1. Approach to the Wheezing Child
Maple Landvoigt, MD
11/7/14

2. Disclosures
I have no actual or potential conflict of interest in relation to this program/presentation.
I have no financial relationships to disclose.

3. Objectives Summarize the current scientific understanding of asthma.
Recognize when to treat and when to refer the child for further evaluation.
Recall current treatments for asthma.
Review best practice aerosol drug delivery devices and methods.
Identify other causes of wheezing including vocal cord dysfunction, malacia, and other underlying immunologic diseases.
Enumerate clinical pearls for the care of children with respiratory disease.

4. Wheezing Very common Asthma
25-30% of infants, at least 1 in 3 children by 3 years.
Asthma
Also common…

5. Scope of the Problem Over 25 million Americans have asthma.
Nearly 3,500 annual deaths attributed to asthma and over 150 in children under the age of 15.
The annual health care costs of asthma is over 50 billion dollars.
It is one of the most common chronic disorders in childhood, affecting over 7 million children or 1 in every 11 kids in the US.
More common in WV with a overall childhood lifetime asthma prevalence of nearly 15%.
Asthma is the third leading cause of hospitalizations among children under the age of 15.
It is one of the leading causes of school absenteeism accounting for approximately 10.5 million lost school days.
The proportion of people with asthma in the United States has grown by nearly 15% in the last decade.
From CDC National Asthma Control Program

6. What is Asthma?
“Asthma is a complex disorder characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and an underlying inflammation.”
National Asthma Education and Prevention Program Expert Panel Report 3 (2007)

8. The Trouble with Being Small
Poiseuille's law R = 8nl/πr4

9. Overall Approach Follow Up
National Asthma Education and Prevention Program Expert Panel Report 3

10. Diagnosis
National Asthma Education and Prevention Program Expert Panel Report 3 (2007):
Episodic symptoms (history, physical exam)
Airflow obstruction that is at least partially reversible (spirometry: ≥ 12% change in FEV1 from baseline following short-acting beta agonist)
Alternative diagnoses are excluded

11. Common Asthma Symptoms
Cough
Particularly with activity
Wheezing
Dyspnea
Chest tightness
Exercise limitation

12. Goals of Treatment Reduce Impairment Reduce Risk
Prevent chronic symptoms.
Decrease frequent need for short-acting beta2-agonist (SABA).
Maintain near normal lung function and normal activity levels.
Reduce Risk
Prevent exacerbations.
Minimize need for emergency care, hospitalization.
Prevent loss of lung function (and for young children prevent reduced lung growth).
Minimize adverse effects of therapy.
No treatments proven to change the disease progression (long term outcomes)

13. Treatment 2007 (NHLBI)

14. Reliever Medications Short acting, used for acute symptoms.
Albuterol sulfate:
Relaxes the smooth muscles of the bronchi
Beta2-adrenergic agonist
Proventil HFA
Ventolin HFA
ProAir HFA
Levalbuterol:
R isomer of albuterol
Reportedly less tachycardia
Xopenex

15. Other Relievers Anticholinergic Agents Ipratropium bromide:
Relaxes the smooth muscles of the bronchi
Inhibits secretions from serous/mucous glands
Typically used second line in Asthma
Sometimes used for tracheomalacia, bronchomalacia.
Atrovent

16. Controller Medications
Leukotriene receptor antagonists:
Non-steroid immunomodulator
Inhibits leukotrienes
Mild potency
Significant behavioral side effects have been noted
Montelukast (Singulair)
Zafirlukast (Accolate)

17. Controller Medications
Inhaled corticosteroids:
Steroids are the most effective drugs for asthma control
Inhaled forms are topically active, poorly absorbed, and least likely to cause adverse effects
Reduce asthma mortality, hospital visits, and exacerbations
Higher doses may lead to steroid side effects
Cochrane review on growth effects:
Daily treatment lead to an approximately 0.5 centimeter decrease in linear growth during the first year of treatment
Effect is less pronounced in subsequent years
“This effect seems minor compared with the known benefit of these medications for asthma control”
Cochrane Database Syst Rev. 2014 Jul 17. Inhaled corticosteroids in children with persistent asthma: effects on growth. Zhang, L.

18. Controller Medications
Inhaled corticosteroids:
Fluticasone (Flovent)
beclomethasone dipropionate (QVAR)
Combination long acting beta agonist and inhaled corticosteroids:
Long acting beta agonists carry a black box warning
Fluticasone/salmeterol (Advair)
Budesonide/formoterol (Symbicort)
Mometasone/formoterol (Dulera)

19. Devices and Drug Delivery
Nebulizers:
Commonly available
Slow – typically minutes
Young children need to wear mask, blow-by decreases drug delivery to lower airways
MDIs without spacers:
Fast 1-2 minutes, portable
May improve adherence
Most of the medication is deposited in the mouth and GI tract
MDIs with spacers:
Significantly increases drug delivery to the lower airways
Proper technique requires slow deep breaths
Younger children or children with cognitive delay should use a spacer with mask
Equally effective as nebulized medication when used properly
Dry powder inhalers:
Fast, portable
Proper technique requires fast deep breaths
Not appropriate for pre-school and younger children.

