1. خدا نیکوست

2. Treatment of Children Asthma
Dr. Fatemeh Behmanesh

3. Key elements to optimal asthma management

4. Assess severity
The classification of asthma severity is based on the following parameters:
Frequency of day time symptoms
Frequency of might time symptoms
Degree of air flow obstruction by spirometry or
PEF variability

5. Asthma severity categorized as
Mild intermittent
Mild persistent
Moderate persistent
Sever persistent

6. Classification of Asthma Severity
FOR ADULTS AND CHILDREN AGE > 5 YEARS WHO CAN USE A SPIROMETER OR PEAK FLOW METER
CLASSIFICATION
STEP
DAYS WITH SYMPTOMS
NIGHTS WITH SYMPTOMS
FEV1 or PEF[*] % Predicted Normal
PEF Variability (%)
Severe persistent 4
Continual
Frequent
≤60
>30
Moderate persistent 3
Daily
>1/wk
>60–<80
Mild persistent 2
>2/wk, but <1 time/day
>2/mo
≥80
20–30
Mild intermittent 1
≤2/wk
<2/mo
<20

7. Stepwise Approach for Managing Infants and Young Children (≤5 Yr of Age) with Acute or Chronic Asthma; Treatment    
Classify Severity: Clinical Features Before Treatment Or Adequate Control
Medications Required To Maintain Long-Term Control   
Symptoms/Day
Symptoms/Night
Daily Medications
Step 4
Severe persistent
Step 3
Moderate persistent
Step 2
Mild persistent
Step 1
Mild intermittent   
Continual
Frequent   
Daily
>1 night/wk
>2/Week but<1 /day
>2 nights/mo
 2days/wk
2nights/mo
Preferred treatment
High-dose inhaled corticosteroids AND
Long-acting inhaled β2-agonists
AND, if needed,
Corticosteroid tablets or syrup long term (2 mg/kg/day, generally do not exceed 60 mg/day).(Make repeat attempts to reduce systemic corticosteroids and maintain control with high-dose inhaled corticosteroids.)
Low-dose inhaled corticosteroids and long-acting inhaled β2-agonists OR
Medium-dose inhaled corticosteroids.
Alternative treatment
Low-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline.
If needed (particularly in patients with recurring severe exacerbations):
Medium-dose inhaled corticosteroids and long-acting β2-agonists.
Medium-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline.
Low-dose inhaled corticosteroid (with nebulizer or MDI with holding chamber with or without face mask or DPI).
Cromolyn (nebulizer is preferred or MDI with holding chamber)
OR leukotriene receptor antagonist.
No daily medication needed.
 Quick Relief All Patients
Bronchodilator as needed for symptoms. Intensity of treatment will depend on severity of exacerbation.
Preferred treatment: Short-acting inhaled β2-agonists by nebulizer or face mask and space/holding chamber
Alternative treatment: Oral β2-agonist
With viral respiratory infection
Bronchodilator q 4–6 hr up to 24 hr (longer with physician consult); in general, repeat no more than once every 6 wk
Consider systemic corticosteroid if exacerbation is severe or patient has history of previous severe exacerbations
Use of short-acting β2-agonists >2 times/wk in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate (increase) long-term-control therapy.

9. Treat all persistent asthma with anti-inflammatory controller medication.
the type and amounts of daily controller medication are determined by asthma severity.

10. Three strikes rule:
Symptom or uses quick-relif medication at least 3 times per week.
Awakens at might due to asthma at least 3 times per months.
Experiences asthma exacerbations at least 3 times per year.
Or require short courses of systemic cortico-steroids at least 3 times a year.
Patient should receive daily controller therapy

11. Controller therapy can be considered for children who present with frequent exacerbation
At least 2 exacerbation occuring < 6 week apart

12. All levels of persistent asthma should be treated with daily medications include:
ICS
LABA
Leukotriene modifiers
Nonsteroidal anti-inflamatory agents
Sustained – release theophylline
Anti- IgE (omalizumab, Xolair) approved by add- on therapy for patients with moderate to sever allergic asthma.
Most potent and effective medication is corticosteroids
Acute (systemically)
Chronic (inhalation)

13. ICS First line treatment for persistent asthma Reduce asthma symptoms
Improve lung function
Reduce AHR
Reduce “rescue” medication use
Reduce urgent care visits & hospitalization
Lower the risk of death

