Presentation on theme: "Diagnosis and Management"— Presentation transcript:
1 Diagnosis and Management ASTHMA IN CHILDREN:Diagnosis and ManagementMilagros S. Salvani-Bautista, MDPediatric Pulmonologist
2 OPERATIONAL DESCRIPTION: “ Asthma is a chronic inflammatory disorderof 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
4 What is known about Asthma? increasing PREVALENCE especially in childrenCHRONIC INFLAMMATORY DISORDER of the airwayschronically inflamed airways are HYPERRESPONSIVEEPISODIC WHEEZING, BREATHLESSNESS, CHEST TIGHTNESS and COUGHINGcan be CONTROLLED
6 DETAILED HISTORY AND PE PRESENTING FEATURESWheezeDry coughBreathlessnessNoisy breathingDETAILED HISTORY AND PEPattern of illnessSeverity/controlDifferential cluesNoIS IT ASTHMA?Follow relevant course of actionSeek specialist assistanceProbablyPossiblyINVESTIGATE OR SEEKCausal factorsExacerbating factorsComplicationsComorbidityDIFFERENTIAL DIAGNOSTIC TESTS &/or TRIALS OF ASTHMA THERAPYAsthma likelyAsthma unlikelyASTHMA ACTION PLANDIAGNOSIS OF ASTHMA IN CHILDRENPoor responseGood response
7 CLASSIFICATION OF ASTHMA SEVERITY GINA 2002IntermittentSymptoms less than once a weekBrief exacerbationsNocturnal symptoms not more than 2x/mo.• FEV1 or PEF ≥ 80% predicted• PEF or FEV1 variability < 20%Mild PersistentSymptoms more than once a week but less than once a dayExacerbations may affect activity and sleepNocturnal symptoms more than 2x/mo.• PEF or FEV1 variability < 20 – 30%Moderate PersistentSymptoms dailyExacerbations may affect activity & sleepNocturnal 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 PersistentFrequent exacerbationsFrequent nocturnal asthma symptomsLimitation of physical activities• FEV1 or PEF ≤ 60% predicted
8 Level of Asthma Control CharacteristicControlled (All of the ff)Partly Controlled (Any measure present in any week)UncontrolledDaytime symptomsNone (2x or </wk.)More than 2x/wkThree or more features of partly controlled asthma present in any weekLimitations of activitiesNoneAnyNocturnal symptoms/ awakeningNeed for reliever/rescue txNone (2x or less/week)More than 2x/ wkLung function (PEF or FEV1)+Normal<80% predicted or personal best (if known)ExacerbationsOne or more/ yr*One in any wk╪* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate By definition, an exacerbation in any week makes that an uncontrolled asthma week ╪ Lung function testing is not reliable for children 5 years and younger.GINA 2006
9 ASTHMA MANAGEMENT: COMPONENTS OF THERAPY Assess and monitor asthma severity and asthma controlEducation for a partnership in careControl of environmental factors and co-morbid conditions that affect asthmaMedications
10 Medicines in Childhood Asthma GINA ASTHMA GUIDELINES 2002, 2006, 2007Medicines in Childhood AsthmaControllersInhaled and systemic corticosteroidsLeukotriene modifiersLong-acting B2 agonist (LABA) with Inhaled Corticosteroid ICSSustained release theophyllinesCromonesRelieversRapid-acting inhaled Beta (B)2 agonistInhaled anti-cholinergicsShort acting theophyllineShort acting B2 agonist(SABA)Classification of medication are the same.
