Asthma in Children

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Asthma in Children

• October 29, 2002
• Swedish Family Medicine
• Jorge Garcia, MD

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Case 1 Naomi J.
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CASE 1 An 7-year old girl has just moved into
town and presents to her doctor. She has history
of wheezing and rhinitis and recurrent otitis
media since infancy. Over the past 2 years her
symptoms have worsened. She complains of coughing
and SOB daily and claims to awaken at least once
a week in the middle of the night by these
symptoms.
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Her family history consists of maternal asthma,
and atopy in both parents. Physical exam finds
inflamed nose, mild wheezing, otherwise
unremarkable. The patient's mother states that
her daughter was previously prescribed an
albuterol puffer to use prn, which her daughter
uses daily and requires monthly refills. The
child is able to remain active. In the past year
she has had 4 courses of prednisone.
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According to the above information How would
you classify this patient's severity?Mild
intermittent Mild persistent Moderate
persistent Severe persistent
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Diagnosis of Asthma Severity Diagnosis Days
w/Sx Nights w/Sx PEF (Step) ( personal
best) or FEV2
predicted best) severe
persistent(4) Continual Frequent lt60 modera
te persistent(3) Daily gt5 / month 60-80 mild
persistent (2) gt2/wk 3 to 4 / month gt80 mild
intermittent (1) lt2 /wk lt2 per month gt80
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What makes you think this is

• ASTHMA?

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SUSPECT ASTHMA WITH

• Intermittent wheezing, cough, dyspnea.
• Increased rate of breathing.
• Sx worse at night and in early morning.
• Associated with triggers.
• Onset before age 5. (80)

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What is your differential?
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Wheezing can be caused by

• URIs
• Rhinitis
• Sinusitis
• CF
• Cardiac disease
• GERD
• Foreign body aspiration...

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Workup?

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New Asthma Dx

• Confirm with PFT
• Consider Allergy testing if the child also has
  significant allergic rhinitis.

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With the diagnosis of Asthma

• What are the findings on PFT?

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PFT

• Increase in forced expiratory volume in one
  second (FEV1) of 12 percent or more after
  bronchodilator therapy.
• variable airflow obstruction (20 percent or more)
  with serial spirometry or peak expiratory flow
  (PEF).
• Not reliable in kids lt3-4.

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CASE 1 Naomi J. An 7-year old girl has just
moved into town and presents to her doctor. She
has history of wheezing and rhinitis and
recurrent otitis and sinusitis since infancy.
Over the past 2 years her symptoms have worsened.
She complains of coughing and SOB daily and
claims to awaken at least once a week in the
middle of the night by these symptoms.
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Her family history consists of maternal asthma,
and atopy in both parents. Physical exam finds
inflamed nose, mild wheezing, otherwise
unremarkable. The patient's mother states that
her daughter was previously prescribed an
albuterol puffer to use prn, which her daughter
uses daily and requires monthly refills, but the
patient is able to remain active. In the past
year she has had 4 courses of prednisone.
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What more would you want to know about your
patient?

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Obtain a history to rule out triggers

• What are some possible triggers of RAD?

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Obtain a history to rule out triggers.

• What are some possible triggers of RAD?

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dust mites and mold spores, pollen animal dander,
cockroaches, indoor and outdoor pollutants,
irritants (e.g., tobacco smoke, smoke from
wood-burning stoves or fireplaces, perfumes,
cleaning agents), pharmacologic triggers (e.g.,
aspirin or other nonsteroidal anti-inflammatory
drugs, beta blockers and sulfites), physical
triggers (e.g., exercise, hyperventilation, cold
air) physiologic factors (e.g., stress,
gastroesophageal reflux, respiratory infection
viral, bacterial and rhinitis). Kitchen sink.
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What is the best way to treat her today?

• ?

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Treatment of children with asthma should begin
with the most aggressive therapy necessary to
achieve control, followed by "stepping down" to
the minimal therapy that will maintain control.
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Moderate Persistent Asthma (Step 3)

• High dose corticosteroid inhaler daily.
• Long acting daily bronchodilators.
• Short acting bronchodilator for symptoms.

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Asthma treatment by severity

• Step 1 mild, intermittent
• days with symptoms lt2 times per week
• nights with symptoms lt2 per month
• PEFgt80 predicted.

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Asthma treatment by severityStep 1 mild,
intermittent

• No daily preventive meds needed treat symptoms
  only.
• Treatment should be required no more than 2/week.
• Short acting beta-2 agonist Albuterol MDI with
  face mask or spacer.
• Cost 30-50/ canister.

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Step one

• One inhaler...

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Asthma treatment by severityStep 2 mild,
persistent

• Days with symptoms gt2 times per week
• Nights with symptoms gt2 per month but less than
  5 times/month.
• percent predicted PEF gt80.

