Presentation on theme: "Approach to the Wheezing Child"— Presentation transcript:
1Approach to the Wheezing Child Maple Landvoigt, MD11/7/14
2DisclosuresI have no actual or potential conflict of interest in relation to this program/presentation.I have no financial relationships to disclose.
3Objectives 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.
4Wheezing Very common Asthma 25-30% of infants, at least 1 in 3 children by 3 years.AsthmaAlso common…
5Scope 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
6What 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)
8The Trouble with Being Small Poiseuille's law R = 8nl/πr4
9Overall Approach Follow Up National Asthma Education and Prevention Program Expert Panel Report 3
10DiagnosisNational 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
11Common Asthma Symptoms CoughParticularly with activityWheezingDyspneaChest tightnessExercise limitation
12Goals 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 RiskPrevent 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)
14Reliever Medications Short acting, used for acute symptoms. Albuterol sulfate:Relaxes the smooth muscles of the bronchiBeta2-adrenergic agonistProventil HFAVentolin HFAProAir HFALevalbuterol:R isomer of albuterolReportedly less tachycardiaXopenex
15Other Relievers Anticholinergic Agents Ipratropium bromide: Relaxes the smooth muscles of the bronchiInhibits secretions from serous/mucous glandsTypically used second line in AsthmaSometimes used for tracheomalacia, bronchomalacia.Atrovent
16Controller Medications Leukotriene receptor antagonists:Non-steroid immunomodulatorInhibits leukotrienesMild potencySignificant behavioral side effects have been notedMontelukast (Singulair)Zafirlukast (Accolate)
17Controller Medications Inhaled corticosteroids:Steroids are the most effective drugs for asthma controlInhaled forms are topically active, poorly absorbed, and least likely to cause adverse effectsReduce asthma mortality, hospital visits, and exacerbationsHigher doses may lead to steroid side effectsCochrane review on growth effects:Daily treatment lead to an approximately 0.5 centimeter decrease in linear growth during the first year of treatmentEffect 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.
18Controller Medications Inhaled corticosteroids:Fluticasone (Flovent)beclomethasone dipropionate (QVAR)Combination long acting beta agonist and inhaled corticosteroids:Long acting beta agonists carry a black box warningFluticasone/salmeterol (Advair)Budesonide/formoterol (Symbicort)Mometasone/formoterol (Dulera)
19Devices and Drug Delivery Nebulizers:Commonly availableSlow – typically minutesYoung children need to wear mask, blow-by decreases drug delivery to lower airwaysMDIs without spacers:Fast 1-2 minutes, portableMay improve adherenceMost of the medication is deposited in the mouth and GI tractMDIs with spacers:Significantly increases drug delivery to the lower airwaysProper technique requires slow deep breathsYounger children or children with cognitive delay should use a spacer with maskEqually effective as nebulized medication when used properlyDry powder inhalers:Fast, portableProper technique requires fast deep breathsNot appropriate for pre-school and younger children.
20How much is too much?When do children need to see a specialist?
21Stepwise Approach for managing asthma in children 5-11 years of age IntermittentAsthmaPersistent Asthma: Daily MedicationConsult asthma specialist if step 4 care or higher is required.Consider consultation at step 3Step up if needed(first check adherence, environmental control, and comorbid conditions)PreferredHigh Dose ICS+ LABA+ oral corticosteroidAlternativeHigh dose ICS + either LTRA, or TheophyllineStep 6PreferredHigh Dose ICS + LABAAlternativeHigh dose ICS + either LTRA, orTheophyllineStep 5PreferredMedium Dose ICS + LABAAlternativeMedium dose ICS + either LTRA, orTheophyllineStep 4PreferredEitherLow Dose ICS + LABA, LTRA, or TheophyllineORMedium Dose ICSStep 3PreferredLow dose ICSAlternativeLTRA, CromolynNedocromil orTheophyllineStep 2PreferredSABA PRNStep 1Assess controlStep down if possible(and asthma is well controlled at least 3 months)Patient Education and Environmental Control at Each StepQuick-relief medication for ALL patientsSABA as needed for symptoms.Short course of oral corticosteroids maybe needed.
23Types of Wheezing Polyphonic: Multiple tones Sounds musical Associated with more distal airway diseaseClassic asthma wheezing
24Types of Wheezing Monophonic: Single tone Repeated same sound Associated with central airway diseaseConcerning for underlying structural airway disease
25Structural 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.
26Structural Airway Disease Stenosis can be either congenital or acquired in nature.Associated with monophonic wheezing.Risk factors:prolonged intubationaspirationprolonged or severe infectionsprevious airway surgeryCompression is typically vascular in nature.Consider vascular rings or slings.Both stenosis/compression impair mucous clearance (can lead to recurrent pneumonias).
27Foreign 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 eventPersistent cough or wheezePoor response to beta-agonistPersistent respiratory infectionsKey respiratory findings include:Focal monophonic wheezeX ray or direct airway endoscopy may be need to confirm the diagnosis.
28Chronic Aspiration Syndromes Unrecognized or untreated can lead to bronchiectasis and severe lung disease.Risk factors include:Neurologic disease or developmental delayVocal paralysis or paresisSwallowing dysfunctionReflux or upper GI anatomic abnormalitiesIncreased work of breathing.Concerning historical points include:Coughing, choking, or gagging with oral intakeRecurrent respiratory infectionsPooling of oral secretions
29Occult Immunodeficiency Can lead to bronchiectasis and severe lung disease.Concerning historical points include:Persistent cough or wheezeProductive coughRecurrent respiratory and unusual non-respiratory infections.Key respiratory findings include:Coarse cracklesMonophonic and/or polyphonic wheezingAssociated findings of chronic inflammation (i.e. digital clubbing).
31Vocal 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 painExtreme sensitivity to smells (perfume, etc)Inspiratory stridor in the older child, particularly during exercisePoor response to controller medicationsSpirometry can be diagnostic when showing intermittent inspiratory obstruction.
32SummaryAsthma 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.