Transcript Slide 1

Managing the Child with Asthma:
Don’t Forget Environmental Controls
James R. Roberts MD, MPH
Associate Professor of Pediatrics
Medical University of South Carolina
Financial Relationships
• As it pertains to CME, I need to
disclose that I have no relevant
financial relationships with any
commercial interest to disclose.
Learning Objectives
• Be familiar with the epidemiology and medical
•
management of pediatric asthma in the US
Be aware of the scientific evidence
– demonstrating that environmental exposures
impact asthma incidence and prevalence
– demonstrating that environmental controls can
reduce asthma morbidity
• Be able to provide specific guidance about
controlling environmental exposures
Pediatric Asthma
• Most prevalent chronic medical condition
in childhood
• > 6 million US children
• Low income children are:
– More likely to have increased morbidity from
asthma
– Less likely to receive preventive care
Current Asthma Prevalence by
Race/Ethnicity: United States, 2005
Race/ Ethnicity:* Current Asthma Prevalence
15
10
14.5
9.6
9.1
7.3
9.1
7.3
7
5.6
4.5
3.9
5
0
n
No
n
No
-H
-H
ck
Bla
ite
Wh
an
Ric
an
o
ert
ic
an
xic
Me
Pu
p
His
n
k
ian
Ind
ia
As
Am
c
Bla
ite
Wh
All
*CDC Health Data for All Ages (age-adjusted) (HDAA) 2003-2005
Variation in Asthma Care by
Race/Ethnicity
• African-American children less likely to have
made office visit for asthma (OR 0.48)
– P Lozano, FA Connell, TD Koepsell. Use of health services by AfricanAmerican children with asthma on Medicaid. JAMA 1995; 274 (6); pages .
• African-American and Latino children less
likely to use inhaled corticosteroids (OR 0.69
and 0.58 respectively)
– TA Lieu, et al. Racial/Ethnic Variations in Asthma Status and Management
Practices in Managed Medicaid. Pediatrics 2002; 109(5):857-865.
This is not good
African-American children as compared
to white children
– >3 times as likely to be hospitalized
– >4 times as likely to die from asthma
LJ Akinbami, KC Schoendorf.Pediatrics 2002: 110; 315-322.
Barriers to Asthma Care
• Health Care System
– Lack of health insurance, primary care, coordination
of care
– High cost of medications and services
• Health care providers
– Lack of recognition and severity
– Suboptimal compliance with guidelines
• Family
– Confusion about symptoms and therapies
Pediatric Asthma Care
1997 NAEPP Asthma Guidelines
• Stepwise approach to managing asthma
– Gaining control
– Maintaining control
• Classifying asthma severity
– Controller medication for persistent asthma
• Provide WRITTEN asthma action plan
• Control of factors contributing to severity
National Institutes of Health. Practical Guide for the Diagnosis and Management of
Asthma. National Asthma Education and Prevention Program (NAEPP) 1997
National Asthma
Education and Prevention
Program Expert Panel
Report-3: Guidelines for
the Diagnosis and
Management of Asthma
EPR-3 slides courtesy of:
James P. Kiley, M.S., Ph.D.
American College of Chest
Physicians
October 25, 2007
Monitoring Asthma Control
• New framework for measuring control:
– Impairment: current experience with symptoms, low
lung function, or activity limitation
– Risk: likelihood of future exacerbations, progressive
loss of lung function or, for children, lung
growth, or medication side effects
• Both domains are important:
– Treatment may affect impairment or risk differently
– Patients may have low day-to-day impairment but
high risk of frequent exacerbations
Control of Environmental Factors
• New recommendation: comprehensive
approaches are necessary (single steps
are not sufficient)
• Emphasis on avoidance of tobacco smoke
• New consideration of specific
immunotherapy for selected allergic pts.
Childhood Asthma
• New distinction of 3 age groups to reflect
new evidence on children
– 0-4 years
– 5-11 years
– 12 years and adult
• Children may respond differently to
asthma medications
– (e.g. more children may do well on ICS alone
rather than combination therapy)
Six Key Messages
• Inhaled corticosteroids are the most effective antiinflammatory medication for long term management of
persistent asthma
All patients should receive:
• Written asthma action plan
• Initial assessment of asthma severity
• Review of the level of asthma control (impairment and risk)
at all follow up visits
• Periodic, follow up visits (at least every 6 months)
• Assessment of exposure and sensitivity to [environmental]
allergens and irritants and recommendation to reduce
relevant exposures
Asthma Case
• This patient is a 3 yo AA female
• Presents with respiratory distress and wheezing
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•
after staying with grandmother for the weekend
Also has had rhinorrhea and cough for months
Further hx
– Coughs at night at least 3-4 nights per week
– ER visits on two other occasions (1 month ago and 3
months ago) for breathing difficulties:
Rx
albuterol only
– Past Medical Hx of atopic dermatitis and “allergies”
– Grandmother smokes outside
Your Treatment Plan?