12 Severity of Asthma Exacerbations….. GINA 2002, 2006, 2007Severity of Asthma Exacerbations…..MILD MODERATE SEVERE RESPIRATORYARRESTIMMINENTBreathless Walking Talking At restInfants – softer Infants- Stopsshorter cry feedingCan lie flat Prefers sitting *Hunched forwardTalks in Sentences Phrases WordsAlertness May be agitated Usually agitated Usually agitatedRespiratory Rate Increased Increased *Often >30/min BradypneaGUIDE TO RATES OF BREATHING ASSOCIATED WITHRESPIRATORY DISTRESS IN AWAKE CHILDRENAGE NORMAL RATE> 2 months < 60/min2-12 months < 50/min1-5 years < 40/min6-8 years < 30/minThe 2002 ,2006 and the 2007 GINA GUIDELINES are in agreement regarding the severity classification of asthma exacerbations
13 Severity of Asthma Exacerbations….. GINA 2002, 2006, 2007Severity of Asthma Exacerbations…..MILD MODERATE SEVERE RESPIRATORYARREST IMMINENTAccessory None Present Present PresentMuscles & Thoraco-abdominalSuprasternal MovementRetractionWheeze Audible with Audible with Audible w/o Absence of wheezestethoscope stethoscope stethoscope with decreased toabsent breathe soundsPulses/min < > BradycardiaGUIDE TO LIMITS OF NORMAL PULSE RATE IN CHILDRENAge Normal LimitsInfants months <160/minPreschool 1-2 years <120/minSchool Age 2-6 years <110/min
14 Severity of Asthma Exacerbations GINA 2002,2006,2007Severity of Asthma ExacerbationsMILD MODERATE SEVERE RESPIRATORYARRESTIMMINENTPulses Paradoxus Absent May be present Often present Absence suggests<10mm Hg 10—20mm Hg 20-40mm Hg respiratory musclefatiguePEF 80% % <60%%predictedOr%personal bestPaO2 RA Normal 60mm Hg <60mmHgtest NOT usually Possible CyanosisnecessaryPaCO2 45 mm Hg 45 mm Hg >45 mm Hg possiblerespiratory failureSaO2 RA 95% % <90%Hypercapnea (hypoventilation) develops more rapidly in young children
15 GINA ASTHMA GUIDELINES: (2002, 2006,2007) Management of Asthma Exacerbation in Acute CareS1Initial AssessmentHistory, Physical Examination(auscultation, use of accessory muscles,HR, RR, PEF or FEV1, O2 saturation, ABG’s if patient in extremis)Initial TreatmentOxygen to achieve O2 saturation ≥90% (95% in children)Inhaled rapid β2-agonist continuously for one hourSystemic GCS, if no immediate response, or if patient recently tookOral GCS, of if episode is severeSEDATION is CONTRAINDICATED in the treatment of an exacerbationReassess after 1 hour : PE, PEF, O2 saturation & other tests as neededCriteria for MODERATE Episode:PEF 60-80% predicted/personal bestPhysical exam: moderate symptoms,Accessory muscle useTreatment:O2,Inhaled β2 agonist + anticholinergic every 60 minOral GCSContinue treatment for 1-3 hours,providedThere is improvementCriteria for SEVERE Episode:History of risk factors for near fatal asthmaPEF < 60% predicted/personal bestPE: severe symptoms at rest, chest retractionNO improvement after initial treatmentTreatment:O2,Inhaled β2 agonist + anticholinergicSystemic GCSIV MagnesiumContinuation next slide
16 GINA ASTHMA GUIDELINES: (2002, 2006,2007) Cont. (S2)Management of Asthma Exacerbation in Acute CareReassess after 1 – 2 hoursGood Response within 1-2 hours:Response sustained 60 minutesafter last treatmentPE normal: no distressPEF > 70%O2 saturation > 90% (95% in children)Incomplete Response within 1-2 hours:Risk Factors for near fatal asthmaPE : mild to moderate signsPEF < 60%O2 saturation: NOT IMPROVINGPoor Response within 1-2 hours:Risk factors fro near fatal asthmaPE : symptoms severe, drowsiness,confusionPEF : < 30%PCO2 : > 45mmHgPO2: < 60mmHgADMIT to ACUTE CARE SettingOxygenInhaled β2-agonist ± anticholinergicSystemic GCSIntravenous MagnesiumMonitor PEF, O2 saturation, PulseADMIT to INTENSIVE CareOxygenInhaled β2-agonist+anticholinergicIV GCSConsider IV β2 agonistConsider IV theophyllinePossible intubationmechanical ventilationImproved: Criteria for Discharging HomePEF > 60% predicted / personal bestSustained on oral/inhaled medicationsHOME TREATMENT:Continue inhaled β2 agonistConsider in most cases, oral GCSConsider adding a combination inhalerPatient education: take medicine correctlyreview action planclose medical check upReassess at IntervalsPoor Response:Admit to intensive CareIncomplete response in 6-12 hoursConsider admission to Intensive CareIf No improvement within hoursImproved
