Transcript 2016 Paper on Childhood Asthma - Medical Women Association of

Dr ONUBOGU UCHENNA MBBS;FWACP
CONSULTANT PAEDIATRICIAN
BRAITHWAITE MEMORIAL SPECIALIST HOSPITAL
11th October 2016
MWAN CME at House of Assembly complex PH
Outline
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Introduction
Epidemiology
Etiology
Pathogenesis
Symptoms
Diagnosis
Laboratory Test
Management
Conclusion
Introduction
 Asthma is a chronic inflammatory disease of the airways,
characterized by variable and recurring symptoms,
reversible airflow obstruction and bronchospasm.
Prevalence of asthma in children aged
13-14 years
© Global
Initiative for Asthma
GINA 2016 Appendix Box A1-1; figure provided by
R Beasley
© Global Initiative for Asthma
Epidemiology
 Global increase in asthma prevalence of about 50% per decade.
 80% of all asthmatics report disease onset prior to 6 yr of age.
 More common among city dwellers than those living in rural areas
Portharcourt
BMSH
 Asthma accounted for
3.82% of Children
emergency room visits.
12
10
10
 Highest prevalence in
May
number of patients
8
6
6
6
5.5
5
4.5
4
4
4
4
3.5
3
2
0.5
0
Portharcourt BMSH
Portharcourt (BMSH Peadiatric respiratory clinic)
 54.1% of patients were diagnosed by 6yrs
 Age range at diagnosis is 1mth - 12yrs
 M:F 1.06:1
Etiology
Pathogenesis
 Mediators - helper T lymphocytes, other immune cells ( producing
IL-4, IL-5, IL-13 and eotaxin).
 Inflammatory cells and exudates which are high eosinophils , fill
and obstruct the airways
 Induce epithelial damage and desquamation into the airways lumen
Pathogenesis
 Airways edema
 Basement membrane thickening
 Sub epithelial collagen deposition
 Smooth muscle and mucous gland hypertrophy
 Mucus hypersecretion
Pathogenesis
SYMPTOMS
 Frequent/intermittent cough
 Wheezing
 Shortness of breath
 Chest congestion/tightness
 Chest pain
 Trouble sleeping
 Limited physical activity
Asthma Triggers
 respiratory tract infections
 Animal dander
 Indoor allergens
 Dust mites
 Cockroaches
 Molds
 Seasonal aeroallergens
 Pollens (trees, grasses, weeds)
 Seasonal molds
 Gastroesophageal reflux
 Environmental tobacco smoke
 Air pollutants
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Ozone
Sulfur dioxide
Particulate matter
Wood- or coal-burning smoke
Endotoxin, mycotoxins
Dust
Asthma Triggers
 Strong or noxious odors or
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fumes
Perfumes, hairsprays
Cleaning agents
Occupational exposures
Farm and barn exposures
Formaldehydes, cedar, paint
fumes
Cold air, dry air
 Exercise
 Crying, laughter,
hyperventilation
 Co-morbid conditions
 Rhinitis
 Sinusitis
Probability of asthma diagnosis or response to asthma treatment
in children ≤5 years
GINA 2015, Box 6-1 (1/2)
Portharcourt (BMSH) 61.5% have known family history of atopy
© Global Initiative for Asthma
Diagnosis
Asthma Predictive Index for Children
MAJOR CRITERIA
MINOR CRITERIA
Parent asthma
Allergic rhinitis
Eczema
Wheezing apart from colds
Inhalant allergen sensitization
Eosinophils ≥ 4%
Food allergen sensitization
1 Major or 2 minor specificity 97%, PPV 77% for persistent asthma into later childhood
Laboratory test
Laboratory tests
 Spirometry - Low FEV1 , FEV1/FVC ratio <0.80
 Bronchodilator response - ↑ FEV1 ≥12% or ≥200 mL[*]
 Exercise challenge - Worsening in FEV1 ≥15%[*]
 PEF variation >20% is consistent
Laboratory test
PEF monitoring
Spirometry
Laboratory test
Laboratory test
 Exhaled nitric oxide (FENO) ↑
 CXR - often normal, but can show flattening of the diaphragms and
peribronchial thickening
 Allergy testing to assess sensitization
Goal of management
 Minimal or no chronic symptoms day or night
 Minimal or no exacerbations
 No limitations on activities; no school/parent's work missed
Management
CONTROL OF FACTORS CONTRIBUTING TO ASTHMA
SEVERITY
 Eliminate or reduce problematic environmental exposures
 Treat co-morbid conditions: rhinitis, sinusitis,
gastroesophageal reflux.
