Transcript Diagnosing and Managing Asthma in Children

Diagnosing and Managing
Asthma in Children
LARRY S. POSNER M.D.
Associate Clinical Professor of Pediatrics, UCSF
Principal, North Bay Allergy and Asthma Associates
Asthma Is Prevalent:
Significant Morbidity and
Mortality
32.6 Million People Have Had an Asthma Diagnosis in
Their Lifetime
22.2 Million People Are Currently
Diagnosed With Asthma
12.2 Million People Suffer From
Asthma Attacks Annually
Approximately 4000 AsthmaRelated Deaths Occur Annually
Approximately 11 People Die From Asthma Each Day
Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/asthma/asthma.htm. Accessed March 12, 2007.
Pediatric Asthma: Facts and
Figures
• Asthma is the most common chronic
disorder in children and adolescents1
• Asthma is a leading cause of school
absences, resulting in 14 million
missed school days a year2
1. American Academy of Allergy, Asthma, and Immunology, Inc., 1999.
2. Mannino DM, et al. MMWR Morb Mortal Wkly Rep. March 29, 2002;51(SS01);1-13.
Prevalence (%)
Child and Adult Asthma Prevalence
United States, 1980-2007
14
• Child
12
 Adult
Lifetime
10
8
6
Current
4
2
12-Month
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
20
06
0
Source: National Health Interview Survey; CDC National Center for Health Statistics
Year
Asthma Trends
A child born a generation
from now is twice as
likely to develop
asthma as one
born today
Number of Deaths Among Children
Aged 0-17 Years Due to Asthma
Has Declined Since 1996
4
3
ICD Revision 1999
Asthma Deaths per
1 Million Children
5
2
1
0
1980
1984
1988
1992
1996
2000
2004
Beginning with data year 1999, cause-of-death statistics published by NCHS are classified according to the Tenth
Revision of the International Classification of Diseases (ICD-10).
CDC/NCHS, Mortality Component of the National Vital Statistics System.
US Department of Health and Human Services. Centers for Disease Control and Prevention National Center for
Health Statistics. Number 381, December 12, 2006.
Emergency Department Visits and
Hospitalizations for Asthma Remain High
Among Children Aged 0-17 Years
40
140
Asthma Hospitalizations
per 10,000 Children
Emergency Visits
per 10,000 Children
120
100
80
60
40
30
20
10
20
0
1992
1994
1996
1998
2000
2002
CDC/NCHS, National Hospital Ambulatory
Medical Care Survey
2004
0
1980
1984
1988
1992
1996
2000
2004
CDC/NCHS, National Hospital Discharge Survey
Asthma ED visits represented about 3% of all ED visits among children 0-17 years of age in 2004.
Asthma hospitalizations represented about 3% of all hospitalizations among children 0-17 years of age in 2004.
US Department of Health and Human Services. Centers for Disease Control and Prevention National Center for
Health Statistics. Number 381, December 12, 2006.
Are Children With Asthma
Achieving the NIH Goals of
Therapy?
Where Should We Start
NIH Goals of Asthma Therapy
• Minimal or no chronic symptoms day or night
• Minimal or no exacerbations
• No limitations on activities; no missed
school/work
• Maintain (near) normal pulmonary function
• Minimal use of inhaled short-acting beta2-
agonists
• Minimal or no adverse effects from medications
Guidelines for the Diagnosis and Management of Asthma—Update on
Selected Topics 2002. NIH, NHLBI. May 2003 (reprint).
NIH publication 02-5075.
Children and Asthma in America
Goals of Asthma Therapy Are Inadequately
Met
% of Respondents
100
80
67%
62%
54%
60
54%
40
20
0
Activity
Limitation
Missed School
in Past Year
Symptoms in
Past 4 Weeks
Sudden Severe
Episodes in Past Year
Children and Asthma in America: A Landmark Survey. Executive Summary. SRBI; 2004.
Children and Asthma in America
Parent-Child Gap in Perception of
Asthma Symptoms in the Past 4 Weeks
68%
70%
Parents
Children (10-15)
60%
% of Respondents
60%
50%
50%
44%
40%
27% 26%
30%
20%
10%
0%
During Day
During Exercise
During Night
Children and Asthma in America: A Landmark Survey. Executive Summary. SRBI; 2004.
Children and Asthma in America
• Many children with asthma are not achieving
the NIH goals of therapy
• Poorly controlled asthma has a significant
impact on daily lives of children and their
families
• The survey highlights the need for improved
asthma management
•
Better assessment and treatment
• Proper patient and family education
• Improved dialogue between the child, parents, and
their clinician
Diagnosing Asthma:
Spirometry
Testing of lung
function is one
means of
diagnosing asthma.
Challenges in Treating Childhood
Asthma
 May
be difficult to make a “definitive” diagnosis
in very young children
 Lack of objective measurement
 Lack of subjective awareness of symptoms
 Underdiagnosis
in children
of asthma is a frequent problem
Diagnosing Asthma:
Medical History
• Symptoms
• Coughing
• Wheezing
• Shortness of breath
• Chest tightness
• Patterns to Symptoms
• Family History
• Response to medication
Onset of Symptoms in Children With
Asthma
20%
1-2 years
20%
2-3 years
McNicol and Williams. BMJ 1973;4:7-11.
Wainwright et al. Med J Aust 1997;167:218-222.
30%
<1 year
30%
>3 years
Asthma is a Spectrum of
Disease
Mild intermittent asthma
Cough/wheeze only with
colds or exercise
Severe persistent asthma
Daily symptoms
at rest
Precipitating / Aggravating Factors
“Asthma triggers”


