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ASTHMA IN CHILDREN: Diagnosis and Management Milagros S. Salvani-Bautista, MD Pediatric Pulmonologist.

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Presentation on theme: "ASTHMA IN CHILDREN: Diagnosis and Management Milagros S. Salvani-Bautista, MD Pediatric Pulmonologist."— Presentation transcript:

1 ASTHMA IN CHILDREN: Diagnosis and Management Milagros S. Salvani-Bautista, MD Pediatric Pulmonologist

2 OPERATIONAL DESCRIPTION: “ Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. The chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment” GINA: 2002,2006,2007

3 What Is Asthma ?

4 What is known about Asthma? increasing PREVALENCE especially in children CHRONIC INFLAMMATORY DISORDER of the airways chronically inflamed airways are HYPERRESPONSIVE EPISODIC WHEEZING, BREATHLESSNESS, CHEST TIGHTNESS and COUGHING can be CONTROLLED

5 PATTERNS OF RECURRENT WHEEZE IN PEDIATRIC PATIENTS 1. Transient wheezing 2. Non-atopic wheezing 3. Persistent asthma Tucson Children’s Respiratory Study JACI 2003; 111: Severe, intermittent wheezing Bacharier. JACI 2007; 119:

6 PRESENTING FEATURES Wheeze Dry cough Breathlessness Noisy breathing DETAILED HISTORY AND PE Pattern of illness Severity/control Differential clues IS IT ASTHMA? Follow relevant course of action Seek specialist assistance INVESTIGATE OR SEEK Causal factors Exacerbating factors Complications Comorbidity DIFFERENTIAL DIAGNOSTIC TESTS &/or TRIALS OF ASTHMA THERAPY ASTHMA ACTION PLAN No ProbablyPossibly Asthma likely Asthma unlikely Poor responseGood response DIAGNOSIS OF ASTHMA IN CHILDREN

7 Intermittent Symptoms less than once a week Brief exacerbations Nocturnal symptoms not more than 2x/mo. FEV1 or PEF ≥ 80% predicted PEF or FEV1 variability < 20% Mild Persistent Symptoms more than once a week but less than once a day Exacerbations may affect activity and sleep Nocturnal symptoms more than 2x/mo. FEV1 or PEF ≥ 80% predicted PEF or FEV1 variability < 20 – 30% Moderate Persistent Symptoms daily Exacerbations may affect activity & sleep Nocturnal symptoms more than once a wk. Daily use of inhaled short-acting 2-agonist FEV1 or PEF 60-80% predicted PEF or FEV1 variability > 30% Severe Persistent Symptoms daily Frequent exacerbations Frequent nocturnal asthma symptoms Limitation of physical activities FEV1 or PEF ≤ 60% predicted PEF or FEV1 variability > 30% CLASSIFICATION OF ASTHMA SEVERITY GINA 2002

8 CharacteristicControlled (All of the ff) Partly Controlled (Any measure present in any week) Uncontrolled Daytime symptomsNone (2x or { "@context": "http://schema.org", "@type": "ImageObject", "contentUrl": "http://images.slideplayer.com/4332036/14/slides/slide_7.jpg", "name": "CharacteristicControlled (All of the ff) Partly Controlled (Any measure present in any week) Uncontrolled Daytime symptomsNone (2x or

9 ASTHMA MANAGEMENT: COMPONENTS OF THERAPY  Assess and monitor asthma severity and asthma control  Education for a partnership in care  Control of environmental factors and co-morbid conditions that affect asthma  Medications

10 Medicines in Childhood Asthma Relievers Rapid-acting inhaled Beta (B)2 agonist Inhaled anti- cholinergics Short acting theophylline Short acting B2 agonist (SABA) Controllers Inhaled and systemic corticosteroids Leukotriene modifiers Long-acting B2 agonist (LABA) with Inhaled Corticosteroid ICS Sustained release theophyllines Cromones GINA ASTHMA GUIDELINES 2002, 2006, 2007

11 ACUTE ASTHMA EXACERBATION

12 Severity of Asthma Exacerbations….. MILD MODERATE SEVERERESPIRATORY ARREST IMMINENT BreathlessWalkingTalking At rest Infants – softer Infants- Stops shorter cry feeding Can lie flatPrefers sitting *Hunched forward Talks inSentences PhrasesWords AlertnessMay be agitatedUsually agitatedUsually agitated Respiratory RateIncreasedIncreased*Often >30/minBradypnea GUIDE TO RATES OF BREATHING ASSOCIATED WITH RESPIRATORY DISTRESS IN AWAKE CHILDREN AGENORMAL RATE > 2 months< 60/min 2-12 months< 50/min 1-5 years< 40/min 6-8 years< 30/min GINA 2002, 2006, 2007