• Classify her asthma & educate
• Acute control-- various
• Controller medication
– Inhaled corticosteroid
– Inhaled steroid/salmeterol
– Second line– montelukast sodium
• Continued monitoring– peak flow
• Environmental management of triggers
Acute Management
ED or Office Setting
• Bronchodilator treatment
– *Albuterol 2.5- 5 mg inhaled q 30-60 min
– Albuterol MDI with spacer 4-8 puffs
– Albuterol continuous 0.5 mg/kg/hour (15 mg)
– Ipatropium bromide 250-500 micrograms
• Oral steroids 1-2 mg/kg
– IV if necessary (can’t take PO)
• Magnesium sulfate 40-50 mg/kg iv (ED)
*Others: Pirbuterol, levalbuterol
Criteria for Admission
• Third treatment in our office
• O2 requirement
• Late afternoon and unable to observe
several hours
• Social concerns
Use Steroids when Necessary
• Acute exacerbation
– Prednisolone 1-2 mg/kg/day
– Syrup is 15 mg/5mL
– Effect within 4 hours
• Controller/ Preventive
– Fluticasone 44 mcg 110, and 220 mcg
– Fluticasone/salmeterol 100/50; 250/50; 500/50
– Alternatives: beclamethasone (40 and 80 mcg/puff),
budesinide (Dry powder inhaler 90,180 and 200
mcg/dose), several others
National Institutes of Health. Practical Guide for the Diagnosis and Management of
Asthma. National Asthma Education and Prevention Program (NAEPP) 1997
Reiterated in 2007 Report.
Other Controllers
• Cromolyn MDI 1 mg/puff 1-2 qid
• Salmeterol (suggest using only in
combination with fluticasone)
• Montelukast Sodium 4, 5, and 10 mg tabs
– FDA approved for asthma ≥ 12 months
– < 5 years old: 4 mg qHS
– 5-11 years: 5 mg
– 12 years or older: 10 mg
National Institutes of Health. Practical Guide for the Diagnosis and Management of
Asthma. National Asthma Education and Prevention Program (NAEPP) 1997
Reiterated in 2007 Report.
Your Treatment Plan?
• Classify her (or His!) asthma
• Acute control-- various
• Controller medication
– Inhaled corticosteroid
– Inhaled steroid/salmeterol
– Second line– montelukast
• Continued monitoring– peak flow
– Written asthma care plan
• Environmental management of triggers
National Institutes of Health. Practical Guide for the Diagnosis and Management of
Asthma. National Asthma Education and Prevention Program (NAEPP) 1997
Reiterated in 2007 Report.
Peak Flow Monitoring
•
•
•
•
Find out predicted based on height
Green Zone: 80% of predicted or >
Yellow Zone: 50-80% of predicted
Red Zone: 50% of predicted or less
Write it Down!
Written plans help keep kids out of
the hospital
Your Treatment Plan?
• Classify her asthma and educate
• Acute control-- various
• Controller medication
– Inhaled corticosteroid
– Inhaled steroid/salmeterol
– Second line– montelukast
• Continued monitoring– peak flow
• Environmental management of triggers
National Survey on Environmental
Management of Asthma
Assessed public’s knowledge of environmental
asthma triggers and their actions to manage
environmental triggers
Some Key Findings:
• People from low income, low education households are more likely to
have asthma
• Thirty percent of people with asthma have a written asthma
management plan
• Thirty percent of people with asthma are taking essential actions to
manage their environmental triggers
• Children with asthma are nearly twice as likely as other children (19%
vs 11%) to be regularly exposed to secondhand smoke in their homes
US Environmental Protection Agency 2003
Environmental Management
of Pediatric Asthma:
Guidelines for Health Care
Providers
Released by the National Environmental Education
Foundation in August 2005
http://www.neefusa.org/health/asthma/index.htm
Overview of Asthma Guidelines
• Developed for children 0-18 years, already
•
diagnosed with asthma
Applies to all settings where children spend time
– Homes, schools, and daycare centers
– Cars, school buses
– Camps, relatives’/friends’ homes, other recreational
or housing settings
– Occupational environments
• Available online, in hard copy, and on CD-ROM
http://www.neefusa.org/health/asthma/index.htm
Environmental History Form (P. 17)
• Quick intake form
• Available online as PDF
•
•
and Word document
Copy into electronic
medical record template
Questions in yes/no
format
– Follow up yes answer with
in-depth questions on
Intervention Guidelines Fact
Sheets
Indoor vs. Outdoor Exposures
• Indoor
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Animal Dander
Dust Mites
Roaches
Mold
Solvents
Second Hand Smoke
(SHS)
• Outdoor Air Pollution
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–
–
–
Particulate Matter
Ozone
VOCs (Solvents)
Metals
• Chromium, Cadmium,
Cobalt, Nickel
– Sulfur and Nitrogen
Dioxides
– Carbon Monoxide
Clearing the Air
Institute of Medicine
• Sufficient evidence of Causal Relationship
– Cat
Cockroach
– House dust mite
ETS (preschooler)
• Sufficient evidence of an Association
– Dog
molds rhinovirus
NO2 & Ozone
• Limited evidence of Association
– Formaldehyde VOCs(solvents) RSV
– ETS (school-aged and older children)
Committee on the Assessment of Asthma and Indoor Air; Division of Health
Promotion and Disease Prevention; Institute of Medicine, 2000.
