Transcript Key elements to optimal asthma management

‫خدا نیکوست‬
Treatment of
Children Asthma
Dr. Fatemeh Behmanesh
Key elements to optimal
asthma management
Assess severity
• The classification of asthma severity is based on the
following parameters:
 Frequency of day time symptoms
 Frequency of might time symptoms
 Degree of air flow obstruction by spirometry or
 PEF variability
• Asthma severity categorized as
 Mild intermittent
 Mild persistent
 Moderate persistent
 Sever persistent
Classification of Asthma Severity
FOR ADULTS AND CHILDREN AGE > 5
YEARS WHO CAN USE A
SPIROMETER OR PEAK FLOW METER
FEV1 or PEF[*] %
PEF Variability (%)
Predicted Normal
CLASSIFICATION
STEP
DAYS WITH SYMPTOMS
NIGHTS WITH
SYMPTOMS
Severe
persistent
4
Continual
Frequent
60≤
30>
Moderate
persistent
3
Daily
>1/wk
80<–60>
30>
Mild
persistent
2
>2/wk, but <1
time/day
>2/mo
80≥
30–20
Mild
intermittent
1
≥2/wk
<2/mo
80≥
20<
Stepwise Approach for Managing Infants and Young Children
(≤5 Yr of Age) with Acute or Chronic Asthma; Treatment
Classify Severity: Clinical Features Before
Treatment Or Adequate Control
Step 4
Severe persistent
Symptoms/Day
Symptoms/Night
Continual
Frequent
Step 3
Moderate persistent
Daily
>1 night/wk
Step 2
Mild persistent
>2/Week but<1 /day
>2 nights/mo
Step 1
Mild intermittent
 2days/wk
2nights/mo
Quick Relief All
Patients



Medications Required To Maintain Long-Term Control
Daily Medications
•
Preferred treatment
High-dose inhaled corticosteroids AND
Long-acting inhaled β2-agonists
AND, if needed,
Corticosteroid tablets or syrup long term (2 mg/kg/day, generally do not exceed 60 mg/day).(Make repeat attempts to reduce
systemic corticosteroids and maintain control with high-dose inhaled corticosteroids.)
•
Preferred treatment
Low-dose inhaled corticosteroids and long-acting inhaled β2-agonists
OR
Medium-dose inhaled corticosteroids.
•
Alternative treatment
Low-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline.
If needed (particularly in patients with recurring severe exacerbations):
•
Preferred treatment
Medium-dose inhaled corticosteroids and long-acting β2-agonists.
•
Alternative treatment
Medium-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline.

Preferred treatment
Low-dose inhaled corticosteroid (with nebulizer or MDI with holding chamber with or without face mask or DPI).

Alternative treatment
Cromolyn (nebulizer is preferred or MDI with holding chamber)
OR leukotriene receptor antagonist.

