Guía Asma Soc. Japonesa

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Guía Asma Soc. Japonesa

  1. 1. Pediatrics International (2010) 52, 319–326 doi: 10.1111/j.1442-200X.2009.03010.xJapan Today ped_3010 319..326Japanese pediatric guidelines for the treatment and management ofbronchial asthma 2008Naomi Kondo,1,5 Toshiyuki Nishimuta,2,5 Sankei Nishima,3,5 Akihiro Morikawa,4,5 Yukoh Aihara,5 Toru Akasaka,5Akira Akasawa,5 Yuichi Adachi,5 Hirokazu Arakawa,5 Takao Ikarashi,5 Toshiichi Ikebe,5 Toshishige Inoue,5 Tsutomu Iwata,5Atsuo Urisu,5 Motohiro Ebisawa,5 Yukihiro Ohya,5 Kenji Okada,5 Hiroshi Odajima,5 Toshio Katsunuma,5 Makoto Kameda,5Kazuyuki Kurihara,5 Yoichi Kohno,5 Tatsuo Sakamoto,5 Naoki Shimojo,5 Yutaka Suehiro,5 Kenichi Tokuyama,5Mitsuhiko Nambu,5 Yuhei Hamasaki,5 Takao Fujisawa,5 Takehiko Matsui,5 Tomoyo Matsubara,5 Mitsufumi Mayumi,5Tokuko Mukoyama,5 Hiroyuki Mochizuki,5 Koichi Yamaguchi5 and Shigemi Yoshihara51 Department of Pediatrics, Graduate School of Medicine, Gifu University, 5Japanese Society of Pediatric Allergy andClinical Immunology, Gifu, 2National Hospital Organization, Shimoshizu National Hospital, Chiba, 3Department ofPediatrics, National Fukuoka Hospital, Fukuoka and 4Department of Pediatrics and Developmental Medicine, GunmaUniversity, Graduate School of Medicine, Gunma, JapanAbstract The fourth version of the Japanese Pediatric Guidelines for the Treatment and Management of Bronchial Asthma 2008 (JPGL 2008) was published by the Japanese Society of Pediatric Allergy and Clinical Immunology in December 2008. In JPGL 2008, the recommendations were revised on the basis of the JPGL 2005. The JPGL 2008 is different to the Global Initiative for Asthma guideline in that it contains the following items: a classification system of asthma severity; recommendations for long-term management organized by age; a special mention of infantile asthma; and an emphasis on prevention and early intervention. Here we show a summary of the JPGL 2008 revising our previous report concerning JPGL 2005.Key words acute attacks, childhood asthma, prevention, guideline, long-term management.After the publication of the first version of the Japanese Pediatric and recurrent symptoms of airway narrowing, including episodesGuidelines for the Treatment and Management of Bronchial of dyspnea, wheezing, and coughing. Patients commonly showAsthma (JPGL) in 2000, the pediatric asthma mortality rate bronchial hyperresponsiveness associated with chronic allergicdecreased in Japan. However, the methodology of asthma treat- inflammation of the airway, mainly due to environmentalment has evolved over the years, and the JPGL were revised in allergens.4,52002, 2005, and 20081,2 by the Japanese Society of Pediatric Similarly to adult asthma, childhood asthma is also consid-Allergy and Clinical Immunology (JSPACI). In the JPGL 2008, ered to be a chronic inflammatory airway disease. However, therewe revised our recommendations on the basis of the JPGL 2005. are some differences between children and adults in the mecha-The JPGL 2008 is different to the Global Initiative for Asthma nism of an asthma attack, and the pathophysiology of asthma(GINA) guideline 20063 in that it contains the following items: a attacks in children is not fully understood.classification system of asthma severity; recommendations for An assessment of the severity of a patient’s asthma attacks islong-term management organized by age; a special mention essential in developing a plan for the adequate treatment andof infantile asthma; and an emphasis on prevention and early management of the disease. Childhood asthma attacks are clas-intervention.1 sified into four stages of severity: mild attacks, moderate attacks, Here we show a summary of the JPGL 2008 revising our severe attacks, and acute respiratory failure. The criteria for eachprevious report concerning JPGL 2005.4 of these stages are shown in Table 1. With regard to the percentage of peak expiratory flow (PEF),Definition, pathophysiology, diagnosis, and GINA guidelines and other guidelines established in Japan haveclassification of childhood asthma adopted PEF measured after b2-agonist inhalation, as a referenceIn previous years, asthma was defined as a respiratory disease point. This PEF reflects airflow limitation and reversibility, and isinvolving a chronic airway inflammation, airway remodeling, useful for evaluating the severity of attacks.6 In the JPGL 2008, similarly to JPGL 2005, it is recommended that PEF should be measured both before and after b2-agonist inhalation.Correspondence: Naomi Kondo, md phd, Department of Pediatrics,Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu Regarding the severity of asthma, the classification system501-1194, Japan. Email: nkondo@gifu-u.ac.jp outlined by the JSPACI has been used for a long time and it Received 5 November 2009; accepted 19 November 2009. includes mild asthma, moderate asthma, and severe asthma.© 2010 Japan Pediatric Society