Viral upper respiratory
infections
Allergen exposure

Exercise

Irritants (especially smoke)

Weather
 Strong emotion
 Gastroesophageal reflux
Approaches to Treatment
• AVOIDANCE

Environmental control
• PHARMACOLOGIC THERAPY

Step therapy per NHLBI guidelines
• ALLERGY IMMUNOTHERAPY
Avoidance
• Influenza vaccination
• Tobacco smoke
• Fireplace smoke
• Air “fresheners”
• Allergens
Reducing Indoor Allergens
House-Dust Mites
• Essential:
•
•
•
•
•
Encase mattress/box-spring in an allergenimpermeable cover
Encase pillow in an allergen-impermeable cover or
wash weekly
Wash sheets and blankets in hot water weekly
(>130o F is necessary for killing mites)
Remove other reservoirs from the bedroom
Carpet treatments unclear
Cat Allergen
• Major cat allergen Fel d1 found in saliva
and dander
• In homes with indoor cats, 35% of
allergen reservoir is continually airborne.
• Dander accumulates in carpet upholstered
furniture and bedding
• Cat dander is an almost ubiquitous indoor
allergen
Teach Patients To Reduce
Exposure to Inhalant Allergens
ANIMAL DANDER
• Remove pet from
• Wipe down surfaces
house (ideal)
• Keep animal out of
patient’s bedroom
(at a minimum)
• Mattress/pillow
encasements
with a damp cloth
• Portable HEPA air
filtration
• Keep window closed
• Seal or put a filter on air
ducts that lead to
bedroom
Pharmacotherapy
Stepwise Approach to Therapy
for Adults and Children:
Maintaining Control
STEP 4
Multiple longterm-control medications,
including prednisone
STEP 4
Severe Persistent
STEP 3
Moderate Persistent
STEP 2
Mild Persistent
STEP 1
Mild Intermittent
Step
Down
STEP 3
> 1 Long-term-control meds
(Preferred low dose ICS+LABA)
STEP 2
1 Long-term-control
medication: anti-inflammatory
(Preferred low-dose ICS)
STEP 1
Quick-relief medication: PRN
Step
Up
2007 NIH Asthma Guidelines: Patients 5-11 Years of Age
(For patients newly diagnosed or on SABA alone)
COMPOMENTS OF
SEVERITY
Impairment
Classification of Asthma Severity: 5–11 Years of Age
PERSISTENT
NTERMITTENT
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 beta2agonist use for
symptom control (not
prevention of EIB)
≤2 days/week
>2 days/week but
not daily
Daily
Interference with
normal activity
None
Minor limitation
Some limitation
• Normal FEV1 between
Lung function
exacerbations
• FEV1 >80% predicted
• FEV1 = >80%
predicted
• FEV1/FVC >80%
• FEV1/FVC >85%
0–1/year
Risk
Exacerbations
requiring oral systemic
corticosteroids
• FEV1 = 60%–
80%
predicted
• FEV1/FVC =
Several times
per day
Extremely limited
• FEV1 < 60%
predicted
• FEV1/FVC <75%
75%–80%
≥2/year
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 therapy
Step 1
Step 2
Step 3,
medium-dose
ICS option
Step 3, mediumdose ICS option, or
step 4
and consider short course of systemic
oral corticosteroids
In 2–6 weeks, evaluate level of asthma control achieved; adjust therapy accordingly
NIH, National Heart, Lung and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR–3 2007). NIH
Item No. 08–4051. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed December 19, 2008.`
Goal of Asthma Therapy:
ACHIEVE CONTROL
Reduce Impairment
• Prevent chronic and troublesome symptoms
• Require infrequent use of inhaled SABA (≤2 days/week)
• Maintain (near) “normal” pulmonary function
• Maintain normal activity levels