No daily medication needed.
Bronchodilator as needed for symptoms. Intensity of treatment will depend on severity of exacerbation.
Preferred treatment: Short-acting inhaled β2-agonists by nebulizer or face mask and space/holding chamber
Alternative treatment: Oral β2-agonist
With viral respiratory infection
Bronchodilator q 4–6 hr up to 24 hr (longer with physician consult); in general, repeat no more than once every 6 wk
Consider systemic corticosteroid if exacerbation is severe or patient has history of previous severe exacerbations
Use of short-acting β2-agonists >2 times/wk in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate
(increase) long-term-control therapy.
• Treat
all
persistent
asthma
with
anti-
inflammatory controller medication.
• the type and amounts of daily controller
medication are determined by asthma severity.
• Three strikes rule:
• Symptom or uses quick-relif medication at
least 3 times per week.
• Awakens at might due to asthma at least 3
times per months.
• Experiences asthma exacerbations at least 3
times per year.
• Or require short courses of systemic corticosteroids at least 3 times a year.
Patient should receive daily controller therapy
• Controller therapy can be considered for children
who present with frequent exacerbation
 At least 2 exacerbation occuring < 6 week apart
• All levels of persistent asthma should be treated with
daily medications include:
 ICS
 LABA
 Leukotriene modifiers
 Nonsteroidal anti-inflamatory agents
 Sustained – release theophylline
 Anti- IgE (omalizumab, Xolair) approved by addon therapy for patients with moderate to sever
allergic asthma.
• Most potent and effective medication is
corticosteroids
 Acute (systemically)
 Chronic (inhalation)
ICS
• First line treatment for persistent asthma
• Reduce asthma symptoms
• Improve lung function
• Reduce AHR
• Reduce “rescue” medication use
• Reduce urgent care visits & hospitalization
• Lower the risk of death
Estimated Comparative Daily Dosages for
Inhaled Corticosteroids
LOW DAILY DOSE
DRUG
MEDIUM DAILY DOSE
HIGH DAILY DOSE
Adult
Child[*]
Adult
Child[*]
Adult
Child[*]
Beclomethasone CFC 42 or 84 μg/puff
168–504 μg
84–336 μg
504–840 μg
336–672 μg
>840 μg
>672 μg
Beclomethasone HFA 40 or 80 μg/puff
80–240 μg
80–160 μg
240–840 μg
160–320 μg
>480 μg
>320 μg
Budesonide DPI 200 μg/inhalation
200–600 μg
200–400 μg
600–1,200 μg
400–800 μg
>1,200 μg
>800 μg
Inhalation suspension for nebulization (child
dose)
Flunisolide 250 μg/puff
0.5 μg
1.0 μg
2.0 μg
500–1,000 μg
500–750 μg
1,000–2,000 μg
1,000–1,250 μg
>2,000 μg
>1,250 μg
Fluticasone MDI: 44, 110, or 220 μg/puff
88–264 μg
88–176 μg
264–660 μg
175–440 μg
>660 μg
>440 μg
DPI: 50, 100, or 250 μg/inhalation
100–300 μg
100–200 μg
300–600 μg
200–400 μg
>600 μg
>400 μg
400–1,000 μg
400–800 μg
1,000–2,000 μg
800–1,200 μg
>2,000 μg
>1,200 μg
Triamcinolone acetonide 100 μg/puff
* Children ≤ 12 years of age
Leukotrience pathway modifiers
• Two classes of leukotrene modifiers:
 Inhibitors of leukotriene synthesis: zileuton
 Leukotriene receptor antagonists:
o Montelukast
o Zafirlukast
1. Zileuton:
• Not upproved for children < 12 year
• 4 times daily
• Elevated liver function enzymes
2. Montelukast
• Approved for children 1 year
• One daily
3. Zafirlukast
• Approved in children  5 year
• Twic daily
Leukotriene modifiers are considered
alternative controllers for mild
persistent asthma
Sustained- Release Theophylline
 Considered
on
alternative
monotherapy
controller agent for older children and adults
with mild persistent asthma.
 No longer considered a first line agent for small
children
LABA
• Daily controller medication
• Not as monotherapy for persistent asthma
• Add- on agent for patients suboptimally
controlled on ICS therapy alone
• Salmetrol
• For moterol
• In patients with nocturnal asthma
• Low dose ICS with LABA for moderate persistent
asthma in older children and adult
• High dose ICS + LABA for sever persistent asthma
Non-steroidal Anti- Inflammatory Agents
• Cromolyn and nedocromil
• Non- corticosteroid anti- inflammatory
• Reduce exercise- induced bronchospasm
• For mild persistent asthma
• Adminstered frequently 2-4 times/day
• Not nearly as effective daily contoller as ICS
• For mild persistent asthma
Anti IgE (omalizumal)
• Humanized monoclonal antibody that binds IgE
• FDA approved for patients > 12 year old
• For moderate to sever asthma
• For Patients with inadequate disease control with
ICS or oral corticosteroids
• Every 2-4 week
Step-up, step up- Down Approach
•
•
•
•
Initiating higher-level controller therapy
Step down after good asthma control
Decrease ICS dose about 25% every 2-3 months
If control is not maintained, step up,
review patient medication technique
Adherence
Environment
Quick – Reliever medications
• Rescue medications:
 Short acting inhaled -agonist
 Inhaled antichilinergics
 Short course systemic corticosteriods
• For management of acute asthma
SABA
•
•
•
•
•
•
Rapid onset of action
4-6 hr duration of action
First choice for acute asthma symptom
For preventing exercise induced bronchospasm
It is helpful to monitor the frequency of SABA
Use
1. At least 1 MDI/Month
• Indicate Inadequate Asthma Control
2. Al least 3 MDI/ year
Anticholinergic Agents
• Ipratropium bromide
• Tretament of acute sever asthma
• Combination with SABA
• Improve lung function
• Reduce the rate of hospitalization
• MDI, Nebulizer formulation
• Approved by FDA for children > 12 year of age
Management acute asthma
The home
The emergency department
The hospital
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Home Management
