Take My Breath Away Common Pediatric Asthma Topics Sara Ryder, MD April 2016

• I have no financial disclosures

Objectives

• Appropriately utilize predictive indices for asthma, particularly when PFT studies are not available/applicable.

• Review asthma maintenance management including both pharmacologic and non-pharmacologic options.

• Compare and contrast medication delivery systems for common asthma medications.

• Recognize acute asthma exacerbations and manage these effectively.

• Determine when stepping down therapy is necessary/medically appropriate.

Quick Review: What

• What is Asthma? • Chronic inflammation • Airway hyperresponsivness • Reversible airflow obstruction

Quick Review: Why

• Why do we care? • Asthma = one of the most common chronic diseases • Major cause of school absences • Poorly controlled asthma = $$$$$$

Case #1: DM

• CC: 2 yo WCC • HPI: 2 yo M presenting for regular WCC. Mom

concerned that he may have asthma. Wants to know if you can diagnose him.

• PMH: Atopic dermatitis. 3 previous episodes of wheezing with a URI, tx with SABA with improvement.

• FH: Mom with h/o asthma, Brother (5 yo) with atopic dermatitis and asthma.

• SH: Dad smokes outside.

Key Questions

• Is this asthma? • How do you know?

Diagnosis of Asthma: 0-4 years old

• Asthma Predictive Index • Risk of developing persistent asthma in kids <3 yo with >4

episodes of wheezing during previous year • One of the following:

• Parental hx of asthma • Physician dx of atopic dermatitis • Evidence of aeroallergen sensitization

• OR two of the following: • Evidence of food sensitization • >4% blood eosinophilia • Wheezing not related to infections

Diagnosis of Asthma: 5-11 years old

• Hx: • Episodic obstruction/hyperresponsiveness

• Partially reversible • Sx not consistent with another diagnosis • Completed medical hx

• Exam: Focus on HEENT, Lungs, skin • Spirometry

Case #2: ST

• CC: Asthma/allergy follow up • HPI: 13 yo F presenting for

asthma maintenance visit. Reports daytime symptoms 3-4 times per week, nighttime cough 2-3 times per week, SABA use almost daily, but no exercise intolerance. She has had 1 ED visit since her last appointment and received PO steroids at that time. Reports that she is responsible for her meds and misses then 3-4 days per week.

• Meds: Qvar 80 mcg 2 puffs BID, Singulair 5 mg daily, Flonase 1 SEN daily, Cetirizine 10 mg daily, Albuterol PRN.

• PMH: Obesity with BMI 96th%. Has been hospitalized 3 times for asthma exacerbations. No ICU.

• SH: Lives with Mom, Dad, and 10 yo sister. Mom and Dad both smoke.

• PFT: FEV1 72% predicted, FEV1/FVC 80%

Key Questions

• Does this patient need stepped up? • What other factors may be contributing to symptoms?

• Clue: Non-pharmacologic! • What do you do today? • When do you bring them back?

Tackling Asthma Maintenance

• Assess symptoms • Assess compliance • Review appropriate technique • Explore exposures • Adjust therapies as needed

Follow Up for Maintenance > 12 yo

• Initiation of meds = 2-6 week intervals • Maintenance = 1-6 month intervals** • Adjustments = 2-6 week intervals **

Follow Up for Maintenance > 12 yo

• Determine impairment (aka. Severity/Level of Control) • Symptom assessment • SABA use • PFTs • Questionnaires

• Determine risk (aka. Exacerbation Severity)

Follow Up for Maintenance > 12 yo

• At every visit: • Review regimen (and family’s understanding) • Evaluate compliance • Assess medication administration technique • Promote allergen/irritant avoidance • Discuss co-morbidities • Review/update Asthma Action Plan

Step Up?

• When poorly controlled: • Consider stepping up therapy BUT ONLY AFTER

• Assessing compliance • Assessing technique • Assessing exposures • Assessing co-morbidities

Case #3: FR

• CC: Cough, wheezing x 2 days • HPI: 5 yo F with hx of mild intermittent asthma

presenting with cough and wheezing for 2 days, getting worse. Also having congestion and rhinorrhea, Tm 100.7. Mom ran out of SABA so hasn’t been giving.

• Meds: Albuterol Neb 1 vial q4hr PRN

Case #3: FR

• Exam: • VS: T100.3 HR 104 RR 22 SpO2 96% • Gen: NAD, smiling, talkative. • HEENT: Copious clear rhinorrhea and congestion, clear

TM. MMM. • Resp: Adequate air entry. No retractions. Scattered end exp

wheezing, most notable in bases. No rales. • Given 4 puffs albuterol MDI with spacer. Repeat exam with no

audible wheezing.

Case #3: FR

• A/P: Mild asthma exacerbation due to URI. Plan to tx with albuterol q4hr x 48hr then space to as needed.

• Mom wants nebulizer, NOT MDI!

Key Questions

• Which works better, nebulizer or MDI? • At what age can patients begin to use MDIs? • How do you approach that conversation with families?

Nebulizer vs MDI Delivery: Efficacy

• Ploin et al - Pediatrics 2000 • Castro-Rodriguez et al – Journal of Pediatrics 2004 • Delgado et al – Archives of Pediatric and Adolescent

Medicine 2003

• How much actually gets in there?

Nebulizer vs MDI Delivery: Age

• MDI delivery systems CAN be used in children < 5 yo** • What about babies?

