Transcript is it asthma?

ASTHMA IN CHILDREN:
Diagnosis and Management
Milagros S. Salvani-Bautista, MD
Pediatric Pulmonologist
OPERATIONAL DESCRIPTION:
“ Asthma is a chronic inflammatory disorder
of the airways in which many cells and cellular
elements play a role. The chronic inflammation is
associated with airway hyperresponsiveness that
leads to recurrent episodes of wheezing,
breathlessness, chest tightness, and coughing,
particularly at night or in the early morning.
These episodes are usually associated with
widespread, but variable, airflow obstruction
within the lung that is often reversible either
spontaneously or with treatment”
GINA: 2002,2006,2007
What Is Asthma ?
What is known about Asthma?
 increasing PREVALENCE especially in children
 CHRONIC INFLAMMATORY DISORDER of the
airways
 chronically inflamed airways are
HYPERRESPONSIVE
 EPISODIC WHEEZING, BREATHLESSNESS, CHEST
TIGHTNESS and COUGHING
 can be CONTROLLED
PATTERNS OF RECURRENT WHEEZE
IN PEDIATRIC PATIENTS
1. Transient wheezing
2. Non-atopic wheezing
3. Persistent asthma
Tucson Children’s Respiratory Study
JACI 2003; 111: 661-675
4. Severe, intermittent wheezing
Bacharier. JACI 2007; 119: 604-610
PRESENTING FEATURES
Wheeze
Dry cough
Breathlessness
Noisy breathing
DETAILED HISTORY AND PE
Pattern of illness
Severity/control
Differential clues
IS IT ASTHMA?
Probably
INVESTIGATE OR
SEEK
Causal factors
Exacerbating factors
Complications
Comorbidity
No
Follow relevant course of action
Seek specialist assistance
Possibly
DIFFERENTIAL
DIAGNOSTIC TESTS
&/or TRIALS OF
ASTHMA THERAPY
Asthma
likely
ASTHMA ACTION PLAN
Poor response
Good response
Asthma
unlikely
DIAGNOSIS OF
ASTHMA IN
CHILDREN
CLASSIFICATION OF ASTHMA SEVERITY
GINA 2002
Intermittent
Symptoms less than once a week
Brief exacerbations
Mild Persistent
Symptoms more than once a week but less
than once a day
Exacerbations may affect activity and sleep
Nocturnal symptoms not more than 2x/mo. Nocturnal symptoms more than 2x/mo.
• FEV1 or PEF ≥ 80% predicted
• FEV1 or PEF ≥ 80% predicted
• PEF or FEV1 variability < 20%
• PEF or FEV1 variability < 20 – 30%
Moderate Persistent
Symptoms daily
Exacerbations may affect activity & sleep
Nocturnal symptoms more than once a
wk.
Daily use of inhaled short-acting 2-agonist
• FEV1 or PEF 60-80% predicted
• PEF or FEV1 variability > 30%
Severe Persistent
Symptoms daily
Frequent exacerbations
Frequent nocturnal asthma symptoms
Limitation of physical activities
• FEV1 or PEF ≤ 60% predicted
• PEF or FEV1 variability > 30%
Level of Asthma Control
Characteristic
Controlled
(All of the ff)
Partly Controlled
(Any measure
present in any
week)
Daytime symptoms
None (2x or </wk.)
More than 2x/wk
Limitations of
activities
None
Any
Nocturnal
symptoms/
awakening
None
Any
Need for
reliever/rescue tx
None (2x or
less/week)
More than 2x/ wk
Lung function (PEF
or FEV1)+
Normal
<80% predicted or
personal best (if
known)
Exacerbations
None
One or more/ yr*
* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate.
+ By definition, an exacerbation in any week makes that an uncontrolled asthma week.
╪ Lung function testing is not reliable for children 5 years and younger.