Home treatment based on changes in PEF values
Green zone
Yellow zone
Red zone
In children too young or otherwise incapable of
performing PFT, sing & symptoms to be
evaluated: (e.g., color changes, respiratory rate,
location/extent of retractions, duration of
inspiratory/ expiratory phases, presence or
absence of cough/wheezing)
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…Home Management
Note signs and symptoms: Degrees of cough, breatlessness,
wheeze and chest tightness, corrolate imperfectly with
severity of exacebration. Accessory muscle use and
suprasternal retraction suggest severed exacebration.
If PEF<50% predicted: initial treatment
Inhaled short-acting β2 agonist: up to three treatment of 2-4
puff 20-min intervales by
MDI
MDI + Spacer device
DPI
Hand nebulizer
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…Home Management
After 1 hour
Good response
Incomplete response
Poor response
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Good Response (Mild Episode)
PFE>80% predicted
No wheezing or shortness of breath
Response to β2 agonist sustained for 4 hours
May continue β2 agonist every 3-4h for 24-48h
For patients on inhaled corticosteroids, double dose
for 7-10 days and contact clinician
30
Incomplete Response (Moderate Episode)
PEF 50%-80% predicted
Persistent wheezing and shortness of breath
Add oral corticosteroid
Continue β2 agonist
Contact clinician urgently (this day)
31
Poor Response (Sever Episode)
PEF<50% predicted
Marked wheezing 8 shortness of breath
Add oral corticosteroid
Repeat β2 agonist immediately
Call your doctor
Proceed to emergency department
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Office or Emergency Department Management
A brief history of the events leading up to the exacerbation and the
medications used both chronically and acutely to treat
Physical examination: RR, PR, Pluse oximetry, use of accessory
muscle, air flow, wheezing, (1÷E), verbalization, puls paradoxus.
Studies: PEF, FEV1, ABG
Routine
CXRnot
nessary
unless
complication
pneumothorax, pneumomediastinum, aspiration)
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(e.g.,
Respiratory arrest imminent
Intubate and mechanically ventilate with 100% O2.
Nebulized β2 agonist and anticholinergic
IV corticosteroid.
Admit to ICU
Continuous monitoring
Intensive asthma management
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… Respiratory arrest imminent
Improved
Admit to hospital ward
O2 to maintain good saturation
Nebulized β2 agnoist +/- anticholinergic
PO or IV corticoesteroid
Monitor vital signs, O2 saturation, FEV1 or PEF
35
… Respiratory arrest imminent
Improved
Discharge to home
Continue home treatment with inhaled β2 agonist
Consider need for oral corticosteroids or controller
medication
Educate patient in medication use and action plans
Arrange follow-up
36
Emergency department management
Give nebulized albuterol with o2 at 6 liters flow, 2.5mg per
dose q 20min.
O2 to achieve saturation>90%
Give corticosteroid po or IV if FEV1 or PEF<50%
Or
If the patient was recently receiving corticosteroids
Or
If the patient in historically a high risk patient
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Reassess
Physical examination: RR, HR, Pulse oximetry, use of
accessory
muscles,
airflow,
verbalization, pulsus paradoxus
Studies; PEF, FEV1
Mild exacerbation
Moderate exacerbation
Sever exacerbation
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wheezing,
(1÷E)
Mild Exacerbation
FEV1 or PEF>80%
Good response
Maintained without repeated treatments during ER
PE: Normal
Discharge to home
Continue home treatment with inhaled β2 agonist
Consider need for oral corticosteroids or controller medication
E ducat patient in medication use and action plus
Arrange follow up
39
Moderate Exacerbation
FEV1 or PEF>50% but <80%
In complete response to treatment
PE: RR, Wheezing present, mild to moderate
accessory muscle use,
O2 satiration 91-95%
1:E<1:2
PP=10-25mmHg
40
… Moderate Exacerbation
Admit to Hospital Ward
02 up to 02 sat >95%
Nebulized β2 agonist +/- anticholinergic
Po or IV corticosteroid
Monitor vital signs, 02 saturation, FEV1 or PEF
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… Moderate Exacerbation
Improved
Discharge to home
Continue home treatment with inhaled β2 agonist
Consider need for oral corticosteroid or controller
medication
Educate patient in medications and action plan
Arrange follow up
42
Sever Exacerbatis
FEV1 or PEF<50%
Poor response to treatment
PE: RR, Wheezing present, poor airflow
Moderate-sever accessory muscle use, 02 sat<91%
PP>25mmHg
Admit to ICU
Continuous monitoring
Intensive asthma management
43
… Sever Exacerbatis
Improved
Admit to hospital ward
O2 to maintain good saturation
Nebulized β2 agnoist +/- anticholinergic
PO or IV corticoesteroid
Monitor vital signs, O2 saturation, FEV1 or PEF
44
… Sever Exacerbatis
Improved
Discharge to home
Continue home treatment with inhaled β2 agonist
Consider need for oral corticosteroids or controller
medication
Educate patient in medication use and action plans
Arrange follow-up
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Therapy of EIA
Useful prophylactic approaches
Class
Drug
Dose inhaled
Time delay
Duration
Long- acting 2 agonist
Salmeterol
1 inhalation DPI
20 min
8-10 hr
Short-acting 2 agonist
Albuterol
2 puffs MDI
15 min
3-4 hr
Antileukotriene
Montelukast
10 mg orally
30 min
8-10 hr
Mast cell stabilizers
Cromolyn
2 puffs MDI
15 min
1.5-2 hr
Duration of protection may decrease with regularly scheduled use
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