13 MILD MODERATE SEVERE RESPIRATORY ARREST IMMINENT Accessory None Present Present Present Muscles & Thoraco-abdominal Suprasternal Movement Retraction Wheeze Audible with Audible with Audible w/o Absence of wheeze stethoscope stethoscope stethoscope with decreased to absent breathe sounds Pulses/min 120 Bradycardia GUIDE TO LIMITS OF NORMAL PULSE RATE IN CHILDREN Age Normal Limits Infants2-12 months<160/min Preschool1-2 years<120/min School Age2-6 years<110/min Severity of Asthma Exacerbations….. GINA 2002, 2006, 2007

14 Severity of Asthma Exacerbations MILDMODERATE SEVERERESPIRATORY ARREST IMMINENT Pulses ParadoxusAbsent May be presentOften presentAbsence suggests <10mm Hg10—20mm Hg20-40mm Hgrespiratory muscle fatigue PEF  80%60-79%<60% %predicted Or %personal best PaO2 RANormal  60mm Hg <60mmHg test NOT usually Possible Cyanosis necessary PaCO2  45 mm Hg  45 mm Hg >45 mm Hg possible respiratory failure SaO2 RA  95%90-94%<90% Hypercapnea (hypoventilation) develops more rapidly in young children GINA 2002,2006,2007

15 GINA ASTHMA GUIDELINES: (2002, 2006,2007) Management of Asthma Exacerbation in Acute Care Initial Assessment History, Physical Examination(auscultation, use of accessory muscles, HR, RR, PEF or FEV1, O2 saturation, ABG’s if patient in extremis) Initial Treatment Oxygen to achieve O2 saturation ≥90% (95% in children) Inhaled rapid β2-agonist continuously for one hour Systemic GCS, if no immediate response, or if patient recently took Oral GCS, of if episode is severe SEDATION is CONTRAINDICATED in the treatment of an exacerbation Reassess after 1 hour : PE, PEF, O2 saturation & other tests as needed Criteria for MODERATE Episode: PEF 60-80% predicted/personal best Physical exam: moderate symptoms, Accessory muscle use Treatment: O2, Inhaled β2 agonist + anticholinergic every 60 min Oral GCS Continue treatment for 1-3 hours,provided There is improvement Criteria for SEVERE Episode: History of risk factors for near fatal asthma PEF < 60% predicted/personal best PE: severe symptoms at rest, chest retraction NO improvement after initial treatment Treatment: O2, Inhaled β2 agonist + anticholinergic Systemic GCS IV Magnesium Continuation next slide S1

16 GINA ASTHMA GUIDELINES: (2002, 2006,2007) Reassess after 1 – 2 hours Good Response within 1-2 hours: Response sustained 60 minutes after last treatment PE normal: no distress PEF > 70% O2 saturation > 90% (95% in children) Incomplete Response within 1-2 hours: Risk Factors for near fatal asthma PE : mild to moderate signs PEF < 60% O2 saturation: NOT IMPROVING Poor Response within 1-2 hours: Risk factors fro near fatal asthma PE : symptoms severe, drowsiness, confusion PEF : < 30% PCO2 : > 45mmHg PO2: < 60mmHg ADMIT to ACUTE CARE Setting Oxygen Inhaled β2-agonist ± anticholinergic Systemic GCS Intravenous Magnesium Monitor PEF, O2 saturation, Pulse ADMIT to INTENSIVE Care Oxygen Inhaled β2- agonist+anticholinergic IV GCS Consider IV β2 agonist Consider IV theophylline Possible intubation mechanical ventilation Reassess at Intervals Poor Response: Admit to intensive Care Incomplete response in 6-12 hours Consider admission to Intensive Care If No improvement within hours Improved Improved: Criteria for Discharging Home PEF > 60% predicted / personal best Sustained on oral/inhaled medications HOME TREATMENT: Continue inhaled β2 agonist Consider in most cases, oral GCS Consider adding a combination inhaler Patient education: take medicine correctly review action plan close medical check up Management of Asthma Exacerbation in Acute Care Cont. (S2)