Uncontrolled
Three or more
features of
partly controlled
asthma present
in any week
One in any wk╪
GINA 2006
ASTHMA MANAGEMENT:
COMPONENTS OF THERAPY
 Assess and monitor asthma severity
and asthma control
 Education for a partnership in care
 Control of environmental factors
and co-morbid conditions that
affect asthma
 Medications
GINA ASTHMA GUIDELINES 2002, 2006, 2007
Medicines in Childhood Asthma
 Relievers
 Rapid-acting inhaled
Beta (B)2 agonist
 Inhaled anticholinergics
 Short acting
theophylline
 Short acting B2
agonist
(SABA)
 Controllers
 Inhaled and systemic
corticosteroids
 Leukotriene modifiers
 Long-acting B2
agonist (LABA) with
Inhaled
Corticosteroid ICS
 Sustained release
theophyllines
 Cromones
ACUTE ASTHMA EXACERBATION
GINA 2002, 2006, 2007
Severity of Asthma Exacerbations…..
MILD
BreathlessWalking
Talking
Can lie flat
MODERATE
SEVERE
At rest
Infants – softer
shorter cry
Prefers sitting
Infants- Stops
feeding
*Hunched forward
Talks in
Sentences
Phrases
Alertness
May be agitated
Usually agitated
Usually agitated
Respiratory Rate
Increased
Increased
*Often >30/min
RESPIRATORY
ARREST
IMMINENT
Words
GUIDE TO RATES OF BREATHING ASSOCIATED WITH
RESPIRATORY DISTRESS IN AWAKE CHILDREN
AGE
NORMAL RATE
> 2 months
< 60/min
2-12 months
< 50/min
1-5 years
< 40/min
6-8 years
< 30/min
Bradypnea
GINA 2002, 2006, 2007
Severity of Asthma Exacerbations…..
MILD
Accessory
Muscles &
Suprasternal
Retraction
Wheeze
Pulses/min
None
Audible with
stethoscope
<100
MODERATE
SEVERE
Present
Present
Audible with
stethoscope
100-120
RESPIRATORY
ARREST IMMINENT
Present
Thoraco-abdominal
Movement
Audible w/o
stethoscope
>120
Absence of wheeze
with decreased to
absent breathe sounds
Bradycardia
GUIDE TO LIMITS OF NORMAL PULSE RATE IN CHILDREN
Age
Normal Limits
Infants
2-12 months
<160/min
Preschool
1-2 years
<120/min
School Age
2-6 years
<110/min
GINA 2002,2006,2007
Severity of Asthma Exacerbations
MILD
MODERATE
SEVERE
May be present
10—20mm Hg
Often present
20-40mm Hg
Pulses Paradoxus
Absent
<10mm Hg
PEF
%predicted
Or
%personal best
 80%
60-79%
PaO2 RA
Normal
test NOT usually
necessary
60mm Hg
<60mmHg
Possible Cyanosis
PaCO2
45 mm Hg
45 mm Hg
>45 mm Hg possible
respiratory failure
SaO2 RA 95%
90-94%
<60%
<90%
Hypercapnea (hypoventilation) develops more rapidly in young children
RESPIRATORY
ARREST
IMMINENT
Absence suggests
respiratory muscle
fatigue
GINA ASTHMA GUIDELINES: (2002, 2006,2007)
Management of Asthma Exacerbation in Acute Care
S1
Initial Assessment
History, Physical Examination(auscultation, use of accessory muscles,
HR, RR, PEF or FEV1, O2 saturation, ABG’s if patient in extremis)
Initial Treatment
Oxygen to achieve O2 saturation ≥90% (95% in children)
Inhaled rapid β2-agonist continuously for one hour
Systemic GCS, if no immediate response, or if patient recently took
Oral GCS, of if episode is severe
SEDATION is CONTRAINDICATED in the treatment of an exacerbation
Reassess after 1 hour : PE, PEF, O2
saturation & other tests as needed
Criteria for MODERATE Episode:
• PEF 60-80% predicted/personal best
• Physical exam: moderate symptoms,
• Accessory muscle use
Treatment:
O2,
Inhaled β2 agonist + anticholinergic
every 60 min
Oral GCS
Continue treatment for 1-3
hours,provided
There is improvement
Criteria for SEVERE Episode:
• History of risk factors for near fatal
asthma
• PEF < 60% predicted/personal best
• PE: severe symptoms at rest, chest
retraction
NO improvement after initial treatment
Treatment:
O2,
Inhaled β2 agonist + anticholinergic
Systemic GCS
IV Magnesium
Continuation next slide
GINA ASTHMA GUIDELINES: (2002, 2006,2007)
Cont. (S2)
Management of Asthma Exacerbation in Acute Care
Reassess after 1 – 2 hours
Good Response within 1-2
hours:
Response sustained 60 minutes
after last treatment
PE normal: no distress
PEF > 70%
O2 saturation > 90% (95% in
children)
Incomplete Response within 1-2
hours:
Risk Factors for near fatal asthma
PE : mild to moderate signs
PEF < 60%
O2 saturation: NOT IMPROVING
ADMIT to ACUTE CARE Setting
• Oxygen
• Inhaled β2-agonist ±
anticholinergic
• Systemic GCS
• Intravenous Magnesium
•Monitor PEF, O2 saturation, Pulse
Improved: Criteria for Discharging Home
PEF > 60% predicted / personal best
Sustained on oral/inhaled medications
HOME TREATMENT:
• Continue inhaled β2 agonist
•Consider in most cases, oral GCS
•Consider adding a combination inhaler
•Patient education: take medicine correctly
review action plan
close medical check up
Poor Response within 1-2 hours:
Risk factors fro near fatal asthma
PE : symptoms severe, drowsiness,
confusion
PEF : < 30%
PCO2 : > 45mmHg
PO2: < 60mmHg
ADMIT to INTENSIVE Care
• Oxygen
• Inhaled β2agonist+anticholinergic
• IV GCS
•Consider IV β2 agonist
• Consider IV theophylline
• Possible intubation
• mechanical ventilation
Reassess at Intervals
Improved
Poor Response:
• Admit to intensive Care
Incomplete response in 6-12 hours
• Consider admission to Intensive Care
•If No improvement within hours
Inhaled β2-agonists are the
mainstay of therapy in acute
asthma.
However, once response to the initial
β2-agonists is minimal, incomplete or
poor …
COMBINATION of INHALED β2-AGONIST
and INHALED ANTICHOLINERGIC is
RECOMMENDED
GINA ASTHMA GUIDELINES:
2002
Recommended Medications by Level of Severity: Children
All Steps: In addition to daily controller therapy, rapid-acting inhaled β2 agonist* should be taken as
needed to relieve symptoms, but should not be taken more than 3 to 4 times a day.
PERSISTENT
INTERMITTENT
MILD
Daily Controller • None
Medications
necessary
Other
Treatment
Options
MODERATE
SEVERE
• IGCS
100-400mcg
BUD
IGCS 400-800µg BUD
• IGCS >800µg BUD
PLUS one or more
of the following:
• Sustainedrelease
Theophylline,
•IGCS< 800µg BUD
PLUS
Sustained released
theophylline OR
• Sustainedrelease theophylline
OR
• Cromone,
OR
• Leukotriene
modifier
• IGCS <800µg BUD
•PLUS LABA
OR
• IGCS >800µg OR
•IGCS <800mcg PLUS
• Leukotriene
modifier
• Long Acting Inhaled
β-2 agonist
• Leukotriene
modifier
• Oral glucocortico
steroid
In all steps: Once control of asthma is achieved and maintained for at least 3months, a gradual
reduction of the maintenance therapy should be tried in order to identify the minimum therapy
required to maintain control
REDUCE
LEVEL OF CONTROL
TREATMENT OF ACTION
maintain and find lowest
controlling step
partly controlled
consider stepping up to
gain control
INCREASE
controlled
uncontrolled
exacerbation
step up until controlled
treat as exacerbation
GINA Guidelines 2006
REDUCE
TREATMENT STEPS
INCREASE
STEP
STEP
STEP
STEP
STEP
1
2
3
4
5
GINA 2006
Asthma Medications
 As needed: RELIEVER
BRONCHODILATORS
 Short acting β2-Agonists
 Anticholinergics (inhaled)
 Short acting Theophyllines
 Daily: CONTROLLER
ANTI-INFLAMMATORY




Corticosteroids (inhaled and systemic)
Leukotriene modifier
Long acting β2 agonists
Sustained release theophyllines
GINA 2006
Inhaled Corticosteroids
 Most effective long-term control for persistent
asthma
 Small risk for adverse events at recommended
dosage
 Benefits of daily use
 Reduction of
asthma symptoms
 frequency of exacerbations
 airway inflammation
 airway responsiveness
 asthma mortality
 Improvement of
 lung function
 quality of life

Estimated Equipotent Doses of Inhaled
Glucocorticosteroids for Children
Drug
Low Daily Dose
(µg)
Medium Daily
Dose (µg)
High Daily Dose
(µg)
Beclomethasone
dipropionate
100-200
>200-400
>400
Budesonide*
100-200
>200-400
>400
Budesonide-Neb
Inhalation Susp.