• Meet patients’ expectations of, and satisfaction with, asthma care
Reduce Risk
• Prevent recurrent exacerbations
• Minimize need for emergency department visits or hospitalizations
• Prevent progressive loss of lung function
• Provide optimal pharmacotherapy, with minimal or no adverse effects
NAEPP = National Asthma Education and Prevention Program; SABA = short-acting β2-agonists.
Stepwise Approach for Managing Asthma
in Children Aged 5 to 11 Years:
NAEPP Guidelines
Step 6
Step 5
Step 4
Step 3
Step 1
Preferred:
SABA prn
Step 2
Preferred:
Low-Dose ICS (A)
Alternative: LTRA
(B),
Cromolyn (B),
Nedocromil (B),
or
Theophylline (B)
LTRA = leukotriene receptor antagonist.
Preferred:
Medium-Dose
ICS (B)
or
Low-Dose ICS
and either
LABA (B),
LTRA (B),
or
Theophylline (B)
Preferred:
Medium-Dose
ICS + LABA (B)
Alternative:
Medium-Dose
ICS
and either
LTRA (B)
or
Theophylline (B)
Preferred:
High-Dose ICS +
Preferred:
LABA + Oral
High-Dose ICS
Corticosteroid (D)
+ LABA (B)
Alternative:
Alternative:
High-Dose ICS
High-Dose ICS
and either
and either
LTRA or
LTRA (B)
Theophylline
or
and Oral
Theophylline (B) Corticosteroid (D)
----------------------------
Stepwise Approach for Managing Asthma
in Children Aged 0 to 4 Years:
NAEPP Guidelines
Intermittent
Moderate to Severe Persistent
Mild
Persistent
Step 6
Step 5
Step 4
Step 3
Step 2
Step 1
Preferred:
SABA prn
Preferred:
Low-Dose ICS (A)
Alternative:
Montelukast (A)
or
Cromolyn (B)
Preferred:
Medium-Dose
ICS (D)
Preferred:
Medium-Dose
ICS
and either
Montelukast
or
LABA (D)
ICS = inhaled corticosteroid; LABA = long-acting β2-agonist; SABA = short-acting β2-agonist.
Preferred:
High-Dose
ICS
and either
Montelukast
or
LABA (D)
Preferred:
High-Dose
ICS
and either
Montelukast
or LABA
and
Oral
Corticosteroids (D)
Immunotherapy for Asthma
Meta-analyses:
•
Abramson et al
•
•
•
AJRCCM 1995;151:969-974
Allergy 1999;54:1022-41
Ross et al
•
Clinical Therapeutics 2000;22:329-341
What’s the Evidence?
30
25
24
20
Meta-analysis of clinical studies
962 asthmatics with documented allergy
Immunotherapy clinically effective in 71% of studies
15
10
10
7
5
0
Total
Studies
Effective
No. of studies
with children
with children
Source: Ross RN, Nelson HS, Finegold I. Clin Ther 2000
Prevention of asthma in patients
with Seasonal Allergic rhinitis
Percentage of patients
80
Odds ratio 2.52
70
No asthma
Asthma
60
50
40
30
20
10
0
Immunotherapy
Control
Moller et al. J Allergy Clin Immunol. 2002 Feb;109(2):251-6.
Prevention of New Sensitivities
After Treatment of 3 Years
14
12
New sensitivities
10
8
6
4
2
0
None
Cat
Dog
Control
Source:Roches et al. JACI.
Alternaria
Grass
Prevention of New Sensitivities
After Treatment of 3 Years
14
12
New sensitivities
10
8
6
4
2
0
None
Cat
Dog
Control
Source:Roches et al. JACI.
Alternaria
Active
Grass
Summary
• Asthma in children is increasing in prevalence
• While mortality from asthma has improved in recent
years, morbidity has not
• The diagnosis of asthma in young children is challenging
• Asthma is children is generally not adequately controlled.
• Management of asthma includes reduction of triggers,
pharmacotherapy and immunotherapy
• NHLBI guidelines for asthma management emphasizes:
•
assessing control at each visit
•
Stepping up or down therapy