14. Estimated Comparative Daily Dosages for Inhaled Corticosteroids
DRUG
LOW DAILY DOSE
MEDIUM DAILY DOSE
HIGH DAILY DOSE
Adult
Child[*]
Beclomethasone CFC 42 or 84 μg/puff
168–504 μg
84–336 μg
504–840 μg
336–672 μg
>840 μg
>672 μg
Beclomethasone HFA 40 or 80 μg/puff
80–240 μg
80–160 μg
240–840 μg
160–320 μg
>480 μg
>320 μg
Budesonide DPI 200 μg/inhalation
200–600 μg
200–400 μg
600–1,200 μg
400–800 μg
>1,200 μg
>800 μg
Inhalation suspension for nebulization (child dose)
0.5 μg
1.0 μg
2.0 μg
Flunisolide 250 μg/puff
500–1,000 μg
500–750 μg
1,000–2,000 μg
1,000–1,250 μg
>2,000 μg
>1,250 μg
Fluticasone MDI: 44, 110, or 220 μg/puff
88–264 μg
88–176 μg
264–660 μg
175–440 μg
>660 μg
>440 μg
DPI: 50, 100, or 250 μg/inhalation
100–300 μg
100–200 μg
300–600 μg
>600 μg
>400 μg
Triamcinolone acetonide 100 μg/puff
400–1,000 μg
800–1,200 μg
* Children ≤ 12 years of age

15. Leukotrience pathway modifiers
Two classes of leukotrene modifiers:
Inhibitors of leukotriene synthesis: zileuton
Leukotriene receptor antagonists:
Montelukast
Zafirlukast

16. Zileuton:
Not upproved for children < 12 year
4 times daily
Elevated liver function enzymes
Montelukast
Approved for children 1 year
One daily
Zafirlukast
Approved in children  5 year
Twic daily

17. Leukotriene modifiers are considered alternative controllers for mild persistent asthma

18. Sustained- Release Theophylline
Considered on alternative monotherapy controller agent for older children and adults with mild persistent asthma.
No longer considered a first line agent for small children

19. LABA Daily controller medication
Not as monotherapy for persistent asthma
Add- on agent for patients suboptimally controlled on ICS therapy alone
Salmetrol
For moterol
In patients with nocturnal asthma
Low dose ICS with LABA for moderate persistent asthma in older children and adult
High dose ICS + LABA for sever persistent asthma

20. Non-steroidal Anti- Inflammatory Agents
Cromolyn and nedocromil
Non- corticosteroid anti- inflammatory
Reduce exercise- induced bronchospasm
For mild persistent asthma
Adminstered frequently 2-4 times/day
Not nearly as effective daily contoller as ICS

21. Anti IgE (omalizumal) Humanized monoclonal antibody that binds IgE
FDA approved for patients > 12 year old
For moderate to sever asthma
For Patients with inadequate disease control with ICS or oral corticosteroids
Every 2-4 week

22. Step-up, step up- Down Approach
Initiating higher-level controller therapy
Step down after good asthma control
Decrease ICS dose about 25% every 2-3 months
If control is not maintained, step up,
review patient medication technique
Adherence
Environment

23. Quick – Reliever medications
Rescue medications:
Short acting inhaled -agonist
Inhaled antichilinergics
Short course systemic corticosteriods
For management of acute asthma

24. SABA Rapid onset of action 4-6 hr duration of action
First choice for acute asthma symptom
For preventing exercise induced bronchospasm
It is helpful to monitor the frequency of SABA
Use
At least 1 MDI/Month
Indicate Inadequate Asthma Control
Al least 3 MDI/ year

25. Anticholinergic Agents
Ipratropium bromide
Tretament of acute sever asthma
Combination with SABA
Improve lung function
Reduce the rate of hospitalization
MDI, Nebulizer formulation
Approved by FDA for children > 12 year of age

26. Management acute asthma
The home
The emergency department
The hospital

27. Home Management Home treatment based on changes in PEF values
Green zone
Yellow zone
Red zone
In children too young or otherwise incapable of performing PFT, sing & symptoms to be evaluated: (e.g., color changes, respiratory rate, location/extent of retractions, duration of inspiratory/ expiratory phases, presence or absence of cough/wheezing)

28. …Home Management
Note signs and symptoms: Degrees of cough, breatlessness, wheeze and chest tightness, corrolate imperfectly with severity of exacebration. Accessory muscle use and suprasternal retraction suggest severed exacebration.
If PEF<50% predicted: initial treatment
Inhaled short-acting β2 agonist: up to three treatment of 2-4 puff 20-min intervales by
MDI
MDI + Spacer device
DPI
Hand nebulizer

29. …Home Management After 1 hour Good response Incomplete response
Poor response

