Danielle Gilliam M.D., PGY IIIUniversity of South Alabama

Pediatrics 2011

Most common childhood chronic disorder Increase in incidence by 50 % over the

last two decades In 2007, 9% of children 0 to 17 years of

age (6.7 million children) had asthma, according to data from the National Health Interview Survey.

The cost of illness related to asthma is around $6.2 billion per year in the United States.

Each year, an estimated 1.81 million people with asthma require treatment in the emergency department with approximately 500,000 hospitalizations

Family Hx of asthma Prematurity Race ( African and Native Americans ) Low socioeconomic settings Urban settings ( pollutants ) Increased indoor irritants ( cigarette

smoke, dust mites, pets, recycled air ) History of Atopy ( eczema, allergies and

chronic rhinitis / sinusitis )

Cough ( mostly dry and hacking, specially at night ), Wheezing ( mainly expiratory) Shortness of Breath Chest Pain

Precipitating factors [(URIs mostly viral occasionally atypical pneumonia. Bacterial causes very rare)], exercise, cold weather, allergens, cigarette smoke)

Increased AP diameter of the chest with hyperinflation

A silent chest is a medical emergency

Detailed history of the symptoms Physical exam Spirometry with reduced FEV1 < 80 % and FEV/FVC <

65 % indicative of airflow obstruction ( children in which spirometry is not possible a trial of

asthma meds should be done if indicated by other sxs )

Ancilliary studies ( bronchoprovocative testing, CXR, sweat chloride test, barium swallow and skin testing)

Asthma Bronchiolitis (esp in infants), bronchitis,

laryngotracheobronchitis, tracheitis Foreign body aspiration Functional abnormalities ( GERD, CF, BPD,

immunodeficiency etc ) Structural abnormalities ( laryngo-

tracheomalacia, vascular rings, tracheal stenosis / webs, tumors etc )

Assessment of impairment

– Has your asthma awakened you at night or in the early morning?

– Have you needed your quick-acting relief medication more than usual?

– Have you needed any unscheduled care for your asthma, including calling in, an office visit, or going to the emergency room?

– Have you been able to participate in school/work and recreational activities as desired?

Classifying asthma severity and initiating treatment in children 0-4 years of age

Classification of asthma severity (0-4 years of age)

Persistent Components of severity Intermittent

Mild Moderate Severe

Symptoms 2

days/week >2 days/week but not daily Daily Throughout the day

Nighttime awakenings 0 1-2x/month 3-4x/month >1x/week

Short-acting beta2-agonist use for symptom control (not prevention of EIB)

2 days/week

>2 days/week but not daily Daily Several times per day

Impairment

Interference with normal activity None Minor limitation Some limitation Extremely limited

0-1/ year 2 exacerbations in 6 months requiring oral systemic corticosteroids, or 4 wheezing episodes/ 1 year lasting >1 day AND risk factors for

persistent asthma

Consider severity and interval since last exacerbation

Frequency and severity may fluctuate over time

Risk Exacerbations requiring oral systemic corticosteroids

Exacerbations of any severity may occur in patients in any severity category.

Step 1 Step 2 Step 3 and consider short course of oral systemic corticosteroids

Recommended step for initiating treatment

In 2-6 weeks, depending on severity, evaluate level of asthma control that is achieved. I f no clear benefit is observed in 4-6 weeks, consider adjusting therapy or alternative diagnoses.

Assessing asthma control and adjusting therapy in children 0-4 years of age Classification of asthma control (0-4 years of age)

Components of control Well-controlled Not-well controlled Very poorly controlled

Symptoms 2 days/week >2 days/week Throughout the day

Nighttime awakenings 1x/month >1x/month >1x/week

Interference with normal activity None Some limitation Extremely limited Impairment Short-acting beta2-agonist use for symptom control (not prevention of EIB)

2 days/week >2 days/week Several times per day

Exacerbations requiring oral systemic corticosteroids

0-1/ year 2-3/ year >3/ year

Risk

Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.

Recommended action for treatment

Maintain current treatment.

Regular followups every

1-6 months.

Consider step down if

well controlled for at least 3 months.

Step up (1 step) and

Reevaluate in 2-6 weeks.

I f no clear benefit in 4-6 weeks, consider alternative diagnoses or

adjusting therapy.

For side effects, consider

alternative treatment options.

Consider short course of oral systemic corticosteroids,

Step up (1-2 steps), and

Reevaluate in 2 weeks.

I f no clear benefit in 4-6 weeks, consider alternative diagnoses or

adjusting therapy.

For side effects, consider

alternative treatment options.