17 Inhaled β 2 -agonists are the mainstay of therapy in acute asthma.

18 However, once response to the initial β 2 -agonists is minimal, incomplete or poor … COMBINATION of INHALED β 2 -AGONIST and INHALED ANTICHOLINERGIC is RECOMMENDED

19 GINA ASTHMA GUIDELINES: Recommended Medications by Level of Severity: Children 2002 Daily Controller Medications Other Treatment Options INTERMITTENT PERSISTENT MILD MODERATE SEVERE None necessary IGCS mcg BUD IGCS µg BUD IGCS< 800µg BUD PLUS Sustained released theophylline OR IGCS <800µg BUD PLUS LABA OR IGCS >800µg OR IGCS <800mcg PLUS Leukotriene modifier IGCS >800µg BUD PLUS one or more of the following: Sustained- release theophylline Long Acting Inhaled β-2 agonist Leukotriene modifier Oral glucocortico steroid Sustained- release Theophylline, OR Cromone, OR Leukotriene modifier All Steps: In addition to daily controller therapy, rapid-acting inhaled β2 agonist* should be taken as needed to relieve symptoms, but should not be taken more than 3 to 4 times a day. In all steps: Once control of asthma is achieved and maintained for at least 3months, a gradual reduction of the maintenance therapy should be tried in order to identify the minimum therapy required to maintain control

20 controlled partly controlled uncontrolled exacerbation LEVEL OF CONTROL maintain and find lowest controlling step consider stepping up to gain control step up until controlled treat as exacerbation TREATMENT OF ACTION TREATMENT STEPS REDUCEINCREASE STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 REDUCE INCREASE GINA Guidelines 2006

21 GINA 2006

22 Asthma Medications As needed: RELIEVER BRONCHODILATORS Short acting β 2-Agonists Anticholinergics (inhaled) Short acting Theophyllines Daily: CONTROLLER ANTI-INFLAMMATORY Corticosteroids (inhaled and systemic) Leukotriene modifier Long acting β 2 agonists Sustained release theophyllines GINA 2006

23 Inhaled Corticosteroids Most effective long-term control for persistent asthma Small risk for adverse events at recommended dosage Benefits of daily use Reduction of asthma symptoms frequency of exacerbations airway inflammation airway responsiveness asthma mortality Improvement of lung function quality of life

24 Estimated Equipotent Doses of Inhaled Glucocorticosteroids for Children DrugLow Daily Dose (µg) Medium Daily Dose (µg) High Daily Dose (µg) Beclomethasone dipropionate > >400 Budesonide* > >400 Budesonide-Neb Inhalation Susp > >1000 Ciclesonide*80-160> >320 Flunisolide > >1250 Fluticasone > >500 Mometasone furoate* > >400 Triamcinolone acetonide > >1200 GINA 2006

25 COMPARISON OF PHARMACOKINETICS & PHARMACODYNAMIC PARAMETERS OF ICS PARAMETERSBDP/BMPBUDFP LIPOPHILICITYMod/highLowHigh PROTEIN BINDING:FREE FRACTION 87:1388:1290:10 T1/2, hr0.5/ Vd, Li20/ Clearance, L/h15/

26 TECHNIQUES FOR BALANCING SAFETY AND EFFICACY OF ICS Selection and use of ICS 1. Select safest ICS drug 2. Use minimum effective dose 3. Dose in AM when once daily dosing 4. If control is poor, add another controller rather than double dose of ICS 5. To maximize ICS delivery to lung, consider: CFC vs HFA propellant formulation pMDI vs DPI formulation Use of spacer device Patient technique 6. Rinse mouth of ICS and discard

27 TECHNIQUES FOR BALANCING SAFETY AND EFFICACY OF ICS Use of ICS – sparing strategies Reduce allergens and smoke Inoculate with influenza vaccine Diagnose and treat rhinosinusitis or GERD Use add-on therapies Monitor growth at all ICS doses Monitor eyes and bone mineral density when using > 1600 ug/day ICS Consider first line alternatives to ICS for mild persistent asthma

28 SYSTEMIC SIDE EFFECTS OF ICS THERAPY IN CHILDREN EVIDENCE GRADE EFFECT ON CONCLUSION A, B, CGROWTH Potential to decrease growth velocity. Effects are small, non-progressive, reversible ABONE MINERAL DENSITY No serious adverse effects A, CCATARACTS GLAUCOMA No significant effects on incidence of subcapsular cataracts or glaucoma A, CHPA AXIS FUNCTION Rare individuals may be susceptible to ICS effects on HPA axis even on conventional doses