30. Good Response (Mild Episode)
PFE>80% predicted
No wheezing or shortness of breath
Response to β2 agonist sustained for 4 hours
May continue β2 agonist every 3-4h for 24-48h
For patients on inhaled corticosteroids, double dose for 7-10 days and contact clinician

31. Incomplete Response (Moderate Episode)
PEF 50%-80% predicted
Persistent wheezing and shortness of breath
Add oral corticosteroid
Continue β2 agonist
Contact clinician urgently (this day)

32. Poor Response (Sever Episode)
PEF<50% predicted
Marked wheezing 8 shortness of breath
Add oral corticosteroid
Repeat β2 agonist immediately
Call your doctor
Proceed to emergency department

33. Office or Emergency Department Management
A brief history of the events leading up to the exacerbation and the medications used both chronically and acutely to treat
Physical examination: RR, PR, Pluse oximetry, use of accessory muscle, air flow, wheezing, (1÷E), verbalization, puls paradoxus.
Studies: PEF, FEV1, ABG
Routine CXRnot nessary unless complication (e.g., pneumothorax, pneumomediastinum, aspiration)

34. Respiratory arrest imminent
Intubate and mechanically ventilate with 100% O2.
Nebulized β2 agonist and anticholinergic
IV corticosteroid.
Admit to ICU
Continuous monitoring
Intensive asthma management

35. … Respiratory arrest imminent
Improved
Admit to hospital ward
O2 to maintain good saturation
Nebulized β2 agnoist +/- anticholinergic
PO or IV corticoesteroid
Monitor vital signs, O2 saturation, FEV1 or PEF

36. … Respiratory arrest imminent
Improved
Discharge to home
Continue home treatment with inhaled β2 agonist
Consider need for oral corticosteroids or controller medication
Educate patient in medication use and action plans
Arrange follow-up

37. Emergency department management
Give nebulized albuterol with o2 at 6 liters flow, 2.5mg per dose q 20min.
O2 to achieve saturation>90%
Give corticosteroid po or IV if FEV1 or PEF<50% Or
If the patient was recently receiving corticosteroids
If the patient in historically a high risk patient

38. Reassess
Physical examination: RR, HR, Pulse oximetry, use of accessory muscles, airflow, wheezing, (1÷E) verbalization, pulsus paradoxus
Studies; PEF, FEV1
Mild exacerbation
Moderate exacerbation
Sever exacerbation

39. Mild Exacerbation FEV1 or PEF>80% Good response
Maintained without repeated treatments during ER
PE: Normal
Discharge to home
Continue home treatment with inhaled β2 agonist
Consider need for oral corticosteroids or controller medication
E ducat patient in medication use and action plus
Arrange follow up

40. Moderate Exacerbation
FEV1 or PEF>50% but <80%
In complete response to treatment
PE: RR, Wheezing present, mild to moderate accessory muscle use,
O2 satiration 91-95%
1:E<1:2
PP=10-25mmHg

41. … Moderate Exacerbation
Admit to Hospital Ward
02 up to 02 sat >95%
Nebulized β2 agonist +/- anticholinergic
Po or IV corticosteroid
Monitor vital signs, 02 saturation, FEV1 or PEF

42. … Moderate Exacerbation
Improved
Discharge to home
Continue home treatment with inhaled β2 agonist
Consider need for oral corticosteroid or controller medication
Educate patient in medications and action plan
Arrange follow up

43. Sever Exacerbatis FEV1 or PEF<50% Poor response to treatment
PE: RR, Wheezing present, poor airflow
Moderate-sever accessory muscle use, 02 sat<91%
PP>25mmHg
Admit to ICU
Continuous monitoring
Intensive asthma management

44. … Sever Exacerbatis Improved Admit to hospital ward
O2 to maintain good saturation
Nebulized β2 agnoist +/- anticholinergic
PO or IV corticoesteroid
Monitor vital signs, O2 saturation, FEV1 or PEF

45. … Sever Exacerbatis Improved Discharge to home
Continue home treatment with inhaled β2 agonist
Consider need for oral corticosteroids or controller medication
Educate patient in medication use and action plans
Arrange follow-up

46. Short-acting 2 agonist
Therapy of EIA
Useful prophylactic approaches
Class
Drug
Dose inhaled
Time delay
Duration
Long- acting 2 agonist
Salmeterol
1 inhalation DPI
20 min
8-10 hr
Short-acting 2 agonist
Albuterol
2 puffs MDI
15 min
3-4 hr
Antileukotriene
Montelukast
10 mg orally
30 min
8-10 hr
Mast cell stabilizers
Cromolyn
1.5-2 hr
Duration of protection may decrease with regularly scheduled use