Allergy Referral?
• In vitro testing for allergens can be
considered, but false positives occur
– Should focus on allergens identified in history
– Should not replace timely allergy referral
• Low cost environmental interventions are
reasonable, especially where wide spread
exposure occurs (i.e. dust mites in SE)
– Costly interventions should be done after you
have referred patient for skin testing
Dust Mite Control
• Randomized controlled trial
– Group 1-- polyurethane casings for bedding, tannic
acid on the carpets
– Group 2-- Benzyl benzoate on mattresses and
carpets at time 0, and 4 & 8 months
– Group 3-- Placebo foam on the mattresses and
carpets at time 0, and 4 & 8 months
• Decreased mite allergen on Gp 1 mattresses
• Children of Group 1 with reduced airway
reactivity
Enhert B, et al. Allergy Clin Immunology 1992;90:135-8
Dust Mite Control
• Danish study in children (n= 60)
– Allergen impermeable mattress covers
• Significant reduction in dust mite
concentration for intervention group
• Significant decrease in effective dose of
inhaled steroid
Halken S, et al. J Allergy Clin Immunol 2003;112:220
Dust Mites
P. 20
Simple, but Effective Interventions
• Encase all pillows and mattresses of the beds
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•
•
the child sleeps on with allergen impermeable
www.nationalallergy.com
encasings
Wash bedding weekly to remove allergen
Wash in HOT water (130°F) to kill mites
Results generally seen in 1 month
• Avoid ozone generators and some ionic air
cleaners that produce ozone
Dust Mites
P. 20
Other Interventions
• Synthetic materials in bedding
• Remove or wash and dry stuffed toys weekly
• Vacuum with a HEPA-filtered vacuum cleaner
• Avoid humidifiers
• Additional suggestions in guidelines
Cats Stick with You
• Classrooms with many (>25% of class) cat
•
•
owners had cat allergen than other
classrooms
Allergen levels in non-cat owners’ clothes
increased after one day in that classroom
Exposure through school can exacerbate
asthma in sensitized children even if they
don’t own a cat
Almqvist C. J Allergy Clin Immunol 1999;103:1002-4
Almqvist C et al. Am J Respir Crit Care Med 2001;163:694-8
Control of Cat Ag
• RCT with 35 cat-allergic (and owner) subjects
– HEPA room air cleaner
– Mattress and pillow covers
– Cat exclusion from bedroom
• Reduced airborne cat allergen levels
• No effect on disease activity
• In cat allergic individuals with asthma,
intranasal steroids were effective
Wood RA Am J Respir Crit Care Med 1998;158:115-20
Wood RA, Eggleston PA. Am J Respir Crit Care Med 1995;15:315-20
Animal Allergens
P. 21
Effective Interventions
• Find a new home for indoor pets
• Keep pet outside
• If these aren’t possible…
– Similar interventions as with dust mites
– Encasings, HEPA air cleaner, HEPA Vacuum,
– Keep pet out of bedroom
• Takes 24-30 weeks before allergen levels
reach those of non-cat households1
Wood RA et al. J Allergy Clin Immunol 1989;83:730-4
Animal Allergens
Unlikely Interventions
• Bathing cats MAY be effective at reducing
allergen (n = 8 cats)
– The reduction was not maintained by 1 week1
– Therefore it had been recommended
to bathe the cat twice a week…
• However, A more recent study of 12
cats suggests the decrease in
dander after bathing lasts about 1 day2
Avner DB et al. J Allergy Clin Immunol 1997;100:307-12
Ownby D et al. J Allergy Clin Immunol 2006:118:521-2
Mouse Ag
• 18 homes of children with persistent
asthma and positive mouse allergen
• Integrated pest management
– Filled holes
– Vacuum and cleaning
– Low-toxicity pesticides and traps
• Mouse allergen levels significantly
reduced during 5 month period
Phipatanakul W et al. Ann Allergy Asthma Immunol 2004;92:420-5
Cockroach Ag Control
• Home extermination– 2 applications
– Abamectin, Avert (Derived from the soil bacterium
•
•
•
Streptomyces avermitilis)
Directed education on cockroach allergen removal
50% of families followed cleaning instructions, no
greater effect was found in these homes
At 12 months, allergen had returned
to or exceeded baseline levels
Gergen PJ et al. J allergy Clin Immunol 1999;103:501-6
Cockroach Ag Control
• Occupant education, professional cleaning
• Insecticide bait
• Substantial reductions in cockroach allergy
levels achieved1
• Second Study– Professional cleaning
– Bait traps with insecticide
– Bait traps without insecticide
– Significant reduction in cockroach allergen2
Arbes SJ et al. J Allergy Clin Immunol 2003;112:339-45
McConnell R et al. Ann Allergy Asthma Immunol 2003;91:546-52
Is it the Cleaning?