  2. 2. 320 N Kondo et al. However, we adopted the GINA guidelines as a model for JPGL (mmHg) PaCO2 41–60 2002: intermittent, mild persistent, moderate persistent, and <41 <41 >60 severe persistent asthma (Table 2). The long-term management criteria in the JPGL 2008 were also divided into four steps that were coordinated with the GINA or Japanese adult asthma guide- air) (%) 92–95 (Room SpO2 lines. However, a step for the same condition is graded to be more 396 291 <91 severe in JPGL 2008 than in other guidelines, in order for it to be more useful in clinical practice for childhood asthma. For example, in the case of symptoms occurring less than once a inhalation (%) After b2 week, the grade is intermittent in the GINA guidelines, but it is mild persistent in JPGL 2008 as well as in JPGL 2005. 50–80 n.m. >80 <50 PEFR Epidemiology of childhood asthma inhalation (%) At present, two survey methods are utilized in Japan: the Inter- Before b2 national Study of Asthma and Allergies in Childhood (ISAAC)7 30–60 and the American Thoracic Society – Division of Lung Diseases n.m. (ATS-DLD) modified Japanese version.8 The ISAAC survey >60 <30 includes cases of asthma ranging from mild to severe, and the ATS-DLD survey includes only typical cases of asthma with n.m. not measured; PaCO2, carbon dioxide partial pressure; PEFR, peak expiratory flow rate; SpO2, oxygen saturation. Respiratory dyspnea. Therefore, the reported prevalence is different depend- Unstable rate ing on the survey method used. The prevalence of asthma symp- ↑↑ ↑↑ toms determined using ISAAC is 2–2.5-fold higher than that ↑ determined using ATS-DLD. ATS-DLD is often used in Japan, which shows a 7–8% prevalence of asthma. Cyanosis Nishima et al. reported that the prevalence of asthma based on (-) (-) (1) (+) an ATS-DLD survey performed in elementary schools at the same time each year was 3.2% in 1982, 4.6% in 1992, and 6.5% in 2002, indicating a twofold increase within 20 years.9,10 These results show that the prevalence of asthma in Japan is increasing, Leaning forward particularly in children. The JPGL 2008 revision includes the Posture Lying down latest epidemiological data. Sitting Symptoms – Risk factors and prevention of asthma in infants and children of expiration Prolongation The risk factors for childhood asthma are listed in the JPGL 2008, (++) (++) as shown in Table 3. The assessment of newborns and infants is (-) (+) important for evaluating the risk factors for childhood asthma. The influences of smoking during pregnancy and viral respiratory infections including respiratory syncytial virus, rhinovirus, and Retraction influenza virus as risk factors for asthma development and (-)–(+) asthma exacerbation are becoming more obvious.11,12 (++) (++) (+) Three levels of prevention have been described and, in relation to asthma, include primary, secondary and tertiary preventions as shown in Table 4.13 Table 1 Severity of asthma attack Breathless wheezing A prerequisite for establishing any form of preventive strategy (1)–(-) (++) (++) is to have reliable markers that predict the progression of a (1) disease, but to date there are no such markers available for asthma. At all levels of prevention, many of the issues remain speculative and have yet to be tested in appropriate long-term Respiratory attack Moderate attack controlled clinical studies, though many such studies are in Severe attack progress. Mild attack The usefulness of early intervention with inhaled corticoster- oids and other anti-inflammatory drugs in the early phase of asthma development has also been discussed in the JPGL 2008.© 2010 Japan Pediatric Society
  3. 3. Jpn pediatric guidelines for asthma 2008 321Table 2 Differences in classification of asthma severityJPGL 2008 GINA 2006Step1: Intermittent Step1: Intermittent• Symptoms less than several times a year • Symptoms less than once a week• Brief exacerbation • Nocturnal symptoms not more than twice a monthStep2: Mild persistent Step2: Mild persistent• Symptoms less than once a week • Symptoms more than once a week• Normal daily life • Nocturnal symptoms more than twice a monthStep3: Moderate persistent Step3: Moderate persistent• Symptoms more than once a week • Symptoms daily• Sometimes, moderate or severe attack • Nocturnal symptoms more than once a weekStep4: Severe persistent Step4: Severe persistent• Symptoms daily • Symptoms daily• Moderate or severe attack more than several times a week • Frequent exacerbations• Troubles in daily life • Frequent nocturnal symptoms GINA, Global Initiative for Asthma; JPGL 2008, Japanese Pediatric Guidelines for the Treatment and Management of