Classifying asthma severity and initiating treatment in children 5-11 years of age Classification of asthma severity (5-11 years of age)

Persistent Components of severity Intermittent

Mild Moderate Severe

Symptoms 2 days/week >2 days/week but not daily

Daily Throughout the day

Nighttime awakenings 2x/month 3-4x/month >1x/week but not nightly

Often 7x/week

Short-acting beta2-agonist use for symptom control (not prevention of EIB)

2 days/week >2 days/week but not daily

Daily Several times per day

Interference with normal activity None Minor limitation Some limitation Extremely limited Impairment

Lung function

Normal FEV1 between exacerbations

FEV1 >80 percent predicted

FEV1/FVC >85 percent

FEV1 = >80 percent predicted

FEV1/FVC >80 percent

FEV1 = 60-80 percent predicted

FEV1/FVC = 75-80 percent

FEV1 <60 percent predicted

FEV1/FVC <75 percent

0-1/ year (see footnote)

2/ year (see footnote)

Consider severity and interval since last exacerbation

Frequency and severity may fluctuate over time for patients in any severity category

Risk

Exacerbations requiring oral systemic corticosteroids

Relative annual risk of exacerbations may be related to FEV1

Step 3, medium dose ICS option

Step 3, medium dose ICS option, or step 4

Step 1 Step 2

And consider short course of oral systemic corticosteroids

Recommended step for initiating treatment

In 2-6 weeks, evaluate level of asthma control that is achieved, and adjust therapy accordingly.

Assessing asthma control and adjusting therapy in children 5-11 years of age Classification of asthma control (5-11 years of age)

Components of control Well-controlled Not-well controlled Very poorly controlled

Symptoms 2 days/week but not more than

once on each day >2 days/week or multiple times on 2 days/week

Throughout the day

Nighttime awakenings 1x/month 2x/month 2x/week

Interference with normal activity

None Some limitation Extremely limited

Short-acting beta2-agonist use for symptom control (not prevention of EIB)

2 days/week >2 days/week Several times per day

Lung function

Impairment

FEV1 or peak flow

FEV1/FVC

>80 percent predicted/personal best

>80 percent

60-80 percent predicted/personal best

75-80 percent

<60 percent predicted/personal best

<75 percent

0-1/ year 2/ year (see footnote) Exacerbations requiring oral systemic corticosteroids Consider severity and interval since last exacerbation

Reduction in lung growth Evaluation requires long-term followup Risk

Treatment-related adverse effects

Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.

Recommended action for treatment

Maintain current step.

Regular followup every 1-6

months.

Consider step down if well

controlled for at least 3 months.

Step up at least 1 step and

Reevaluate in 2-6 weeks.

For side effects, consider alternative treatment options.

Consider short course of oral systemic corticosteroids,

Step up 1-2 steps, and

Reevaluate in 2 weeks.

Classifying asthma severity and initiating treatment in youths greater than or equal to 12 years of age and adults

Classification of asthma severity ( 12 years of age)

Persistent Components of severity Intermittent

Mild Moderate Severe

Symptoms 2 days/week >2 days/week but not daily Daily Throughout the day

Nighttime awakenings 2x/month 3-4x/month >1x/week but not nightly

Often 7x/week

Short-acting beta2-agonist use for symptom control (not prevention of EIB)

2 days/week >2 days/week but not daily, and not more than 1x on any day

Daily Several times per day

Interference with normal activity None Minor limitation Some limitation Extremely limited

Impairment

Normal FEV1/FVC:

8-19 yr 85 percent

20-39 yr 80 percent

40-59 yr 75 percent

60-80 yr 70 percent

Lung function

Normal FEV1 between exacerbations

FEV1 >80 percent predicted

FEV1/FVC normal

FEV1 80 percent predicted

FEV1/FVC normal

FEV1 >60 but <80 percent predicted

FEV1/FVC reduced 5 percent

FEV1 <60 percent predicted

FEV1/FVC reduced >5 percent

0-1/ year (see footnote)

2/ year (see footnote)

Consider severity and interval since last exacerbation

Frequency and severity may fluctuate over time for patients in any severity category

Risk

Exacerbations requiring oral systemic corticosteroids

Relative annual risk of exacerbations may be related to FEV1

Step 3 Step 4 or 5 Recommended step for initiating treatment Step 1 Step 2

And consider short course of oral

In 2-6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly.

Assessing asthma control and adjusting therapy in youths greater than or equal to 12 years of age and adults

Classification of asthma control ( 12 years of age) Components of control

Well-controlled Not-well controlled Very poorly controlled

Symptoms 2 days/week >2 days/week Throughout the day

Nighttime awakenings 2x/month 1-3x/week 4x/week

Interference with normal activity

None Some limitation Extremely limited

Short-acting beta2-agonist use for symptom control (not prevention of EIB)

2 days/week >2 days/week Several times per day

FEV1 or peak flow >80 percent predicted/personal best 60-80 percent predicted/personal best

<60 percent predicted/personal best

Validated questionnaires

ATAQ 0 1-2 3-4

ACQ 0.75* 1.5 N/A

Impairment

ACT 20 16-19 15

0-1/ year 2/ year (see footnote) Exacerbations requiring oral systemic corticosteroids Consider severity and interval since last exacerbation

Progressive loss of lung function

Evaluation requires long-term followup care Risk

Treatment-related adverse effects

Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.