Assessment in young children
Asthma CONTROL means the extent to which
manifestation of asthma is removed or reduced
including by treatment has 2 components:
 Symptom control – asthma status in previous 4
weeks
 Future risk – how asthma may affect the child in
future
GINA assessment of asthma control in
children ≤5 years
A. Symptom control
Level of asthma symptom control
In the past 4 weeks, has the child had:
• Daytime asthma symptoms for more than
few minutes, more than once/week? Yes No
• Any activity limitation due to asthma?
(runs/plays less than other children,
tires easily during walks/playing)
Yes No
• Reliever needed* more than once a
week?
• Any night waking or night coughing
due to asthma?
Wellcontrolled
Partly
controlled
Uncontrolled
None of
these
1-2 of
these
3-4 of
these
Yes No
Yes No
B. Risk factors for poor asthma outcomes
ASSESS CHILD’S RISK FOR:
• Exacerbations within the next few months
• Fixed airflow limitation
• Medication side-effects
GINA 2016, Box 6-4A
© Global Initiative for Asthma
Risk factors for poor asthma outcomes in
children ≤5 years
Risk factors for exacerbations in the next few months
•
•
•
•
Uncontrolled asthma symptoms
One or more severe exacerbation in previous year
The start of the child’s usual ‘flare-up’ season (especially if autumn/fall)
Exposures: tobacco smoke; indoor or outdoor air pollution; indoor allergens (e.g.
house dust mite, cockroach, pets, mold), especially in combination with viral infection
• Major psychological or socio-economic problems for child or family
• Poor adherence with controller medication, or incorrect inhaler technique
GINA 2016, Box 6-4B (1/3)
© Global Initiative for Asthma
Risk factors for poor asthma outcomes in
children ≤5 years
Risk factors for exacerbations in the next few months
•
•
•
•
Uncontrolled asthma symptoms
One or more severe exacerbation in previous year
The start of the child’s usual ‘flare-up’ season (especially if autumn/fall)
Exposures: tobacco smoke; indoor or outdoor air pollution; indoor allergens (e.g.
house dust mite, cockroach, pets, mold), especially in combination with viral infection
• Major psychological or socio-economic problems for child or family
• Poor adherence with controller medication, or incorrect inhaler technique
Risk factors for fixed airflow limitation
• Severe asthma with several hospitalizations
• History of bronchiolitis
GINA 2016, Box 6-4B (2/3)
© Global Initiative for Asthma
Risk factors for poor asthma outcomes in
children ≤5 years
Risk factors for exacerbations in the next few months
•
•
•
•
Uncontrolled asthma symptoms
One or more severe exacerbation in previous year
The start of the child’s usual ‘flare-up’ season (especially if autumn/fall)
Exposures: tobacco smoke; indoor or outdoor air pollution; indoor allergens (e.g.
