Transcript Link to presentation - University of South Alabama Health System

Danielle Gilliam M.D., PGY III
University of South Alabama
Pediatrics
2011
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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.
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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
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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 )
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Cough ( mostly dry and hacking, specially at night ),
Wheezing ( mainly expiratory)
Shortness of Breath
Chest Pain
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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
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A silent chest is a medical emergency
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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)
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Asthma
Bronchiolitis (esp in infants), bronchitis,
laryngotracheobronchitis, tracheitis
Foreign body aspiration
Functional abnormalities ( GERD, CF, BPD,
immunodeficiency etc )
Structural abnormalities ( laryngotracheomalacia, 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?
Assessing asthma control and adjusting therapy in children 0-4 years of age
Components of control
Classification of asthma control (0-4 years of age)
Well-controlled
Very poorly controlled
Symptoms
2 days/week
>2 days/week
Throughout the day
Nighttime awakenings
1x/month
>1x/month
>1x/week
Some limitation
Extremely limited
>2 days/week
Several times per day
2-3/year
>3/year
Impairment Interference with normal activity None
Short-acting beta2-agonist use for
symptom control (not prevention 2 days/week
of EIB)
Exacerbations requiring oral
systemic corticosteroids
Risk
Not-well controlled
0-1/year
Medication side effects can vary in intensity from none to very troublesome and worrisome. The
Treatment-related adverse effects level of intensity does not correlate to specific levels of control but should be considered in the
overall assessment of risk.
Maintain current
treatment.
Recommended action for treatment
Step up (1 step) and
Reevaluate in 2-6 weeks.
Regular followups every
If no clear benefit in 4-6 weeks,
1-6 months.
consider alternative diagnoses or
adjusting therapy.
Consider step down if
well controlled for at
For side effects, consider
least 3 months.
alternative treatment options.
Consider short course of oral
systemic corticosteroids,
Step up (1-2 steps), and
Reevaluate in 2 weeks.
If 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)
Components of severity
Intermittent
Persistent
Mild
Moderate
Severe
Symptoms
2 days/week
>2 days/week but
Daily
not daily
Nighttime awakenings
2x/month
3-4x/month
Short-acting beta2-agonist use for
symptom control (not prevention of EIB)
2 days/week
>2 days/week but
Daily
not daily
Several times per day
Minor limitation
Some limitation
Extremely limited
FEV1 = >80
percent predicted
FEV1 = 60-80
percent predicted
FEV1/FVC >80
percent
FEV1/FVC = 75-80
FEV1/FVC <75 percent
percent
Interference with normal activity
None
Throughout the day
>1x/week but not
Often 7x/week
nightly
Impairment
Normal FEV1 between
exacerbations
Lung function
FEV1 >80 percent
predicted
FEV1 <60 percent
predicted
FEV1/FVC >85 percent
0-1/year (see
footnote)
Risk
Exacerbations requiring oral
systemic corticosteroids
2/year (see footnote)
Consider severity and interval since last exacerbation
Frequency and severity may fluctuate over time for patients in any severity
category
Relative annual risk of exacerbations may be related to FEV1
Step 1
Recommended step for initiating treatment
Step 2
Step 3, medium
dose ICS option
Step 3, medium dose
ICS option, or step 4
And consider short course of oral systemic
corticosteroids
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
Components of control
Symptoms
Nighttime awakenings
Interference with normal
activity
Short-acting beta2-agonist use
for symptom control (not
Impairment prevention of EIB)
Classification of asthma control (5-11 years of age)
Well-controlled
Not-well controlled
Very poorly controlled
2 days/week but not more than >2 days/week or multiple times
Throughout the day
once on each day
on 2 days/week
1x/month
None
2 days/week
2x/month
2x/week
Some limitation
Extremely limited
>2 days/week
Several times per day
Lung function
FEV1 or peak flow
FEV1/FVC
>80 percent predicted/personal 60-80 percent
best
predicted/personal best
>80 percent
75-80 percent
<60 percent
predicted/personal best
<75 percent
2/year (see footnote)
Exacerbations requiring oral 0-1/year
systemic corticosteroids
Consider severity and interval since last exacerbation
Risk
Reduction in lung growth
Evaluation requires long-term followup
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.