250-500
>500-1000
>1000
80-160
>160-320
>320
Flunisolide
500-750
>750-1250
>1250
Fluticasone
100-200
>200-500
>500
Mometasone
furoate*
100-200
>200-400
>400
Triamcinolone
acetonide
400-800
>800-1200
>1200
Ciclesonide*
GINA 2006
COMPARISON OF PHARMACOKINETICS &
PHARMACODYNAMIC PARAMETERS OF ICS
PARAMETERS
BDP/BMP
BUD
FP
LIPOPHILICITY
Mod/high
Low
High
PROTEIN
BINDING:FREE
FRACTION
T1/2, hr
87:13
88:12
90:10
0.5/2.7
2.8
7.8
Vd, Li
20/424
183
318
Clearance, L/h
15/120
84
69
TECHNIQUES FOR BALANCING SAFETY
AND EFFICACY OF ICS

Selection and use of ICS
1. Select safest ICS drug
2. Use minimum effective dose
3. Dose in AM when once daily dosing
4. If control is poor, add another controller rather
than double dose of ICS
5. To maximize ICS delivery to lung, consider:




6.
CFC vs HFA propellant formulation
pMDI vs DPI formulation
Use of spacer device
Patient technique
Rinse mouth of ICS and discard
TECHNIQUES FOR BALANCING SAFETY
AND EFFICACY OF ICS
 Use of ICS – sparing strategies
 Reduce allergens and smoke
 Inoculate with influenza vaccine
 Diagnose and treat rhinosinusitis or GERD
 Use add-on therapies
 Monitor growth at all ICS doses
 Monitor eyes and bone mineral
density when using > 1600 ug/day
ICS
 Consider first line alternatives to ICS
for mild persistent asthma
SYSTEMIC SIDE EFFECTS OF ICS THERAPY IN
CHILDREN
EVIDENCE
GRADE
EFFECT ON
CONCLUSION
A, B, C
GROWTH
Potential to decrease growth velocity. Effects are small,
non-progressive, reversible
A
BONE
MINERAL
DENSITY
No serious adverse effects
A, C
CATARACTS
GLAUCOMA
No significant effects on incidence of subcapsular
cataracts or glaucoma
A, C
HPA AXIS
FUNCTION
Rare individuals may be susceptible to ICS effects on
HPA axis even on conventional doses
LEUKOTRIENE MODIFIERS
Mechanisms
5-LO inhibitors (zileuton)
CysLT 1 receptor antagonists (montelukast,
pranlukast, zafirlukast)
Indications
•
•
•
•
Alternative treatment in mild
persistent asthma
Aspirin-sensitive asthma
Add-on therapy, but less effective than LABA
Concomitant asthma with allergic rhinitis
LEUKOTRIENE MODIFIERS
CHILDREN OLDER THAN 5 YRS.
 Clinical benefit at all levels of severity,
but, generally less that that of low-dose
ICS
 Partial protection against EIA
 As add-on treatment
CHILDREN 5 YRS. AND YOUNGER
 In addition to above, it reduces viral-
induced asthma exacerbation in children
2-5 yrs with a history of intermittent
asthma.