• RCT of 150 children with asthma
• Peer Health Educators
– Reduce harborage and access to food
– Cleaning and applying boric acid
– Allergen impermeable covers for bedding
• 60% decrease in number of cockroaches
• 64% decrease in cockroach Ag from
child’s bedding
McConnell R et al. Clinical & Experimental Allergy 35(4):426-333, 2005
P. 22
Cockroach Allergen
Do’s and Don’ts of Roach Control
• Integrated pest
management (IPM)
– Least toxic methods first
• Boric acid
• Bait stations/ gels
• Allergen impermeable
• Clean up food/spills
covers
• Food and trash storage • Don’t!!
•
•
in closed containers
Fix water leaks
Clean counter tops
daily
– Spray liquids in house,
especially play and sleep
space
– Use industrial strength
pesticide sprays that require
dilution
Mold and Asthma Symptoms
• Cross sectional study of 2568 children 1 - 6 years old in
•
•
•
Helsinki, Finland
Exposures included histories of water damage, presence
of moisture and visible molds and perceived mold odor
at home
Outcomes included persistent cough, phlegm and
wheezing, persistent nasal congestion and excretion
during the past 12 months and current asthma
Mold odor during the past year and water damage
over a year ago had the strongest association with
the respiratory symptoms.
Jaakkola et al. J Expo Anal Environ Epidemiol. 1993;3 Suppl 1:129-42.
Mold and Mildew
P. 23
Interventions
• Ways to control moisture and/or decrease
humidity to < 50%
– Dehumidifier or central air conditioner
– Do not use a humidifier
– Vent bathrooms/clothes dryers to outside
– Use exhaust fan in bathroom/ other damp
areas
– Check faucets and pipes for leaks and repair
Mold and Mildew
Cleaning up the Mess
• Items too moldy to clean should be discarded
• An area larger than 3 ft x 3 ft should be
•
professionally cleaned
Chlorine solution 1:10 with water
is acceptable for smaller areas
– Don’t mix with cleaners containing ammonia!
• Quaternary ammonium compounds are also
good fungicides if bleach isn’t used
SHS = most important indoor
pollutant for child health
• According to the 2006 Report of the
Surgeon General ‘almost 60 percent of
children aged 3 through 11 years’ are
exposed to SHS.
http://www.hhs.gov/surgeongeneral/library/smokingconsequences
• Each year, secondhand smoke is
associated with an estimated 8,000–
26,000 new asthma cases in children.
U.S. Environmental Protection Agency. Respiratory Health Effects of Passive
Smoking: Lung Cancer and Other Disorders. Washington, DC: U.S. Environmental
Protection Agency;1992. Pub. No. EPA/600/6-90/006F. Accessed: March 2008.
Second Hand Smoke
Possible Interventions
P. 24
• Keep home and care smoke free
• Encourage support to quit smoking
– Recommend aids such as nicotine gum/patch
– Medication from physician to assist in quitting
• Choose smoke free social settings
• At the very least, do not smoke around your
child or in the car!
– (This should not keep us from encouraging parents to
quit)
Reducing Traffic Reduces Asthma 1996 Atlanta Olympics
• The Intervention:
– Around-the-clock public
transportation
– 1,000 buses added
– Downtown city streets closed to
private cars
– Downtown delivery schedules altered
– Flexible and telecommuting work
schedules encouraged
Friedman, M. S. et al. JAMA 2001;285:897-905.
