Pink line = pediatric
Blue line = adult
0
2
4
6
8
10
12
14
16
18
Pre
va
len
ce
(%
)
Year
Prevalence by Race and
Ethnicity 1997-2008
▲ Black NH
White NH
Hispanic
Attack Rate
Lifetime
Current disease
Asthma and Health Disparities
S Prevalence in children 8700 per 100,000
S Only ADHD at 9000 per 100,000 has higher prevalence
S By race and ethnicity
S 12.7% in non-Hispanic black children
S 19.2% in Puerto Rican children
S 8.0% in non-Hispanic white children
S Outcomes significantly disparate compared to white children
S Non-Hispanic black children were 2.6 times more likely to have an emergency department visit,
S 2.0 times more likely to be admitted to the hospital, and
S Almost 5.0 times more likely to die of asthma
Risk Factors for Developing Asthma:
Genetic Characteristics
Atopy
S Predisposition to develop IgE to exposure to
environmental allergens
S Can be measured in the blood
S Includes clinical conditions
S Allergic rhinitis,
S Asthma, and
S Eczema
S Clinical triad for allergic reactivity
Risk Factors for Developing Asthma:
Environmental Exposure
Clearing the Air:
Asthma and Indoor Air Exposures
http://www.iom.edu (Publications)
Institute of Medicine, 2000
Committee on the Assessment of Asthma and Indoor Air
Review of current evidence about indoor air exposures and asthma
Clearing the Air:
Categories for Associations of Various Elements
1. Sufficient evidence of a causal relationship
2. Sufficient evidence of an association
3. Limited or suggested evidence of an association
4. Inadequate or insufficient evidence to determine whether an association exists
5. Limited or suggestive evidence of no association
Clearing the Air:
Indoor Air Exposures & Asthma Development
Biological Agents
S Sufficient evidence of causal
relationship
S House dust mite
S Sufficient evidence of association
S None found
S Limited or suggestive evidence of
association
S Cockroach (among pre-school
aged children)
S Respiratory syncytial virus
(RSV))
Chemical Agents
S Sufficient evidence of causal relationship
S None found
S Sufficient evidence of association
S Environmental Tobacco Smoke (among pre-school aged children)
S Limited or suggestive evidence of association
S None found
Clearing the Air:
Indoor Air Exposures & Asthma Exacerbation
Biological Agents
S Sufficient evidence of causal
relationship
S Cat
S Cockroach
S House dust mite
S Sufficient evidence of an association
S Dog
S Fungus/Molds
S Rhinovirus
S Limited or suggestive evidence of
association
S Domestic birds
S Chlamydia and Mycoplasma
pneumonia
S RSV
Chemical Agents
S Sufficient evidence of causal relationship
S Environmental tobacco smoke (among pre-school aged children)
S Sufficient evidence of association
S NO2, NOX (high levels)
S Limited or suggestive evidence of association
S Environmental Tobacco Smoke (among school-aged, older children, and adults)
S Formaldehyde
S Fragrances
Current State of Guidelines
S 4 major guidelines for management of asthma in young
children
S EPR3 of the National Asthma Education Program (NAEPP)
S PRACTALL Consensus Report by the European Academy of
Asthma and Allergy in 2008
S Evidence Based Approach by European Respiratory Society
task force, published in the European Respiratory Journal in
2008 and
S Global Initiative (GINA) for diagnosis and management of
asthma in children <5 in 2009 (www.ginasthma.org)
EPR3 (see references)
S National Asthma Education and Prevention Program (NAEPP)
S Expert Panel Report 3 [EPR3]
S Shifted focus of efforts to:
S Ongoing assessment of disease control with
S Goal of improving the management of asthma over time
S Context in current clinical practice
S Many patients overestimate their level of disease control
S Physicians have a tendency to underestimate the prevalence of asthma symptoms and to overestimate the degree to which their patients’ asthma is controlled
