خدا نیکوست

Treatment of Treatment of Children AsthmaChildren Asthma

Dr. Fatemeh Behmanesh

Key elements to optimal Key elements to optimal

asthma managementasthma management

Assess severityAssess 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

FOR ADULTS AND CHILDREN AGE > 5 YEARS WHO CAN USE A

SPIROMETER OR PEAK FLOW METER

CLASSIFICATIONSTEPDAYS WITH SYMPTOMSNIGHTS WITH SYMPTOMS

FEV1 or PEF[*] % Predicted Normal

PEF Variability )%(

Severe persistent4ContinualFrequent≤60>30

Moderate persistent3Daily>1/wk>60<–80>30

Mild persistent2

>2/wk, but <1 time/day>2/mo≥8020–30

Mild intermittent1≤2/wk<2/mo≥80<20

Classification of Asthma Severity

Stepwise Approach for Managing Infants and Young Children Stepwise Approach for Managing Infants and Young Children (≤5 Yr of Age) with Acute or Chronic Asthma; Treatment(≤5 Yr of Age) with Acute or Chronic Asthma; Treatment        

Classify Severity: Clinical Features Before Treatment Or Adequate ControlMedications Required To Maintain Long-Term Control

      Symptoms/Day

Symptoms/Night Daily Medications Step 4 Severe persistent

Step 3 Moderate persistent       

Step 2 Mild persistent      Step 1 Mild intermittent   

Continual Frequent   

Daily>1 night/wk

>2/Week but<1 /day>2 nights/mo

2days/wk2nights/mo

• Preferred treatment- High-dose inhaled corticosteroids AND- Long-acting inhaled β2-agonistsAND, 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.

 Quick Relief All Patients            

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-anti-

inflammatory controller medicationinflammatory controller medication.

• the type and amounts of daily controller

medication are determined by asthma severityasthma 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 cortico-

steroids at least 3 times a year. Patient should receive daily controller therapyPatient 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 add-

on therapy for patients with moderate to sever allergic asthma.

• Most potent and effective medication is corticosteroids Acute (systemically) Chronic (inhalation)

• 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

ICS

Estimated Comparative Daily Dosages for Estimated Comparative Daily Dosages for Inhaled CorticosteroidsInhaled Corticosteroids

DRUGLOW DAILY DOSEMEDIUM DAILY DOSEHIGH DAILY DOSE

AdultChild[*]AdultChild[*]AdultChild[*]

Beclomethasone CFC 42 or 84 μg/puff168–504 μg84–336 μg504–840 μg336–672 μg>840 μg>672 μg

Beclomethasone HFA 40 or 80 μg/puff80–240 μg80–160 μg240–840 μg160–320 μg>480 μg>320 μg

Budesonide DPI 200 μg/inhalation200–600 μg200–400 μg600–1,200 μg400–800 μg>1,200 μg>800 μg

Inhalation suspension for nebulization (child dose)

0.5 μg1.0 μg2.0 μg

Flunisolide 250 μg/puff500–1,000 μg500–750 μg1,000–2,000 μg1,000–1,250 μg>2,000 μg>1,250 μg

Fluticasone MDI: 44, 110, or 220 μg/puff88–264 μg88–176 μg264–660 μg175–440 μg>660 μg>440 μg

DPI: 50, 100, or 250 μg/inhalation100–300 μg100–200 μg300–600 μg200–400 μg>600 μg>400 μg

Triamcinolone acetonide 100 μg/puff400–1,000 μg400–800 μg1,000–2,000 μg800–1,200 μg>2,000 μg>1,200 μg

* Children ≤ 12 years of age

• Two classes of leukotrene modifiers:

Inhibitors of leukotriene synthesis: zileuton

Leukotriene receptor antagonists:

o Montelukast

o Zafirlukast

Leukotrience pathway modifiers Leukotrience pathway modifiers

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 Leukotriene modifiers are considered

alternative controllers for mild alternative controllers for mild

persistent asthma persistent asthma

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

Sustained- Release TheophyllineSustained- Release Theophylline

• 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

LABA LABA

Non-steroidal Anti- Inflammatory AgentsNon-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)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 ApproachStep-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 medicationsQuick – Reliever medications

• Rescue medications:

Short acting inhaled -agonist

Inhaled antichilinergics

Short course systemic corticosteriods

• For management of acute asthma

SABASABA• 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 AgentsAnticholinergic 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

26

Management acute asthmaManagement acute asthma

The home

The emergency department

The hospital

27

Home ManagementHome Management

Home treatment based on changes in PEF valuesGreen zoneYellow zoneRed 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)

28

……Home ManagementHome 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 treatmentInhaled short-acting β2 agonist: up to three treatment of 2-4

puff 20-min intervales byMDIMDI + Spacer deviceDPIHand nebulizer

29

……Home ManagementHome Management

After 1 hour

Good response

Incomplete response

Poor response

30

Good Response (Mild Episode)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

31

Incomplete Response (Moderate Episode)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)

32

Poor Response (Sever Episode)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

33

Office or Emergency Department ManagementOffice 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 CXRnot nessary unless complication (e.g., pneumothorax,

pneumomediastinum, aspiration)

34

Respiratory arrest imminentRespiratory arrest imminent

Intubate and mechanically ventilate with 100% O2.

Nebulized β2 agonist and anticholinergic

IV corticosteroid.

Admit to ICU

Continuous monitoring

Intensive asthma management

35

… …Respiratory arrest imminentRespiratory 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

36

… …Respiratory arrest imminentRespiratory 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

37

Emergency department managementEmergency 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

38

ReassessReassess

Physical examination: RR, HR, Pulse oximetry, use of

accessory muscles, airflow, wheezing, (1÷E)

verbalization, pulsus paradoxus

Studies; PEF, FEV1

Mild exacerbation

Moderate exacerbation

Sever exacerbation

39

Mild ExacerbationMild ExacerbationFEV1 or PEF>80%

Good responseMaintained without repeated treatments during ER

PE: Normal

Discharge to homeContinue home treatment with inhaled β2 agonist

Consider need for oral corticosteroids or controller medicationE ducat patient in medication use and action plus

Arrange follow up

40

Moderate ExacerbationModerate 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

41

… …Moderate ExacerbationModerate 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

42

… …Moderate ExacerbationModerate 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

43

Sever ExacerbatisSever Exacerbatis

FEV1 or PEF<50%Poor response to treatmentPE: RR, Wheezing present, poor airflowModerate-sever accessory muscle use, 02 sat<91%PP>25mmHg

Admit to ICUContinuous monitoringIntensive asthma management

44

… …Sever ExacerbatisSever 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

45

… …Sever ExacerbatisSever 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

46

Therapy of EIA Therapy of EIA

Useful prophylactic approaches

ClassDrugDose inhaledTime delayDuration

Long- acting 2 agonistSalmeterol1 inhalation DPI20 min8-10 hr

Short-acting 2 agonistAlbuterol2 puffs MDI15 min3-4 hr

AntileukotrieneMontelukast10 mg orally30 min8-10 hr

Mast cell stabilizersCromolyn2 puffs MDI15 min1.5-2 hr

Duration of protection may decrease with regularly scheduled use