Danielle Gilliam M.D., PGY IIIUniversity of South Alabama
Pediatrics 2011
Most common childhood chronic disorder Increase in incidence by 50 % over the
last two decades In 2007, 9% of children 0 to 17 years of
age (6.7 million children) had asthma, according to data from the National Health Interview Survey.
The cost of illness related to asthma is around $6.2 billion per year in the United States.
Each year, an estimated 1.81 million people with asthma require treatment in the emergency department with approximately 500,000 hospitalizations
Family Hx of asthma Prematurity Race ( African and Native Americans ) Low socioeconomic settings Urban settings ( pollutants ) Increased indoor irritants ( cigarette
smoke, dust mites, pets, recycled air ) History of Atopy ( eczema, allergies and
chronic rhinitis / sinusitis )
Cough ( mostly dry and hacking, specially at night ), Wheezing ( mainly expiratory) Shortness of Breath Chest Pain
Precipitating factors [(URIs mostly viral occasionally atypical pneumonia. Bacterial causes very rare)], exercise, cold weather, allergens, cigarette smoke)
Increased AP diameter of the chest with hyperinflation
A silent chest is a medical emergency
Detailed history of the symptoms Physical exam Spirometry with reduced FEV1 < 80 % and FEV/FVC <
65 % indicative of airflow obstruction ( children in which spirometry is not possible a trial of
asthma meds should be done if indicated by other sxs )
Ancilliary studies ( bronchoprovocative testing, CXR, sweat chloride test, barium swallow and skin testing)
Asthma Bronchiolitis (esp in infants), bronchitis,
laryngotracheobronchitis, tracheitis Foreign body aspiration Functional abnormalities ( GERD, CF, BPD,
immunodeficiency etc ) Structural abnormalities ( laryngo-
tracheomalacia, vascular rings, tracheal stenosis / webs, tumors etc )
Assessment of impairment
– Has your asthma awakened you at night or in the early morning?
– Have you needed your quick-acting relief medication more than usual?
– Have you needed any unscheduled care for your asthma, including calling in, an office visit, or going to the emergency room?
– Have you been able to participate in school/work and recreational activities as desired?
Classifying asthma severity and initiating treatment in children 0-4 years of age
Classification of asthma severity (0-4 years of age)
Persistent Components of severity Intermittent
Mild Moderate Severe
Symptoms 2
days/week >2 days/week but not daily Daily Throughout the day
Nighttime awakenings 0 1-2x/month 3-4x/month >1x/week
Short-acting beta2-agonist use for symptom control (not prevention of EIB)
2 days/week
>2 days/week but not daily Daily Several times per day
Impairment
Interference with normal activity None Minor limitation Some limitation Extremely limited
0-1/ year 2 exacerbations in 6 months requiring oral systemic corticosteroids, or 4 wheezing episodes/ 1 year lasting >1 day AND risk factors for
persistent asthma
Consider severity and interval since last exacerbation
Frequency and severity may fluctuate over time
Risk Exacerbations requiring oral systemic corticosteroids
Exacerbations of any severity may occur in patients in any severity category.
Step 1 Step 2 Step 3 and consider short course of oral systemic corticosteroids
Recommended step for initiating treatment
In 2-6 weeks, depending on severity, evaluate level of asthma control that is achieved. I f no clear benefit is observed in 4-6 weeks, consider adjusting therapy or alternative diagnoses.
Assessing asthma control and adjusting therapy in children 0-4 years of age Classification of asthma control (0-4 years of age)
Components of control Well-controlled Not-well controlled Very poorly controlled
Symptoms 2 days/week >2 days/week Throughout the day
Nighttime awakenings 1x/month >1x/month >1x/week
Interference with normal activity None Some limitation Extremely limited Impairment Short-acting beta2-agonist use for symptom control (not prevention of EIB)
2 days/week >2 days/week Several times per day
Exacerbations requiring oral systemic corticosteroids
0-1/ year 2-3/ year >3/ year
Risk
Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Recommended action for treatment
Maintain current treatment.
Regular followups every
1-6 months.
Consider step down if
well controlled for at least 3 months.
Step up (1 step) and
Reevaluate in 2-6 weeks.
I f no clear benefit in 4-6 weeks, consider alternative diagnoses or
adjusting therapy.
For side effects, consider
alternative treatment options.
Consider short course of oral systemic corticosteroids,
Step up (1-2 steps), and
Reevaluate in 2 weeks.
I f no clear benefit in 4-6 weeks, consider alternative diagnoses or
adjusting therapy.
For side effects, consider
alternative treatment options.