Maintain current step.
Recommended action for treatment
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)
Components of severity
Impairment
Normal
FEV1/FVC:
8-19 yr 85
percent
Mild
Moderate
Severe
Throughout the
day
2 days/week
>2 days/week but not daily Daily
Nighttime awakenings
2x/month
3-4x/month
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
Daily
any day
Several times per
day
Minor limitation
Extremely limited
Interference with normal activity
None
Normal FEV1
between
exacerbations
Lung function
60-80 yr 70
percent
FEV1 >80 percent
predicted
FEV1 80 percent
predicted
FEV1/FVC normal
>1x/week but not
Often 7x/week
nightly
Some limitation
FEV1 <60
FEV1 >60 but <80
percent predicted
percent predicted
FEV1/FVC
FEV1/FVC reduced
reduced >5
5 percent
percent
FEV1/FVC normal
0-1/year (see
footnote)
Risk
Persistent
Symptoms
20-39 yr 80
percent
40-59 yr 75
percent
Intermittent
Exacerbations requiring oral
systemic corticosteroids
2/year (see footnote)
Consider severity and interval since last exacerbation
Frequency and severity may fluctuate over time for patients in any severity
category
Relative annual risk of exacerbations may be related to FEV1
Recommended step for initiating treatment
Step 1
Step 2
Step 3
Step 4 or 5
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
Components of control
Classification of asthma control ( 12 years of age)
Well-controlled
Not-well controlled
Very poorly controlled
Throughout the day
Symptoms
2 days/week
>2 days/week
Nighttime awakenings
2x/month
1-3x/week
Interference with normal
activity
None
Some limitation
Extremely limited
>2 days/week
Several times per day
>80 percent predicted/personal best
60-80 percent
predicted/personal best
<60 percent
predicted/personal best
0
1-2
3-4
Short-acting beta2-agonist use
for symptom control (not
Impairment prevention of EIB)
FEV1 or peak flow
4x/week
2 days/week
Validated questionnaires
ATAQ
ACQ
0.75*
ACT
20
1.5
16-19
N/A
15
2/year (see footnote)
Exacerbations requiring oral 0-1/year
systemic corticosteroids
Consider severity and interval since last exacerbation
Risk
Progressive loss of lung
function
Evaluation requires long-term followup care
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.
Maintain current step.
Recommended action for treatment
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
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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 )
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Controller medications:
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Inhaled corticosteroids,
Inhaled cromolyn or nedocromil,
Long-acting bronchodilators (Salmeterol),
Leukotriene antagonists (Montelukast)
Rescue medications:
Short-acting bronchodilators,
Systemic corticosteroids
Inhaled ipratropium or atrovent
Drugs
Beclomethasone
Product Availability
40 mcg to 80mcg/ inh
MDI (QVAR)
Fluticasone HFA MDI
44 mcg, 110 mcg, 220 mcg/inh
(Flovent)
50 mcg, 100 mcg, 250 mcg/inh
Mometasone DPI
110 mcg, 220 mcg/inh
(Ventolin)
COMBOS
Fluticasone + Salmeterol (Advair)
Diskus (all have 50 mcg salmet)
100/50, 250/50, 500/50 mcg/inh
45/21, 115/21, 230/21
HFA (all have 21 mcg salmet)
Budesonide + Formoterol
80/4.5 mcg, 160/4.5 mcg
(Symbicort)
HFA and MDI
Side Effects:
Common= couph, dysphonia, oral candidiasis, upper RTI, throat irritation
Serious= decreased growth velocity in children, HPA suppresion, reduced bone mineral
density, cataracts
(dose and duration dependent)
Combo meds= above +Headache, dizziness, palpitations, tremor
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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
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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
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O2 to keep sats >92%
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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
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Start Corticosteroids if;
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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
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Continuous Albuterol
Magnesium Sulfate (IV)
IV Terbutaline or Epinephrine
Ketamine
Intubation for respiratory failure
Heliox
Solumedrol IV
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Use of ketamine in acute severe asthma
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V. J. Sarma 30 DEC 2008
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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
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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