20. How much is too much?
When do children need to see a specialist?

21. Stepwise Approach for managing asthma in children 5-11 years of age
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult asthma specialist if step 4 care or higher is required.
Consider consultation at step 3
Step up if needed
(first check adherence, environmental control, and comorbid conditions)
Preferred
High Dose ICS
+ LABA
+ oral corticosteroid
Alternative
High dose ICS + either LTRA, or Theophylline
Step 6
Preferred
High Dose ICS + LABA
Alternative
High dose ICS + either LTRA, or
Theophylline
Step 5
Preferred
Medium Dose ICS + LABA
Alternative
Medium dose ICS + either LTRA, or
Theophylline
Step 4
Preferred
Either
Low Dose ICS + LABA, LTRA, or Theophylline OR
Medium Dose ICS
Step 3
Preferred
Low dose ICS
Alternative
LTRA, Cromolyn
Nedocromil or
Theophylline
Step 2
Preferred
SABA PRN
Step 1
Assess control
Step down if possible
(and asthma is well controlled at least 3 months)
Patient Education and Environmental Control at Each Step
Quick-relief medication for ALL patients
SABA as needed for symptoms.
Short course of oral corticosteroids maybe needed.

22. Not All That Wheezes Is Asthma

23. Types of Wheezing Polyphonic: Multiple tones Sounds musical
Associated with more distal airway disease
Classic asthma wheezing

24. Types of Wheezing Monophonic: Single tone Repeated same sound
Associated with central airway disease
Concerning for underlying structural airway disease

25. Structural Airway Disease
Tracheobronchomalacia:
Associated with coarse, monophonic wheezing.
Symptoms may persist past age 2, but typically do not persist past school age.
Causes impairment of mucous clearance and can lead to recurrent pneumonias.
Beta-agonists may worsen.
Can be associated with other anatomic anomalies.

26. Structural Airway Disease
Stenosis can be either congenital or acquired in nature.
Associated with monophonic wheezing.
Risk factors:
prolonged intubation
aspiration
prolonged or severe infections
previous airway surgery
Compression is typically vascular in nature.
Consider vascular rings or slings.
Both stenosis/compression impair mucous clearance (can lead to recurrent pneumonias).

27. Foreign Body Aspiration
Classically occurs in mobile toddlers, but can occur at any age including infants (particularly with toddler sibs) and older patients (especially those with developmental delays).
Concerning historical points include:
Any witnessed choking event
Persistent cough or wheeze
Poor response to beta-agonist
Persistent respiratory infections
Key respiratory findings include:
Focal monophonic wheeze
X ray or direct airway endoscopy may be need to confirm the diagnosis.

28. Chronic Aspiration Syndromes
Unrecognized or untreated can lead to bronchiectasis and severe lung disease.
Risk factors include:
Neurologic disease or developmental delay
Vocal paralysis or paresis
Swallowing dysfunction
Reflux or upper GI anatomic abnormalities
Increased work of breathing.
Concerning historical points include:
Coughing, choking, or gagging with oral intake
Recurrent respiratory infections
Pooling of oral secretions

29. Occult Immunodeficiency
Can lead to bronchiectasis and severe lung disease.
Concerning historical points include:
Persistent cough or wheeze
Productive cough
Recurrent respiratory and unusual non-respiratory infections.
Key respiratory findings include:
Coarse crackles
Monophonic and/or polyphonic wheezing
Associated findings of chronic inflammation (i.e. digital clubbing).

30. Digital Clubbing

31. Vocal Cord Dysfunction
Partial closure of the vocal cords during inspiration.
Can occur in combination with other pulmonary processes.
In children, often can persist after an initial triggering irritant (reflux, post-nasal drip) or can be related to anxiety.
Concerning historical points include:
Difficulty getting air “in” vs. “out”
Throat tightness or pain
Extreme sensitivity to smells (perfume, etc)
Inspiratory stridor in the older child, particularly during exercise
Poor response to controller medications
Spirometry can be diagnostic when showing intermittent inspiratory obstruction.

32. Summary
Asthma is characterized by respiratory symptoms and airflow obstruction that is reversible or variable in nature.
The diagnosis is typically confirmed by thorough history and physical as well as spirometry.
Current standard of care treatment involves initiation of inhaled corticosteroid controller for frequent symptoms as well as beta-agonist rescue therapy with frequent monitoring to step up or step down therapy as needed.
Common barriers to optimal asthma control include incorrect inhaler technique and poor adherence.
Use of a spacer device improves drug delivery to the lower airways.
Proper evaluation of uncontrolled or severe asthma often requires detailed examination by an asthma specialist and testing to rule out other underlying respiratory disease.

33. The End