17 Inhaled β2-agonists are the mainstay of therapy in acute asthma.
18 However, once response to the initial β2-agonists is minimal, incomplete or poor … COMBINATION of INHALED β2-AGONIST and INHALED ANTICHOLINERGIC is RECOMMENDEDThis is for moderate to severe attacks.
19 GINA ASTHMA GUIDELINES: 2002Recommended Medications by Level of Severity: ChildrenAll 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.INTERMITTENTPERSISTENTMILD MODERATE SEVEREDaily ControllerMedicationsOther TreatmentOptionsNonenecessaryIGCS µg BUDIGCS< 800µg BUDPLUSSustained releasedtheophylline ORIGCS <800µg BUDPLUS LABAORIGCS >800µg ORIGCS <800mcg PLUSLeukotriene modifierIGCS >800µg BUDPLUS one or moreof the following:Sustained-release theophyllineLong Acting Inhaledβ-2 agonistLeukotriene modifierOral glucocorticosteroidIGCSmcgBUDSustained-releaseTheophylline,ORCromone,LeukotrienemodifierIn 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 1 2 3 4 5 LEVEL OF CONTROL TREATMENT OF ACTION TREATMENT STEPS REDUCE controlledpartly controlleduncontrolledexacerbationLEVEL OF CONTROLmaintain and find lowest controlling stepconsider stepping up to gain controlstep up until controlledtreat as exacerbationTREATMENT OF ACTIONINCREASEGINA Guidelines 2006TREATMENT STEPSREDUCEINCREASESTEP12345
22 Asthma Medications As needed: RELIEVER BRONCHODILATORS Short acting β2-AgonistsAnticholinergics (inhaled)Short acting TheophyllinesDaily: CONTROLLERANTI-INFLAMMATORYCorticosteroids (inhaled and systemic)Leukotriene modifierLong acting β2 agonistsSustained release theophyllinesGINA 2006
23 Inhaled Corticosteroids Most effective long-term control for persistent asthmaSmall risk for adverse events at recommended dosageBenefits of daily useReduction ofasthma symptomsfrequency of exacerbationsairway inflammationairway responsivenessasthma mortalityImprovement oflung functionquality 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>>400Budesonide*Budesonide-Neb Inhalation Susp.>>1000Ciclesonide*80-160>>320Flunisolide>>1250Fluticasone>>500Mometasone furoate*Triamcinolone acetonide>>1200GINA 2006
25 COMPARISON OF PHARMACOKINETICS & PHARMACODYNAMIC PARAMETERS OF ICS BDP/BMPBUDFPLIPOPHILICITYMod/highLowHighPROTEIN BINDING:FREE FRACTION87:1388:1290:10T1/2, hr0.5/22.214.171.124Vd, Li20/424183318Clearance, L/h15/1208469
26 TECHNIQUES FOR BALANCING SAFETY AND EFFICACY OF ICS Selection and use of ICSSelect safest ICS drugUse minimum effective doseDose in AM when once daily dosingIf control is poor, add another controller rather than double dose of ICSTo maximize ICS delivery to lung, consider:CFC vs HFA propellant formulationpMDI vs DPI formulationUse of spacer devicePatient techniqueRinse mouth of ICS and discard
27 TECHNIQUES FOR BALANCING SAFETY AND EFFICACY OF ICS Use of ICS – sparing strategiesReduce allergens and smokeInoculate with influenza vaccineDiagnose and treat rhinosinusitis or GERDUse add-on therapiesMonitor growth at all ICS dosesMonitor eyes and bone mineral density when using > 1600 ug/day ICSConsider first line alternatives to ICS for mild persistent asthma
28 SYSTEMIC SIDE EFFECTS OF ICS THERAPY IN CHILDREN EVIDENCE GRADEEFFECT ONCONCLUSIONA, B, CGROWTHPotential to decrease growth velocity. Effects are small, non-progressive, reversibleABONE MINERAL DENSITYNo serious adverse effectsA, CCATARACTSGLAUCOMANo significant effects on incidence of subcapsular cataracts or glaucomaHPA AXIS FUNCTIONRare individuals may be susceptible to ICS effects on HPA axis even on conventional doses
29 LEUKOTRIENE MODIFIERS Mechanisms5-LO inhibitors (zileuton)CysLT 1 receptor antagonists (montelukast, pranlukast, zafirlukast)IndicationsAlternative treatment in mild persistent asthmaAspirin-sensitive asthmaAdd-on therapy, but less effective than LABAConcomitant asthma with allergic rhinitis29