Classification of Asthma
SBased on severity of disease
SSymptom presentation
SSeverity is the intrinsic intensity of disease
How to Classify Asthma Severity
S BEFORE therapy is started
S Classify according to clinical features
S Includes domains of current impairment and
future risk
S Helps guide clinical decisions on appropriate
medication selection
Domains for Classification
S Impairment
S Frequency and intensity of symptoms
S Functional limitations the patient is experiencing
S Future Risk
S Likelihood of;
S Asthma exacerbations,
S Decreased lung growth and development in kids,
S Progressive decline in lung function, or
S Medication adverse effects
Guidelines and Asthma
Classification
S Severity of asthma guides intervention
S Step wise approach to medication use
S Guide for increasing medications and monitoring progress
S Guide for referral for pulmonary testing and consultant
S Not guide for inpatient management
Stepped Approach to Meds
Step 2:
Preferred Daily
Inhaled
Corticosteroid
(ICS) (low dose)
and SABA as
needed
Step 3:
Preferred:
Low-dose
ICS + Long Acting
Beta Agonist (LABA)
OR
Medium-dose ICS
Alternative:
Low-dose ICS +
Leukotriene Receptor
Antagonists (LTRA),
theophylline, or
zileuton
Step 4:
Preferred:
Medium-dose
ICS + LABA
Alternative:
Medium-dose
ICS + LTRA,
theophylline, or
zileuton
Intermittent Mild
Persistent
Severe
Persistent Moderate
Persistent
Highest Medication Levels
Step 5:
Preferred:
high-dose
ICS + LABA
AND
Consider
omalizumab for
patients with
allergies
Step 6:
Preferred:
high-dose
ICS + LABA+
oral
corticosteroid
AND
Consider
omalizumab for
patients with
allergies
Severe Persistent
Videos for Inhaler and
Nebulizer Use
S Instructions for spacer;
youtube.com/watch?v=ma_cmlU9DxU
S Nebulizer demonstration with little girl;
youtube.com/watch?v=KCALJSjGZNc
S Kid in hospital bed nebulizer;
youtube.com/watch?v=e60ewaY8OhU&list=PL1E435A84
54F79937&index=3
Intermittent Asthma
S • Impairment
S Intermittent symptoms ≤ 2 times/week
S Nighttime symptoms ≤ 2 times/month
S Short acting β2 agonist (SABA) use ≤ 2 days/week
S No interference with normal activity
S Forced expiratory volume in one second (FEV1) > 80%
predicted
S Normal lung function between exacerbations
S Risk
S One or fewer exacerbations per year
Mild Persistent Asthma
S Impairment
S Symptoms > 2 days/week but not daily
S Nighttime symptoms 3-4 times/month
S SABA use is > 2 days/week but not > 1x/day
S Minor interference with daily activities
S FEV1 > 80% predicted
S Risk
S 2 or more exacerbations/year
Moderate Persistent Asthma
S Impairment
S Daily symptoms
S Nighttime symptoms > 1 time/week but not
every night
S Daily use of SABA required
S Some limitation of usual activities
S FEV1 > 60%, but < 80% predicted value
S Risk
S 2 or more exacerbations/year
Severe Persistent Asthma
S Impairment
S Symptoms throughout the day
S Nighttime asthma symptoms often 7x/week
S SABA use several times per day
S Physical activity extremely limited by asthma
symptoms
S FEV1 < 60% predicted
S Risk
S 2 or more exacerbations/year
Managing Asthma:
Asthma Management Goals
S Achieve and maintain control of symptoms
S Maintain normal activity levels, including exercise
S Maintain pulmonary function as close to normal levels as possible
S Prevent asthma exacerbations
S Avoid adverse effects from asthma medications
S Theoretical; no inhibition of lung growth and development
S Prevent asthma mortality
Managing Asthma:
Asthma Action Plan
S Develop with a physician
S Tailor to meet individual needs
S Educate patients and families about all aspects of plan
S Recognizing symptoms
S Medication benefits and side effects
S Proper use of inhalers and Peak Expiratory Flow (PEF) meters
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.