house dust mite, cockroach, pets, mold), especially in combination with viral infection
• Major psychological or socio-economic problems for child or family
• Poor adherence with controller medication, or incorrect inhaler technique
Risk factors for fixed airflow limitation
• Severe asthma with several hospitalizations
• History of bronchiolitis
Risk factors for medication side-effects
• Systemic: Frequent courses of OCS; high-dose and/or potent ICS
• Local: moderate/high-dose or potent ICS; incorrect inhaler technique; failure to protect
skin or eyes when using ICS by nebulizer or spacer with face mask
GINA 2016, Box 6-4B (3/3)
© Global Initiative for Asthma
Management
ASTHMA PHARMACOTHERAPY
 Long-term-control vs quick-relief medications
 Classification of asthma severity for anti-inflammatory meds
 Step-up, step-down approach
 Asthma exacerbation management
Classification of Severity
CLASSIFICA
TION
Severe
persistent
Moderate
persistent
Mild
persistent
Mild
intermittent
4
NIGHTS
DAYS WITH WITH
SPIROMETER OR PEAK
SYMPTOMS SYMPTOMS FLOW METER
FEV1 or PEF[*] PEF
% Predicted Variability
Normal
(%)
Continual
Frequent
≤60
>30
3
Daily
2
>2/wk, but <1 >2/mo
time/day
≤2/wk
<2/mo
STEP
1
>1/wk
>60–<80
>30
≥80
20–30
≥80
<20
Symptom severity
(Portharcourt BMSH)
Severe Persitent, 20%
Intermittent , 46%
Moderate Persistent, 23%
Mild persitent, 11%
Control-based asthma management cycle in
children ≤5 years
Diagnosis
Symptom control & risk factors
Inhaler technique & adherence
Parent preference
Symptoms
Exacerbations
Side-effects
Parent satisfaction
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
GINA 2016, Box 6-5 (1/8)
© Global Initiative for Asthma
Stepwise approach – pharmacotherapy
(children ≤5 years)
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
Other
controller
options
Daily low dose ICS
Double
‘low dose’
ICS
Continue
controller
& refer for
specialist
assessment
Leukotriene receptor antagonist (LTRA)
Low dose ICS + LTRA
Add LTRA
Intermittent ICS
Inc. ICS
frequency
Add intermitt ICS
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
STEP 3
STEP 2
As-needed short-acting beta2-agonist (all children)
Infrequent
viral wheezing
and no or
few interval
symptoms
GINA 2016, Box 6-5 (3/8)
Symptom pattern consistent with asthma
and asthma symptoms not well-controlled, or
≥3 exacerbations per year
Asthma diagnosis, and
not well-controlled on
low dose ICS
Symptom pattern not consistent with asthma but
wheezing episodes occur frequently, e.g. every
6–8 weeks.
Give diagnostic trial for 3 months.
First check diagnosis, inhaler skills,
adherence, exposures
Not wellcontrolled
on double
ICS
© Global Initiative for Asthma
Step 1 (children ≤5 years) – as-needed inhaled
SABA
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
Other
controller
options
Daily low dose ICS
Double
‘low dose’
ICS
Continue
controller
& refer for
specialist
assessment
Leukotriene receptor antagonist (LTRA)
Low dose ICS + LTRA
Add LTRA
Intermittent ICS
Inc. ICS
frequency
Add intermitt ICS
As-needed short-acting beta2-agonist (all children)
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
STEP 3
STEP 2
Infrequent
viral wheezing
and no or
few interval
symptoms
GINA 2016, Box 6-5 (5/8)
Symptom pattern consistent with asthma
and asthma symptoms not well-controlled, or
≥3 exacerbations per year
Asthma diagnosis, and
not well-controlled on
low dose ICS
Symptom pattern not consistent with asthma but
wheezing episodes occur frequently, e.g. every
6–8 weeks.
Give diagnostic trial for 3 months.
First check diagnosis, inhaler skills,
adherence, exposures
Not wellcontrolled
on double
ICS
© Global Initiative for Asthma
Step 2 (children ≤5 years) – initial controller
+ as-needed SABA
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
Other
controller
options
Daily low dose ICS
Double
‘low dose’
ICS
Continue
controller
& refer for
specialist
assessment
Leukotriene receptor antagonist (LTRA)
Low dose ICS + LTRA
Add LTRA
Intermittent ICS
Inc. ICS
frequency
Add intermitt ICS
As-needed short-acting beta2-agonist (all children)
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
STEP 3
STEP 2
Infrequent
viral wheezing
and no or
few interval
symptoms
GINA 2016, Box 6-5 (6/8)
Symptom pattern consistent with asthma
and asthma symptoms not well-controlled, or
≥3 exacerbations per year
Symptom pattern not consistent with asthma but
wheezing episodes occur frequently, e.g. every
6–8 weeks.
Give diagnostic trial for 3 months.
Asthma diagnosis, and Not wellnot well-controlled on controlled
low dose ICS
on double
ICS
First check diagnosis, inhaler skills,
adherence, exposures
© Global Initiative for Asthma
Step 3 (children ≤5 years) – medium dose ICS
+ as-needed inhaled SABA
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
Other
controller
options
Daily low dose ICS
Double
‘low dose’
ICS
Continue
controller
& refer for
specialist
assessment
Leukotriene receptor antagonist (LTRA)
Low dose ICS + LTRA
Add LTRA
Intermittent ICS
Inc. ICS
frequency
Add intermitt ICS
As-needed short-acting beta2-agonist (all children)
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
STEP 3
STEP 2
Infrequent
viral wheezing
and no or
few interval
symptoms
GINA 2016, Box 6-5 (7/8)
Symptom pattern consistent with asthma
and asthma symptoms not well-controlled, or
≥3 exacerbations per year
Asthma diagnosis, and
not well-controlled on
low dose ICS
Not wellcontrolled
on double
ICS
Symptom pattern not consistent with asthma but
wheezing episodes occur frequently, e.g. every
6–8 weeks.