Reducing Traffic Reduces
Asthma - 1996 Atlanta Olympics
• The Result:
– Weekday morning traffic counts
dropped 22.5%
– Peak daily ozone concentrations
decreased 27.9%
Friedman, M. S. et al. JAMA 2001;285:897-905.
Mean Levels of Major Pollutants Before, During, and After the
1996 Summer Olympic Games as a Percentage of the National
Ambient Air Quality Standard (NAAQS)
Friedman, M. S. et al. JAMA 2001;285:897-905.
Acute Asthma Events During 1996
Olympics - Atlanta
% change in mean
# of Asthma claims
per day
% change in mean
# of Non-Asthma
claims per day
Medicaid
Hosp and ED Visits
- 41.6%
- 3.1%
HMO
ED, Urgent Visit,
Hosp
- 44.1%
+ 1.3%
Type of claim
Friedman, M. S. et al. JAMA 2001;285:897-905.
2002 Summer Asian Games Korea
• 2002 Summer Asian Games in Busan,
Korea
– Like Atlanta in 1996, ‘Transportation Controls’
led to a reduction in hazardous air pollutant
levels of up to 25%
– Relative Risk of Asthma Hospitalization during
the reduced pollution period was 73% of
baseline (27% decrease)
Lee et al. J Air Waste Manag Assoc. 2007 Aug;57(8):968-73.
Air Pollution
P. 26
Possible Outdoor Air Interventions
• Monitor air quality index levels
– Ozone, Particulate Matter, NOx, SO2
– Reduce child’s outdoor activities if unhealthy
• Orange AQI of 101-150 (unhealthy for sensitive
groups)
• Red AQI of 151-199 (unhealthy for all)
• Contact health care provider if more
albuterol is needed the day after AQI level
is high
www.epa.gov/airnow
Inner City Asthma Study
• Follows 937 urban children with asthma
– 1 year of intervention, 1 additional year of follow up
• Evaluation --questionnaire and skin testing
• Home sampling --dust, cockroach, cat and dog
•
allergen
Interventions aimed at patient-specific triggers
– Allergen impermeable mattress and pillow covers
– HEPA air filters and vacuum cleaners
– Professional pest control
Morgan WJ, et al. New Engl J Med 2004;351:1068-80
Inner City Asthma Study
Results and Cost Effectiveness
• Fewer days with symptoms
• Greater decline in level of allergens at home
– Persisted through 2nd “follow up” year
– Dust and cockroach Ag correlated with fewer
complications of asthma
• *Cost Effectiveness analysis
– 38 more symptom free days
– Under $30 per symptom free day
Morgan WJ, et al. New Engl J Med 2004;351:1068-80
*Kattan M, et al. J allergy Clin Immunol 2005;116:1058-63
OK, But who pays for it?!
• Medications– covered by most insurance
and Medicaid
• Spacers and masks– in our office
• Asthma Education?
• Environmental trigger assessment?
– Working on it
Role of Health Care Plan
• Children’s Mercy, KC: Medicaid Managed Care
– Provider education
– Developed a disease management program to
ASSIST primary care providers
– CPT code to reimburse for asthma education
• Resulted in 60% in ER visits, 50% in
hospitalization
• 30% Decrease in cost for asthma claim!
Kentucky
• Medicaid managed care plan administered by
Amerihealth
– Works with local health department to pay for
environmental assessment of patient’s home
– Provides summary to primary care provider
• We’re not in Kentucky, but….
– Amerihealth administers a number of state health
plans
– Health plans see the data on cost savings
Who takes the Advice?
Seen by Allergists v. Pediatricians
• Patients seen by an allergist had greater knowledge of
environmental allergens
– Dust mite knowledge (71% v. 18%)
– Need for mattress encasements (61% v. 13%)
– Need for pillow encasements (51% v. 11%)
• Increased knowledge, but not statistically significant
– More knowledge about carpet removal (23% v. 11%)
– Stuffed animal removal (10% v. 2%)
• Made some changes in their home
– Use of mattresses encasements (38% v. 11%)-- 0.001
– Use of pillow encasements (36% v. 16%)– 0.009
– Carpet removal (26% v. 36%)-- NS
Callahan KA, et al. Annals Aller Asthma Immunol 2003;90:302-7.
Summary
• Written asthma action plans
• Persistent asthma should be treated with
controller medication
• Environmental management can and
should supplement good medical care
Summary (con’t)
• Ask about environmental exposures and
seek ways to intervene
• Some low cost interventions may be
effective in children
– Should consider comprehensive approach
• Consider allergy referral
– Define exposure risk
– Consider immunotherapy