29 Mechanisms 5-LO inhibitors (zileuton) CysLT 1 receptor antagonists (montelukast, pranlukast, zafirlukast) Indications Alternative treatment in mild persistent asthma Aspirin-sensitive asthma Add-on therapy, but less effective than LABA Concomitant asthma with allergic rhinitis LEUKOTRIENE MODIFIERS

30 CHILDREN OLDER THAN 5 YRS. Clinical benefit at all levels of severity, but, generally less that that of low-dose ICS Partial protection against EIA As add-on treatment CHILDREN 5 YRS. AND YOUNGER In addition to above, it reduces viral- induced asthma exacerbation in children 2-5 yrs with a history of intermittent asthma. GINA 2006

31 LONG-ACTING INHALED B2-AGONISTS Monotherapy should be avoided Most effective when combined with ICS, preferably in a fixed combination inhaler May be used to prevent exercise-induced bronchospasm Regular use of rapid acting B2-agonists, in both short and long acting forms, may lead to relative refractoriness to B2-agonists

32 THEOPHYLLINES Effective as monotherapy and as add-on treatment to ICS or oral steroids, but efficacy is less than that of low-dose ICS Anti-inflammatory function noted at low dose of less than 10 mkd As add-on therapy, theophylline is less effective than LABA Side effects: GI, arrhythmias, seizures, drug interactions

33 CROMONES: Na CROMOGLYCATE AND NEDOCROMIL Na Limited role in long term treatment of asthma in children Can attenuate bronchospasm induced by exercise or cold air Side effect: Uncommon, cough and sore throat

34 Addition to other controller medications has been shown to improve control of allergic asthma (Evidence A) ANTI-IgE TREATMENT (Omalizumab)

35 Manage Exacerbations Do not underestimate the severity of an attack Patient should seek medical help if: The attack is severe The response to the initial bronchodilator treatment is not prompt There is no improvement within 2-6 hours There is further deterioration

36 Manage Exacerbations Asthma Attack requires prompt treatment: Inhaled rapid acting B2-agonists Oral glucocorticosteroids Oxygen (to achieve SaO2 of 95%) Combination B2-agonist/anticholinergic therapy Therapies not recommended: Sedatives Mucolytics Chest physical therapy

37 Manage Exacerbations Do not underestimate the severity of an attack Patient should seek medical help if: The attack is severe The response to the initial bronchodilator treatment is not prompt There is no improvement within 2-6 hours There is further deterioration

38 Bronchodilators : Mechanism of Action

39 RELIEVER MEDICATIONS RAPID ACTING INHALED B2-AGONISTS Most effective bronchodilator Preferred treatment for acute asthma Inhaled route is preferred Protection against exercise-induced bronchoconstriction Oral therapy is rarely needed and reserved for young children who cannot use inhaled therapy

40 RELIEVER MEDICATIONS ANTICHOLINERGICS Inhaled anticholinergics are not recommended for long term management of asthma inchildren

41 Comparative Pharmacokinetics of Nebulized Salbutamol and Ipratropium ParametersSalbutamolIpratropium Onset of bronchodilation within 5 mins.within minutes Peak effect1-2 hours Duration of effect 3-4 hours5-7 hours

42 REFERRAL to an Asthma Specialist (NAEP EPR 3 Report) Difficulties achieving or maintaining control of asthma Patient required > 2 bursts of oral steroids in 1 year or has an exacerbation requiring hospitalization Step 4 care or higher is required (Step 3 care or higher for 0-4 years) If immunotherapy or omalizumab is considered or if additional testing is indicated

43 SUMMARY Asthma is a serious chronic inflammatory disease of the airways Controller medication – primarily inhaled corticosteroids – is the cornerstone of asthma management Essential components of successful asthma management include Pharmacotherapy Allergen avoidance Patient education Use of a standardized diagnostic questionnaire, use of an asthma control test

44 SUMMARY ALLERGEN AVOIDANCE is recommended when there is sensitization and a clear association between allergen exposure and symptoms. ALLERGY TESTING (at all ages) to confirm the possible contribution of allergens to asthma exacerbation EXERCISE SHOULD NOT BE AVOIDED: Asthmatic children should be encouraged to participate in sports, with efficient control of asthma inflammation and symptoms.

45 Thank You


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