Give diagnostic trial for 3 months.
First check diagnosis, inhaler skills,
adherence, exposures
© Global Initiative for Asthma
Step 4 (children ≤5 years) – refer for expert
assessment
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
Other
controller
options
Daily low dose ICS
Double
‘low dose’
ICS
Leukotriene receptor antagonist (LTRA)
Low dose ICS + LTRA
Intermittent ICS
Continue
controller
& refer for
specialist
assessment
Add LTRA
Inc. ICS
frequency
Add intermitt ICS
As-needed short-acting beta2-agonist (all children)
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
STEP 3
STEP 2
Infrequent
viral wheezing
and no or
few interval
symptoms
GINA 2016, Box 6-5 (8/8)
Symptom pattern consistent with asthma
and asthma symptoms not well-controlled, or
≥3 exacerbations per year
Asthma diagnosis, and
not well-controlled on
low dose ICS
Not wellcontrolled
on double
ICS
Symptom pattern not consistent with asthma but
wheezing episodes occur frequently, e.g. every
6–8 weeks.
Give diagnostic trial for 3 months.
First check diagnosis, inhaler skills,
adherence, exposures
© Global Initiative for Asthma
Stepwise management – pharmacotherapy for
children > 5yrs
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Symptoms
Exacerbations
Side-effects
Asthma medications
Patient satisfaction
Non-pharmacological strategies
Lung function
Treat modifiable risk factors
STEP 5
STEP 4
STEP 3
PREFERRED
CONTROLLER
CHOICE
STEP 1
Low dose ICS
Other
controller
options
RELIEVER
Consider low
dose ICS
Refer for
add-on
treatment
STEP 2
Leukotriene receptor antagonists (LTRA)
Low dose theophylline*
As-needed short-acting beta2-agonist (SABA)
GINA 2016, Box 3-5 (2/8) (upper part)
Low dose
ICS/LABA**
Med/high
ICS/LABA
e.g.
tiotropium,*
omalizumab,
mepolizumab*
Med/high dose ICS Add tiotropium* Add low
Low dose ICS+LTRA High dose ICS dose OCS
+ LTRA
(or + theoph*)
(or + theoph*)
As-needed SABA or
low dose ICS/formoterol#
*Not for children <12 years
**For children 6-11 years, the
preferred Step 3 treatment is
medium dose ICS
#For
patients prescribed
BDP/formoterol or BUD/
formoterol maintenance and
reliever therapy
 Tiotropium by mist inhaler is
an add-on treatment for
patients ≥12 years with a
history of exacerbations
© Global Initiative for Asthma
Management
PATIENT EDUCATION
 Explanation of asthma and factors that influence it
 Training on correct inhalational technique with spacer device or
inhaler
 Importance of adherence
 Provide a two-part care plan : Daily management and asthma
exacerbations
Choosing an inhaler device for children ≤5 years
Age
Preferred device
Alternate device
0–3 years
Pressurized metered dose
inhaler plus dedicated spacer
with face mask
Nebulizer with face mask
4–5 years
Pressurized metered dose
inhaler plus dedicated spacer
with mouthpiece
Pressurized metered dose
inhaler plus dedicated spacer
with face mask, or nebulizer
with mouthpiece or face mask
GINA
Box6-7
6-6
GINA2015,
2015, Box
© Global Initiative for Asthma
PRIMARY CARE
ASSESS the CHILD
Child presents with acute or sub-acute asthma exacerbation
or acute wheezing episode
Consider other diagnoses
Risk factors for hospitalization
Severity of exacerbation?