30 LEUKOTRIENE MODIFIERS CHILDREN OLDER THAN 5 YRS.Clinical benefit at all levels of severity, but, generally less that that of low-dose ICSPartial protection against EIAAs add-on treatmentCHILDREN 5 YRS. AND YOUNGERIn 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 avoidedMost effective when combined with ICS, preferably in a fixed combination inhalerMay be used to prevent exercise-induced bronchospasmRegular use of rapid acting B2-agonists, in both short and long acting forms, may lead to relative refractoriness to B2-agonistsAsthma related deaths and deteriorations with long term use of salmeterol among asthmatics with unusual geotype for beta receptors (with substitution of arginine for glucine at position B-16) whether or not administeredwith ICS
32 THEOPHYLLINESEffective as monotherapy and as add-on treatment to ICS or oral steroids, but efficacy is less than that of low-dose ICSAnti-inflammatory function noted at low dose of less than 10 mkdAs add-on therapy, theophylline is less effective than LABASide effects: GI, arrhythmias, seizures, drug interactions
33 CROMONES: Na CROMOGLYCATE AND NEDOCROMIL Na Limited role in long term treatment of asthma in childrenCan attenuate bronchospasm induced by exercise or cold airSide effect: Uncommon, cough and sore throat
34 ANTI-IgE TREATMENT(Omalizumab)Addition to other controller medications has been shown to improve control of allergic asthma (Evidence A)
35 Do not underestimate the severity of an attack Manage ExacerbationsDo not underestimate the severity of an attackPatient should seek medical help if:The attack is severeThe response to the initial bronchodilator treatment is not promptThere is no improvement within 2-6 hoursThere is further deterioration
37 Do not underestimate the severity of an attack Manage ExacerbationsDo not underestimate the severity of an attackPatient should seek medical help if:The attack is severeThe response to the initial bronchodilator treatment is not promptThere is no improvement within 2-6 hoursThere is further deterioration
39 RAPID ACTING INHALED B2-AGONISTS RELIEVER MEDICATIONSRAPID ACTING INHALED B2-AGONISTSMost effective bronchodilatorPreferred treatment for acute asthmaInhaled route is preferredProtection against exercise-induced bronchoconstrictionOral 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 ParametersSalbutamolIpratropiumOnset of bronchodilationwithin 5 mins.within minutesPeak effect1-2 hoursDuration of effect3-4 hours5-7 hoursOnset of bronchodilation is faster with salbutamol. The duration of effect however is longer for ipratropium. These 2 distinct characteristics makes it ideal to combine the 2 drugs.41
42 REFERRAL to an Asthma Specialist (NAEP EPR 3 Report) Difficulties achieving or maintaining control of asthmaPatient required > 2 bursts of oral steroids in 1 year or has an exacerbation requiring hospitalizationStep 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 SUMMARYAsthma is a serious chronic inflammatory disease of the airwaysController medication – primarily inhaled corticosteroids – is the cornerstone of asthma managementEssential components of successful asthma management includePharmacotherapyAllergen avoidancePatient educationUse of a standardized diagnostic questionnaire, use of an asthma control test
44 SUMMARYALLERGEN 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 exacerbationEXERCISE SHOULD NOT BE AVOIDED:Asthmatic children should be encouraged to participate in sports, with efficient control of asthma inflammation and symptoms.
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