GINA 2006
LONG-ACTING INHALED B2-AGONISTS
 Monotherapy should be avoided
 Most effective when combined with ICS,
preferably in a fixed combination inhaler
 May be used to prevent exercise-induced
bronchospasm
 Regular use of rapid acting B2-agonists, in
both short and long acting forms, may lead
to relative refractoriness to B2-agonists
THEOPHYLLINES
 Effective as monotherapy and as add-on
treatment to ICS or oral steroids, but
efficacy is less than that of low-dose ICS
 Anti-inflammatory function noted at low
dose of less than 10 mkd
 As add-on therapy, theophylline is less
effective than LABA
 Side effects: GI, arrhythmias, seizures,
drug interactions
CROMONES: Na CROMOGLYCATE
AND NEDOCROMIL Na
 Limited role in long term treatment of
asthma in children
 Can attenuate bronchospasm induced by
exercise or cold air
 Side effect: Uncommon, cough and sore
throat
ANTI-IgE TREATMENT
(Omalizumab)
Addition to other controller
medications has been shown
to improve control of allergic
asthma (Evidence A)
Manage Exacerbations
 Do not underestimate the severity of an
attack
 Patient should seek medical help if:
 The attack is severe
 The response to the initial bronchodilator
treatment is not prompt
 There is no improvement within 2-6 hours
 There is further deterioration
Manage Exacerbations
 Asthma Attack requires prompt
treatment:
 Inhaled rapid acting B2-agonists
 Oral glucocorticosteroids
 Oxygen (to achieve SaO2 of 95%)
 Combination B2-agonist/anticholinergic
therapy
 Therapies not recommended:
 Sedatives
 Mucolytics
 Chest physical therapy
Manage Exacerbations
 Do not underestimate the severity of an
attack
 Patient should seek medical help if:
 The attack is severe
 The response to the initial bronchodilator
treatment is not prompt
 There is no improvement within 2-6 hours
 There is further deterioration
Bronchodilators : Mechanism of Action
RELIEVER MEDICATIONS
 RAPID ACTING INHALED
B2-AGONISTS
 Most effective bronchodilator
 Preferred treatment for acute asthma
 Inhaled route is preferred
 Protection against exercise-induced
bronchoconstriction
 Oral therapy is rarely needed and reserved
for young children who cannot use inhaled
therapy
RELIEVER MEDICATIONS
 ANTICHOLINERGICS
 Inhaled anticholinergics are not
recommended for long term management of
asthma inchildren
Comparative Pharmacokinetics of
Nebulized Salbutamol and Ipratropium
Parameters
Onset of
bronchodilation
Peak effect
Duration of effect
Salbutamol
Ipratropium
within 5 mins.
within 15-30
minutes
1-2 hours
1-2 hours
3-4 hours
5-7 hours
http://www.medscape.com/druginfo/monograph
REFERRAL to an Asthma Specialist (NAEP
EPR 3 Report)
 Difficulties achieving or maintaining
control of asthma
 Patient required > 2 bursts of oral steroids
in 1 year or has an exacerbation requiring
hospitalization
 Step 4 care or higher is required (Step 3
care or higher for 0-4 years)
 If immunotherapy or omalizumab is
considered or if additional testing is
indicated
SUMMARY
 Asthma is a serious chronic
inflammatory disease of the airways
 Controller medication – primarily
inhaled corticosteroids – is the
cornerstone of asthma management
 Essential components of successful
asthma management include
 Pharmacotherapy
 Allergen avoidance
 Patient education
 Use of a standardized diagnostic
questionnaire, use of an asthma control
test
SUMMARY
• ALLERGEN AVOIDANCE is recommended when
there is sensitization and a clear association
between allergen exposure and symptoms.
• ALLERGY TESTING (at all ages) to confirm the
possible contribution of allergens to asthma
exacerbation
• EXERCISE SHOULD NOT BE AVOIDED:
Asthmatic children should be encouraged to
participate in sports, with efficient control of
asthma inflammation and symptoms.
Thank You