Recommended action for treatment

Maintain current step.

Regular followups every 1-6

months to maintain control.

Consider step down if well

controlled for at least 3 months.

Step up 1 step and

Reevaluate in 2-6 weeks.

For side effects, consider

alternative treatment

Avoidance of risk factors Exercise induced bronchospasm : short acting beta

agonists ( albuterol ) 10-15 min prior to activity Intermittent : Rescue albuterol treatments as needed,

systemic corticosteroids reserved for severe exacerbation Mild Persistent : Low dose inhaled corticosteroids (ICS)

(e.g. Pulmicort, Asmanex, Flovent, QVAR) Moderate persistent : Low to medium dose ICS and

either a long acting beta agonists ( Foradil, Serevent ) or a leukotriene modifier ( Singulair )

Severe Persistent : High dose ICS and a long acting beta agonist

. Advair ( Fluticasone + Salmeterol )

Controller medications:◦ Inhaled corticosteroids, ◦ Inhaled cromolyn or nedocromil, ◦ Long-acting bronchodilators (Salmeterol), ◦ Leukotriene antagonists (Montelukast)

Rescue medications:Short-acting bronchodilators, Systemic corticosteroidsInhaled ipratropium or atrovent

Inhaled Corticosteroidsdirect, local, anti-inflammatory effect, low systemic activity

reduce bronchial hyper-resposiveness to allergensDrugs Product Availability

Beclomethasone

MDI (QVAR)

40 mcg to 80mcg/ inh

Fluticasone HFA MDI

(Flovent)

44 mcg, 110 mcg, 220 mcg/inh

50 mcg, 100 mcg, 250 mcg/inh

Mometasone DPI

(Ventolin)

110 mcg, 220 mcg/inh

COMBOS

Fluticasone + Salmeterol (Advair)

Diskus (all have 50 mcg salmet)

HFA (all have 21 mcg salmet)

100/50, 250/50, 500/50 mcg/inh

45/21, 115/21, 230/21

Budesonide + Formoterol

(Symbicort)

HFA and MDI

80/4.5 mcg, 160/4.5 mcg

Side Effects: Common= couph, dysphonia, oral candidiasis, upper RTI, throat irritationSerious= decreased growth velocity in children, HPA suppresion, reduced bone mineral density, cataracts (dose and duration dependent)Combo meds= above +Headache, dizziness, palpitations, tremor

Evaluate treatments every 2-3 months and step down as appropriate or go up on the dose of ICS for recurrent exacerbations

ICS and long acting beta agonists have proven better efficacy compared to alternative treatments ( leukotriene modifiers, cromolyn. theophylline )

Studies have shown MDIs with spacers to be more efficacious and practical than nebulizers in routine application

Asthma exacerbation is a medical emergency. Don’t delay evaluation and treatment.

1) Early/Immediate Phase : characterized by bronchoconstriction.

2) Late Phase (6-8 hours) : airway inflammation and hyper-responsiveness

Management should emphasize◦ 1) Initial stabilization ◦ 2) progressive monitoring and treatment ◦ 3)eventually discharge planning

O2 to keep sats >92%

Bronchodilators :

Beta Agonist (Albuterol) : via nebulizer Q 15-20 minutes times three then Q2 twice if needed and then Q4-6 hrs ATC/PRN

If needed more frequently PICU admisision Ipratropium ( Atrovent ) via nebulizer may be given

with the first three albuterol treatments then Q4-8 ATC/PRN

Levalbuterol ( Xopenex ) : selective beta 2 agonist. Not routinely used. Good alternative for continuous therapy if side effects from albuterol experienced

Start Corticosteroids if;◦ No response after one nebulised t/t◦ Patient is steroid dependent ◦ Has had a recent ER visit for asthma◦ Previous admission to ICU

Steroid PO (Prednisolone 2mg/k/d) or Steroid IV (Solumedrol 2mg/k IV/IM bolus then 1-2mg/k/d divided Q6) x 3-10 days

If greater than 5 day course, will need to wean

Continuous Albuterol Magnesium Sulfate (IV) IV Terbutaline or Epinephrine Ketamine Intubation for respiratory failure Heliox Solumedrol IV

Use of ketamine in acute severe asthma V. J. Sarma 30 DEC 2008

Randomized, Double-Blind, Placebo-Controlled Trial of Intravenous Ketamine in Acute Asthma, Joseph C Howton MD, John Rose MD, Scott Duffy MD, Tom Zoltanski and M.Andrew Levitt DO

28 November 1994;  

Wean oxygen as tolerated Advance diet as tolerated and wean IVF

accordingly Social services consult : home nebulizer,

supplies, insurance issues Respiratory Consult : teaching nebulizer / MDI

treatments Prescribe controller meds according to

classification Finish course of antibiotics and steroids F/U with pediatrician: two to three days