Classifying asthma severity and initiating treatment in children 5-11 years of age Classification of asthma severity (5-11 years of age)
Persistent Components of severity Intermittent
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 beta2-agonist use for symptom control (not prevention of EIB)
2 days/week >2 days/week but not daily
Daily Several times per day
Interference with normal activity None Minor limitation Some limitation Extremely limited Impairment
Lung function
Normal FEV1 between exacerbations
FEV1 >80 percent predicted
FEV1/FVC >85 percent
FEV1 = >80 percent predicted
FEV1/FVC >80 percent
FEV1 = 60-80 percent predicted
FEV1/FVC = 75-80 percent
FEV1 <60 percent predicted
FEV1/FVC <75 percent
0-1/ year (see footnote)
2/ year (see footnote)
Consider severity and interval since last exacerbation
Frequency and severity may fluctuate over time for patients in any severity category
Risk
Exacerbations requiring oral systemic corticosteroids
Relative annual risk of exacerbations may be related to FEV1
Step 3, medium dose ICS option
Step 3, medium dose ICS option, or step 4
Step 1 Step 2
And consider short course of oral systemic corticosteroids
Recommended step for initiating treatment
In 2-6 weeks, evaluate level of asthma control that is achieved, and adjust therapy accordingly.
Assessing asthma control and adjusting therapy in children 5-11 years of age Classification of asthma control (5-11 years of age)
Components of control Well-controlled Not-well controlled Very poorly controlled
Symptoms 2 days/week but not more than
once on each day >2 days/week or multiple times on 2 days/week
Throughout the day
Nighttime awakenings 1x/month 2x/month 2x/week
Interference with normal activity
None Some limitation Extremely limited
Short-acting beta2-agonist use for symptom control (not prevention of EIB)
2 days/week >2 days/week Several times per day
Lung function
Impairment
FEV1 or peak flow
FEV1/FVC
>80 percent predicted/personal best
>80 percent
60-80 percent predicted/personal best
75-80 percent
<60 percent predicted/personal best
<75 percent
0-1/ year 2/ year (see footnote) Exacerbations requiring oral systemic corticosteroids Consider severity and interval since last exacerbation
Reduction in lung growth Evaluation requires long-term followup Risk
Treatment-related adverse effects
Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Recommended action for treatment
Maintain current step.
Regular followup every 1-6
months.
Consider step down if well
controlled for at least 3 months.
Step up at least 1 step and
Reevaluate in 2-6 weeks.
For side effects, consider alternative treatment options.
Consider short course of oral systemic corticosteroids,
Step up 1-2 steps, and
Reevaluate in 2 weeks.
Classifying asthma severity and initiating treatment in youths greater than or equal to 12 years of age and adults
Classification of asthma severity ( 12 years of age)
Persistent Components of severity Intermittent
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 beta2-agonist use for symptom control (not prevention of EIB)
2 days/week >2 days/week but not daily, and not more than 1x on any day
Daily Several times per day
Interference with normal activity None Minor limitation Some limitation Extremely limited
Impairment
Normal FEV1/FVC:
8-19 yr 85 percent
20-39 yr 80 percent
40-59 yr 75 percent
60-80 yr 70 percent
Lung function
Normal FEV1 between exacerbations
FEV1 >80 percent predicted
FEV1/FVC normal
FEV1 80 percent predicted
FEV1/FVC normal
FEV1 >60 but <80 percent predicted
FEV1/FVC reduced 5 percent
FEV1 <60 percent predicted
FEV1/FVC reduced >5 percent
0-1/ year (see footnote)
2/ year (see footnote)
Consider severity and interval since last exacerbation
Frequency and severity may fluctuate over time for patients in any severity category
Risk
Exacerbations requiring oral systemic corticosteroids
Relative annual risk of exacerbations may be related to FEV1
Step 3 Step 4 or 5 Recommended step for initiating treatment Step 1 Step 2
And consider short course of oral
In 2-6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly.
Assessing asthma control and adjusting therapy in youths greater than or equal to 12 years of age and adults
Classification of asthma control ( 12 years of age) Components of control
Well-controlled Not-well controlled Very poorly controlled
Symptoms 2 days/week >2 days/week Throughout the day
Nighttime awakenings 2x/month 1-3x/week 4x/week
Interference with normal activity
None Some limitation Extremely limited
Short-acting beta2-agonist use for symptom control (not prevention of EIB)
2 days/week >2 days/week Several times per day
FEV1 or peak flow >80 percent predicted/personal best 60-80 percent predicted/personal best
<60 percent predicted/personal best
Validated questionnaires
ATAQ 0 1-2 3-4
ACQ 0.75* 1.5 N/A
Impairment
ACT 20 16-19 15
0-1/ year 2/ year (see footnote) Exacerbations requiring oral systemic corticosteroids Consider severity and interval since last exacerbation
Progressive loss of lung function
Evaluation requires long-term followup care Risk
Treatment-related adverse effects
Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Recommended action for treatment
Maintain current step.