Asthma 2008.Acute attacks in childhood asthma measure percutaneous arterial oxygen saturation (SpO2) and PEFHome management of patients to evaluate the severity of acute attacks (Tables 5–7). Inhaled b2-agonists should be used as an initial therapy, and a treatmentAsthma symptoms vary widely in severity, ranging from mild suitable for each symptom should then be selected. During mod-attacks of wheezing to severe acute respiratory failure. Physi- erate attacks, inhaled b2-agonists should be used several timescians should provide detailed information for home management every 20–30 min. In addition, systemic corticosteroids (by i.v. orto each patient and/or parent, including how to observe asthmatic p.o.) and/or aminophylline (by drip infusion, the target serumsymptoms and how to use drugs for the control or relief of asthma theophylline concentration is 8–15 mg/mL and ~10 mg/mL inattacks and timing of visiting a medical facility. Repeated instruc- patients <2 years) should be administered. Administrationtions on the proper inhalation techniques of b2-agonists are also therapy is necessary during severe attacks and for moderatenecessary. attacks that fail to improve despite the therapies. In addition toManagement in a medical facility (Tables 5–7, organized the therapies already mentioned, a continuous inhalation of iso-by age) proterenol should also be administered during severe attacks andManagement plans should be determined when patients areadmitted to a medical facility for an asthma attack. It is useful to Table 4 Three levels of prevention for asthma13Table 3 Potential Risk Factors of Asthma Primary prevention is introduced before exposure to risk factors known to be associated with a disease.(1) Host factors • The goal is to prevent the onset of disease in susceptible (at-risk)1. Family history and gender individuals.2. Genetic predisposition • This is not yet possible in asthma.• Allergy (Atopy) • Increasing evidence indicates that allergic sensitization is the most• Airway hyperresponsiveness common precursor to the development of asthma.• Obesity and low birthweight • As sensitization can occur antenatally, much of the focus of3. Genes primary prevention will likely be on perinatal interventions.(2) Environmental factors Secondary prevention is employed after primary sensitization to1. Allergens allergen(s) has occurred, but before there is any evidence of• Inhalations disease.• Foods • The aim is to prevent the establishment of chronic, persistent2. Respiratory infections disease in people who are susceptible and who have early signs of• Virus the disease.• Mycoplasma, Chlamydia • This is currently being investigated in asthma.3. Air pollution • Secondary prevention of asthma is likely to focus very specifically• Passive and active smoking on the first year or two of life.• Indoor and outdoor air pollutants Tertiary prevention involves avoidance of allergens and nonspecific• Others triggers when asthma is established.4. Others • The goal is to prevent exacerbations or illness that would• Weather changes otherwise occur with exposure to identified allergens or irritants.• Exercise and hyperventilation • It is considered that tertiary prevention should be introduced when• Extreme emotional expression the first signs of asthma have occurred.• Drugs • However, increasing evidence suggests that the histopathology of• Menstruation the disease is fully established by the time asthma symptoms• Respiratory complications occur. © 2010 Japan Pediatric Society
  4. 4. 322 N Kondo et al.Table 5 Management of exacerbations in hospital (6–15years) Mild Moderate Severe Respiratory failureInitial b2-agonist inhalation Repeat b2-agonist inhalation† Admit to hospital Admit to hospital O2 inhalation (SpO2 <95%) Repeat b2-agonist inhalation† Continuous isoproterenol O2 inhalation inhalation i.v. drip O2 inhalation Systemic glucocorticosteroids i.v. drip (i.v.) Repeat systemic Aminophylline (d.i.v.) glucocorticosteroids (i.v.) Aminophylline (d.i.v.)Additional Repeat b2-agonist Systemic glucocorticosteroids Continuous isoproterenol Continuous isoproterenol inhalation† (i.v. or p.o.) inhalation inhalation and/or Repeat systemic Correct acidosis Aminophylline (d.i.v.) glucocorticosteroids (i.v .) Intubation Consideration for admission to Mechanical ventilation hospital Anesthetics (consideration) † Every 20–30 min, max 3 times. d.i.v., intravenous drip infusion; i.v., intravenous; p.o., per os; SpO2, oxygen saturation.Table 6 Management of exacerbations in hospital (2–5years) Mild Moderate Severe Respiratory failureInitial b2-agonist Repeat b2-agonist inhalation† Admit to hospital Admit to hospital inhalation O2 inhalation (SpO2 <95%) Repeat b2-agonist inhalation† Continuous isoproterenol O2 inhalation inhalation i.v. drip O2 inhalation Systemic glucocorticosteroids i.v. drip (i.v.) Repeat systemic Aminophylline (d.i.v.)