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Asthma treatment by severityStep 2 mild,
persistent

• Daily anti-inflammatory medications
• Cromolyn (Intal) inhaler 47.00 Nedocromil
  (Tilade) inhaler 36.00
• or Low- to medium dose inhaled corticosteroid
  range of prices Budesonide (Pulmicort
  Turbuhaler DPI), 200 µg per puff 19.00 to
  Fluticasone (Flovent), 44 µg per puff 47.00
  (13-g canister)

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Asthma treatment by severityStep 2 mild,
persistent

• Short-acting bronchodilator as needed for
  symptoms. Intensity of treatment depends on
  severity of exacerbation
• Inhaled short-acting beta2 agonist by nebulizer
  or spacer/holding chamber and face maskor Oral
  beta2 agonist.

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Step two

• Two inhalers...

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Treatment of Asthma by severity Moderate
Persistent Asthma (Step 3)

• Day time symptomsDaily
• Night time symptomsgt5 times per month
• PEF gt60 to lt80

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Treatment of Asthma by severity Moderate
Persistent Asthma (Step 3)

• High dose corticosteroid inhaler daily.
• Long acting daily bronchodilators.
• Short acting bronchodilator for symptoms.

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Step 3

• Rx with?

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Step 3

• 3 inhalers...

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High dose corticosteroid inhaler daily.

• Beclomethasone (Vanceril DS MDI), 84 µg per puff
  42.00
• Fluticasone (Flovent 220 µg per puff 95.50
• Reduce to lower dose once symptoms controlled.

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Long acting daily bronchodilators.

• Salmeterol (Serevent MDI) 42.00 (Serevent Diskus
  DPI) 43.50
• Short acting bronchodilators for rescue only
  Albuterol.

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Step 4 Severe and persistent Sx

• Days with symptoms Continual
• nights with symptoms Frequent
• PEF lt60 predicted.

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Treatment of step 4?
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Usually add oral pred to Step 3 medications.

• Treatment can be variable in step 4.

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Step 4 severe, persistent

• Daily anti-inflammatory medications
• High-dose inhaled corticosteroid with spacer/
  holding chamber and face maskand
• If needed, add systemic corticosteroids (0.25 to
  2 mg per kg per day) and reduce to lowest daily
  or alternate-day dosage that stabilizes symptoms.

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What is the role of Antileukotrienes ?

• In patients with chronic asthma who are
  symptomatic while receiving moderate-to-high
  doses of inhaled beclomethasone, the addition of
  2 to 4 times the licensed dose of antileukotriene
  (AL) agents reduces the rate of exacerbations
  that require systemic corticosteroids.
  Insufficient evidence exists that AL confers
  benefit over doubling the dose of corticosteroids
  or that it has an inhaled corticosteroid-sparing
  effect.
• Cochrane Database Syst Rev. 2002(1)CD003133

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What is the role of Antileukotrienes ?

• They are new drugs, and expensive.
• The doses that seem to work are higher than
  marketed recommendations.
• They may help in Step 3 and 4, to reduce
  exacerbations, and reduce need to increase dose
  of inhaled steroids.
• No worrisome side effectsyet.

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Home severity monitoring may help keep kids out
of the hospital.

• First, determine their Personal Best
• Ask them to check PF a few times each day, for
  two weeks, when asthma in good control.

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Write out the PF Color Zones

• PF lt50 Red Zone
• PF 50-80 Yellow Zone
• PFgt 80 Green Zone

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Green Zone PF gt 80 of personal best.

• No symptoms at all.
• Good Control.
• Continue taking regular medications.

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Yellow Zone PF 50-80

• CAUTION! Need rescue meds
• Use short acting Beta-2 agonist (Albuterol MDI or
  nebulizer).
• Consider increasing dose of medication.
• Monitor PF more frequently.

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Red Zone PF lt 50

• Use Short Acting beta-2 Agonist Albuterol.
• Call doctors office, or seek medical attention.

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Kids die of Asthma.

• Mortality rate increasing.

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Who is at risk of dying of asthma?

• Severe disease 1-2 of these kids will die of
  asthma.
• Hx prior hospitalization, steroid need.
• Symptoms triggered by foods.
• Self weaning, esp. off steroids.
• Lack of parental care.
• Poor, African-American, boys.

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Howeverin large study of asthma deaths

• 33 had mild asthma.
• 34 had no prior hospitalization.
• A minority of patients (15-30) die suddenly,
  within two hours of onset of dyspnea.

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When assessing a sick asthmatic

• If they are unable to lie down, the severity is
  moderate of great, and they will need more
  aggressive work up and treatment.

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The end.