Nebulizer vs MDI Delivery: Family Discussion

• MDI Advantages: • Less time! • Equally efficacious at minimum (and possibly more) • Cost • Portable

Case #4: EG

• CC: Cough and wheezing x 2d, SOB x 1d • HPI: 8 yo M with moderate persistent asthma presenting

with cough and wheezing for 2 days, getting worse and new onset SOB today. Also has congestion, rhinorrhea, and fever to 101.2. Mom has been giving albuterol MDI with spacer 4 puffs q4hr, which helped initially but now she doesn’t think are lasting as long. Still taking daily meds of Flovent, Flonase, and Loratidine. No previous hospitalizations or ICU stays for asthma.

Case #4: EG

• Exam: • VS: T 100.9 HR 108 BP 97/64 RR 28 SpO2 94% • Gen: Mild distress. Speaking in full sentences. • HEENT: Congestion, rhinorrhea. MMM. • Resp: Faint suprasternal and intercostal retractions.

Tachypneic. Diminished air movement in b/l bases with prolonged expiratory phase and diffuse end exp wheezing. • Given 4 puffs albuterol MDI with spacer x3, each 20 minutes

apart. Repeat exam with no visible retractions, RR 19, improved air entry into bases, scattered exp wheezing.

Key Questions

• How bad is this? • To PO steroid or not to PO steroid? • Office vs higher level of care (ED, inpatient)? • When do you have the patient come back?

Recognizing Acute Asthma Exacerbations

• What qualifies as an exacerbation? • Acute/subacute, progressive worsening of:

• Wheezing • Cough • SOB • Chest tightness

• Objective measures: • Spirometry or Peak Flow

ERP-3 Fig 5.1

Signs and Symptoms Initial PEF (or FEV1) Clinical Course

Mild Dyspnea only with activity (assess tachypnea in young children)

PEF > 70% predicted or personal best

Usually care for at home Prompt relief with SABA Possible short course of PO steroids

Moderate Dyspnea interferes with or limits usual activity

PEF 40-60% predicted or personal best

Usually requires office or ED visit Relief from frequent SABA PO steroids; some symptoms last for 1-2 days after treatment has begun

Severe Dyspnea at rest; interferes with conversation

PEF <40% predicted or personal best

Usually requires ED visit; likely hospitalization Partial relief from frequent SABA PO steroids; some symptoms last for >3 days after treatment has begun Adjunctive therapies helpful

Subset: Life Threatening

Too dyspneic to speak; perspiring

PEF <25% predicted or personal best

Requires ED/hospitalization; possible ICU Min-no relief with frequent SABA IV steroids Adjunctive therapies helpful

Approach to Acute Asthma Exacerbations

• Be Proactive! • Remember that Asthma Action Plan

• Monitor response to rescue meds • Intensify treatment appropriately

• Aka. PO steroids • Minimize exposures • Know your high risk patients!

Special Population: Infants

• PFTs/Peak flow won’t help you here • Response to SABA is not a slam dunk

• But no response should be a red flag • Consider PO steroids early • Don’t give antibiotics for viruses

Mainstays of Therapy

• Supplemental O2 • Reverse obstruction • PO steroids early for mod-severe exacerbations

To the ED?

• Does your patient require supplemental O2? • Is your patient requiring frequent SABA treatments? • Is your patient having suboptimal response to SABA?

• Magnesium? Heliox? Terb?

Admission?

• The golden hour (s) • SpO2 <92-94% at 1 hr after initial assessment • Severity scores

Follow up

• Asthma follow up: 1-4 weeks • Discharge instructions should be clear and thorough • Return precautions

• Remember health literacy techniques

Case #5

• CC: Asthma follow up • HPI: 10 yo M with hx of moderate persistent asthma

presenting for regular asthma follow up. He was last seen 3 months ago and was doing well at that time. Today, family reports no ED visits, hospitalizations, or PO steroids since last appt. He is denies any daytime sx, has nighttime cough 1-2x/month, last used his SABA about 2 weeks ago, and does not have any exercise intolerance.

• Meds: Qvar 80 mcg 2 puffs BID, Singulair 5 mg daily, Albuterol PRN

• PFT: Normal FEV1, FEV1/FVC 92% predicted

Key Questions

• When can you entertain the idea of stepping down therapy?

• How do you step down therapy? • How do you approach this with families? • When do you see those patients back?

Approach to Stepping Down Therapy 5-11 yo

• Remember: • Determine impairment and risk • Review regimen (and family’s understanding) • Evaluate compliance • Assess medication administration technique • Promote allergen/irritant avoidance • Discuss co-morbidities

Approach to Stepping Down Therapy 5-11 yo

• Patient is well controlled…can they step down? • Yes**

• How do I do that? • Decrease ICS dose by 25-50%

• Then what? • Check back in 3 months

• Don’t forget RETURN PRECAUTIONS

• Consider seasonal ICS use

Thanks!

References

• National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute (US); Aug 2007.

• Ploin D et al. High-dose albuterol by metered-dose inhaler plus a spacer device versus nebulization in preschool children with recurrent wheezing: A double-blind, randomized equivalence trial. Pediatrics. Aug 2000. (2 Pt 1):311-317.

• Castro-Rodriguez JA, Rodrigo DJ. Beta-agonists through metered-dose inhaler with valved holding chamber versus nebulizer for acute exacerbation of wheezing or asthma in children under 5 years of age: a systematic review with meta-analysis. Journal of Pediatrics. Aug 2004. 145(2):172-177.

• Delgado A, Chou KJ, Silver EJ, Crain EF. Nebulizer vs metered-dose inhalers with spacers for bronchodilator therapy to treat wheezing in children aged 2 to 24 months in a pediatric emergency department. Archives of Pediatric and Adolescent Medicine. Jan 2003; 157(1): 76-80.

• Smith C, Goldman RD. Nebulizers versus metered-dose inhalers in preschool children with wheezing. Canada Family Physician. May 2012. 58(5): 528-530.