SEVERE OR LIFE THREATENING
MILD or MODERATE
any of:
Unable to speak or drink
Central cyanosis
Confusion or drowsiness
Marked subcostal and/or sub-glottic
retractions
Oxygen saturation <92%
Silent chest on auscultation
Pulse rate > 200 bpm (0-3 yrs)
or >180 bpm (4-5 yrs)
Breathless, agitated
Pulse rate ≤200 bpm (0-3 yrs) or ≤180 bpm (4-5 yrs)
Oxygen saturation ≥92%
START TREATMENT
Salbutamol 100 mcg two puffs by pMDI + spacer
or 2.5mg by nebulizer
Repeat every 20 min for the first hour if needed
Controlled oxygen (if needed and available):
target saturation 94-98%
URGENT
MONITOR CLOSELY for 1-2 hours
Transfer to high level care if any of:
• Lack of response to salbutamol over 1-2 hrs
• Any signs of severe exacerbation
• Increasing respiratory rate
• Decreasing oxygen saturation
GINA 2016, Box 6-8 (2/3)
Worsening,
or lack of
improvement
TRANSFER TO HIGH LEVEL CARE
(e.g. ICU)
While waiting give:
Salbutamol 100 mcg 6 puffs by pMDI+spacer
(or 2.5mg nebulizer). Repeat every 20 min
as needed.
Oxygen (if available) to keep saturation 9498%
Prednisolone 2mg/kg (max. 20 mg for <2 yrs;
max. 30 mg for 2–5 yrs) as a starting dose
Consider 160 mcg ipratropium bromide
(or 250 mcg by nebulizer). Repeat every
20 min for 1 hour if needed.
© Global Initiative for Asthma
MONITOR CLOSELY for 1-2 hours
Transfer to high level care if any of:
Worsening,
or lack of
improvement
• Lack of response to salbutamol over 1-2 hrs
• Any signs of severe exacerbation
• Increasing respiratory rate
• Decreasing oxygen saturation
IMPROVING
CONTINUE TREATMENT IF NEEDED
Worsening,
or failure to
respond to
10 puffs
salbutamol
over 3-4 hrs
Monitor closely as above
If symptoms recur within 3-4 hrs
• Give extra salbutamol 2-3 puffs per hour
• Give prednisolone 2mg/kg (max. 20mg for
<2 yrs; max. 30mg for 2-5 yrs) orally
TRANSFER TO HIGH LEVEL CARE
(e.g. ICU)
While waiting give:
Salbutamol 100 mcg 6 puffs by pMDI+spacer
(or 2.5mg nebulizer). Repeat every 20 min
as needed.
Oxygen (if available) to keep saturation 9498%
Prednisolone 2mg/kg (max. 20 mg for <2 yrs;
max. 30 mg for 2–5 yrs) as a starting dose
Consider 160 mcg ipratropium bromide
(or 250 mcg by nebulizer). Repeat every
20 min for 1 hour if needed.
IMPROVING
DISCHARGE/FOLLOW-UP PLANNING
Ensure that resources at home are adequate.
Reliever: continue as needed
Controller: consider need for, or adjustment of, regular controller
Check inhaler technique and adherence
Follow up: within 1-7 days
Provide and explain action plan
FOLLOW UP VISIT
Reliever: Reduce to as-needed
Controller: Continue or adjust depending on cause of exacerbation, and duration of need for extra salbutamol
Risk factors: Check and correct modifiable risk factors that may have contributed to exacerbation, including
inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?
Schedule next follow up visit
GINA 2016, Box 6-8 (3/3)
© Global Initiative for Asthma
further management
 Nebulized MgSo4 – 150mg X3 doses in first I hr
 Epinephrine : SC or IM:0.01 mg/kg (max dose 0.5 mg); may repeat
after 15–30 min
 Terbutaline
RISK ASSESSMENT FOR DISCHARGE
Medical Stability Discharge to home if
sustained improvement in
symptoms and
bronchodilator treatments are
at least 3 hr apart, normal
physical findings, PEF > 70%
of predicted or personal best,
oxygen saturation > 92% on
room air
Home
Supervision
Capability to administer
intervention, and to observe
and respond appropriately to
clinical deterioration
Challenges
 Unavailability of spacer devices, Nebulizers, PEF meters.
 Poor compliance to follow up
 Gap in knowledge of health care providers on current
management .
 91.67% of asthmatic patients who needed to be placed on
control medications were not on any medication.
Improvised spacer
Challenges
 Busy clinic with inadequate manpower to assess asthmatics
properly
 Cost of medication increased financial burden on the
family
 Fear and risk of medication Side effects
Conclusion
Childhood asthma can be controlled. Lets implement the
Right management plan to help our patients live a good
quality of life .
THANK YOU