Regular followups every 1-6
months to maintain control.
Consider step down if well
controlled for at least 3 months.
Step up 1 step and
Reevaluate in 2-6 weeks.
For side effects, consider
alternative treatment
Avoidance of risk factors Exercise induced bronchospasm : short acting beta
agonists ( albuterol ) 10-15 min prior to activity Intermittent : Rescue albuterol treatments as needed,
systemic corticosteroids reserved for severe exacerbation Mild Persistent : Low dose inhaled corticosteroids (ICS)
(e.g. Pulmicort, Asmanex, Flovent, QVAR) Moderate persistent : Low to medium dose ICS and
either a long acting beta agonists ( Foradil, Serevent ) or a leukotriene modifier ( Singulair )
Severe Persistent : High dose ICS and a long acting beta agonist
. Advair ( Fluticasone + Salmeterol )
Controller medications:◦ Inhaled corticosteroids, ◦ Inhaled cromolyn or nedocromil, ◦ Long-acting bronchodilators (Salmeterol), ◦ Leukotriene antagonists (Montelukast)
Rescue medications:Short-acting bronchodilators, Systemic corticosteroidsInhaled ipratropium or atrovent
Inhaled Corticosteroidsdirect, local, anti-inflammatory effect, low systemic activity
reduce bronchial hyper-resposiveness to allergensDrugs Product Availability
Beclomethasone
MDI (QVAR)
40 mcg to 80mcg/ inh
Fluticasone HFA MDI
(Flovent)
44 mcg, 110 mcg, 220 mcg/inh
50 mcg, 100 mcg, 250 mcg/inh
Mometasone DPI
(Ventolin)
110 mcg, 220 mcg/inh
COMBOS
Fluticasone + Salmeterol (Advair)
Diskus (all have 50 mcg salmet)
HFA (all have 21 mcg salmet)
100/50, 250/50, 500/50 mcg/inh
45/21, 115/21, 230/21
Budesonide + Formoterol
(Symbicort)
HFA and MDI
80/4.5 mcg, 160/4.5 mcg
Side Effects: Common= couph, dysphonia, oral candidiasis, upper RTI, throat irritationSerious= decreased growth velocity in children, HPA suppresion, reduced bone mineral density, cataracts (dose and duration dependent)Combo meds= above +Headache, dizziness, palpitations, tremor
Evaluate treatments every 2-3 months and step down as appropriate or go up on the dose of ICS for recurrent exacerbations
ICS and long acting beta agonists have proven better efficacy compared to alternative treatments ( leukotriene modifiers, cromolyn. theophylline )
Studies have shown MDIs with spacers to be more efficacious and practical than nebulizers in routine application
Asthma exacerbation is a medical emergency. Don’t delay evaluation and treatment.
1) Early/Immediate Phase : characterized by bronchoconstriction.
2) Late Phase (6-8 hours) : airway inflammation and hyper-responsiveness
Management should emphasize◦ 1) Initial stabilization ◦ 2) progressive monitoring and treatment ◦ 3)eventually discharge planning
O2 to keep sats >92%
Bronchodilators :
Beta Agonist (Albuterol) : via nebulizer Q 15-20 minutes times three then Q2 twice if needed and then Q4-6 hrs ATC/PRN
If needed more frequently PICU admisision Ipratropium ( Atrovent ) via nebulizer may be given
with the first three albuterol treatments then Q4-8 ATC/PRN
Levalbuterol ( Xopenex ) : selective beta 2 agonist. Not routinely used. Good alternative for continuous therapy if side effects from albuterol experienced
Start Corticosteroids if;◦ No response after one nebulised t/t◦ Patient is steroid dependent ◦ Has had a recent ER visit for asthma◦ Previous admission to ICU
Steroid PO (Prednisolone 2mg/k/d) or Steroid IV (Solumedrol 2mg/k IV/IM bolus then 1-2mg/k/d divided Q6) x 3-10 days
If greater than 5 day course, will need to wean
Continuous Albuterol Magnesium Sulfate (IV) IV Terbutaline or Epinephrine Ketamine Intubation for respiratory failure Heliox Solumedrol IV
Use of ketamine in acute severe asthma V. J. Sarma 30 DEC 2008
Randomized, Double-Blind, Placebo-Controlled Trial of Intravenous Ketamine in Acute Asthma, Joseph C Howton MD, John Rose MD, Scott Duffy MD, Tom Zoltanski and M.Andrew Levitt DO
28 November 1994;
Wean oxygen as tolerated Advance diet as tolerated and wean IVF
accordingly Social services consult : home nebulizer,
supplies, insurance issues Respiratory Consult : teaching nebulizer / MDI
treatments Prescribe controller meds according to
classification Finish course of antibiotics and steroids F/U with pediatrician: two to three days