Case History: Emergent Patient
Management
S Kid on nebulizer before transport to hospital;
youtube.com/watch?v=yX3bRFg_J6E
S Kid inpatient with asthma;
youtube.com/watch?v=oSgl2hFyP-E
S Kid with attack after hospital neb;
youtube.com/watch?v=EY8U6JDuIZk
Managing Asthma:
Indications of a Severe Attack
S Breathless at rest
S Hunched forward
S Speaks in words rather than complete
sentences
S Agitated
S Peak flow rate less than 60% of normal
Inpatient Asthma Management
S Admission for children who
S Require beta 2-agonist therapy more often than Q2-3 hours,
S Have not improved after dose of systemic glucocorticoids, or
S Require supplemental oxygen
S Other considerations
S A history of rapid progression of severity in past exacerbations
S Poor adherence with outpatient medication regimen
S Inadequate access to medical care
S Poor social support system at home
Therapies Initiated
S Oxygen administered
S Systemic steroids
S Albuterol nebulized (5 mg is a reasonable dose to start)
S Neb treatment every 20-30 minutes for initial stabilization
S Planning for discharge at admission
S Assess patient's and family's understanding of asthma
S signs and symptoms,
S Triggers,
S Medications,
S Assess understanding of use of equipment for medications
Albuterol Treatments
S Continuously or intermittently; albuterol, salbutamol
S Via nebulizer or metered dose-inhaler (MDI) with spacer)
S Moderate exacerbations treated every 1 to 3 hours
S Doses commonly given; works better with patient sitting up
S 2.5 mg for weight < 30 kg
S 5 mg > 30 kg
S 4 to 8 puffs by metered dose inhaler with mask and spacer
S Young children using mask may not get full dose
S Repeat assessment frequently, every 20 minutes
Frequent Assessments
S Respiratory rate; refer to age norms
S Accessory muscle use; suprasternal, subcostal
S Air exchange; amplitude of inspiratory sounds
S Wheezing; more attention to inspiration
S Inspiratory to expiratory ratio; want <1:3
S Pulse oximetry; saturation above 85%
S Monitor pulse rate for side effects
Continuous SABA
S No improvement after several hours
S Needing treatments more than every 3 hours
S Dosing at
S 0.5 mg/kg per hour for children
S 10-15 mg per hour for adults (clinical decision for adolescents)
S ICU transfer for failure to respond: increasing fatigue,
increasing work of breathing, carbon dioxide retention by
blood gas level, or worsening hypoxemia
Continuous Assessment
S Switch to every 2 to 3 hour nebs with improved signs
S Daily labs; K, Mg, Phosphate
S Decreases reported on continuous treatment
S Significant for patients with concurrent CV disease, diuretic use
S Frequent assessment clinically
S Can patient carry on a conversation?
Steroid Treatment
S Relative contraindications: active herpes, varicella, hypersensitivity
S Medication choices; oral better than IV if child can swallow
S Prednisone, prednisolone, methylprednisolone
S 1 mg/kg every 12 hours for a total of five days
S 7-10 days for persons with past severe exacerbations
S Prednisolone liquid 15mg/5 mL tastes better to kids
S Inhaled not as effective in kids
Use of Oxygen
S Pulse oximetry or blood gas
S Not risk of CO2 retention in kids generally
S Humidified by mask or nasal cannula
S Either method maximum delivery about 40%
S Albuterol treatments may cause O2 sat drops initially
S Increased blood flow to poorly ventilated areas of lungs, bases
S Regional atalectasis from obstructed airways
S Goal to keep sats above 94% (90% at altitude?)
Other Medications
S Ipratropium bromide not recommended as standard therapy
S Theophyllines IV reserved for status asthmaticus
S Leukotriene Receptor Antagonists (LTRA)
S Not studied in hospitalized treatment
S Can hold doses until patient discharged
S Mag Sulfate; reserved for ICU management
S Antibiotics; not standard therapy
Working to Discharge
S Pulmonary consult; probably standard here
S Discharge planner to review financial status
S Asthma symptoms mild; clinical or by score system
S No oxygen need
S Treatments can be given at home, frequency of treatments
S Family has medication and knows how to use
S SABA; albuterol nebs or inhaler 4-6 puffs every 4 to 6 hours
S Oral steroids if hasn’t completed course inpatient
S Follow up scheduled in 2 to 5 days; preferable continuity of care
Asthma Action Plan
S Elements of plan
S Daily medications and the time(s) of day they are to be taken.
S Rescue medication
S Description of the symptoms for which they should be taken
S Frequency of use
S The phone number to call for questions.
S List of triggers that may exacerbate their asthma to avoid
S Primary care follow up and appointment
Referral to Specialist
S Pulmonary or Allergy Immunology
S Considered for any patient
S Asthma is difficult to control,
S Patients without good control on ICS and long acting beta agonist
S Considered for therapy with omalizumab
S Allergy testing for environmental of food triggers
S Desensitization therapy?
Asthma in Med Home
S Clinical quality measure
S UH Pediatric clinic model
S Diagnosis of asthma from chart review (medication)
S Use of Asthma Control Questions
S Assesses function in daily life including sleep interruption
S Frequency of medication use
S Score > 20 represents good control
S Should be given to family at every visit
Cycle for Management
S Assess and monitor asthma control
S Review medication use and techniques and adherence
S Review environmental trigger exposure
S Assess side effects
S Adjust medications; refill, step up, or decrease
S Review asthma action plan, revise as needed
S Schedule next appointment
S Continuity, continuity, continuity; hard to do in “med home”
What Are These?