‡ glucocorticosteroids (i.v.) Aminophylline (d.i.v.)‡Additional Repeat b2-agonist Systemic glucocorticosteroids Continuous isoproterenol Continuous isoproterenol inhalation† (i.v. or p.o.) inhalation inhalation and/or Repeat systemic Correct acidosis Aminophylline (d.i.v.)‡ glucocorticosteroids (i.v.) Intubation Consideration for admission to Mechanical ventilation hospital Anesthetics (consideration) † Every 20–30 min, max 3 times. ‡A well-informed pediatrician is required. d.i.v., intravenous drip infusion; i.v., intravenous; p.o., per os; SpO2,oxygen saturation.Table 7 Management of exacerbations in hospital (<2 years) Mild Moderate Severe Respiratory failureInitial b2-agonist Repeat b2-agonist inhalation† Admit to hospital Admit to hospital inhalation O2 inhalation (SpO2 <95%) Repeat b2-agonist inhalation† Continuous isoproterenol O2 inhalation inhalation i.v. drip O2 inhalation Systemic glucocorticosteroids i.v. drip (i.v.) Repeat systemic glucocorticosteroids (i.v.)Additional Repeat b2-agonist Admit to hospital Continuous isoproterenol Intubation inhalation† Systemic glucocorticosteroids inhalation Mechanical ventilation (i.v. or p.o.) Repeat systemic Aminophylline (d.i.v.) i.v. drip glucocorticosteroids (i.v.) (consideration)‡ Aminophylline (d.i.v) Aminophylline (d.i.v.) Anesthetics (consideration) (consideration)‡ (consideration)‡ † Every 20–30 min. max 3 times. ‡Exercise caution. A well-informed pediatrician is required. d.i.v., intravenous drip infusion; i.v., intravenous;p.o., per os; SpO2, oxygen saturation.© 2010 Japan Pediatric Society
  5. 5. Jpn pediatric guidelines for asthma 2008 323respiratory failure.14 If the respiratory condition fails to improve, need for b2-agonists; (ii) no symptoms, including nocturnalendotracheal intubation and mechanical ventilation must be con- symptoms; (iii) no absence from school classes; (iv) no limita-sidered. Oxygen inhalation can also be considered during mod- tions on activities, including exercise; (v) minor PEF circadianerate attacks, and the SpO2 should be maintained at 95% or variation; (vi) normal PEF; and (vii) normal airway hypersensi-higher (Tables 5–7). tivity (no exacerbation despite exercise or cool air aspiration). The therapy regimen can also be utilized for infantile asthma, The final aim is the remission and cure of the asthma.except for the use of aminophylline. When administering When satisfactory asthma control is maintained for severalaminophylline by drip infusion, theophylline metabolism varies weeks or months, the treatment can be stepped down carefully, asaccording to fever and other factors. The serum theophylline long as the symptom-free condition is maintained. At each step-concentration should therefore be monitored as closely as pos- down, the b2-agonist use should be reduced first. If poor controlsible, and the dosage should be corrected to 210 mg/mL. It is is observed, the treatment should be immediately stepped up.assumed that infantile asthma patients are usually hospitalized in Once satisfactory control of asthma is obtained, treatment can bethe middle of an attack, and steroid administration, fluid therapy cautiously stepped down again.and continuous i.v. infusion of aminophylline should be consid- As severity is changed by the therapies administered (appar-ered with caution to avoid overdosing the patient. ent severity), the actual severity should be determined consider- ing the therapies, as shown in Table 11.Medication plan for long-term management of In JPGL 2008, the Japanese Pediatric Asthma Controlchildhood asthma Program (JPAC) and Childhood Asthma Control test (C-ACT)The medication plan in the JPGL 2008 as well as the JPGL 2005 are shown for the judgment of a successful long-termis divided into three age brackets: older children, younger chil- management.15,16dren, and infants. The medication plan for long-term manage-ment was simplified and reconstructed in the JPGL 2008 and Treatment of intermittent asthma (step 1)inhaled corticosteroids (ICS) and other anti-inflammatory drugs In intermittent asthma, symptomatic therapy is administered toare the recommended treatment options (Tables 8–10). each patient (Tables 8–10). An important factor in the long-term medication plan iscontinuous monitoring in order to control asthma symptoms. Treatment of mild persistent asthma (step 2)Regular follow-up monitoring should be performed every 1 or 2 In older children, ICS are used as the first-choice medication, andmonths, including a record of symptoms in an asthma diary, 100 mg/day of fluticasone propionate (FP) or hydrofluoroalkanemeasurement of PEF, sleep and exercise habits, and the (HFA)-beclomethasone dipropionate (BDP) should be adminis-frequency of b2-agonist use. tered twice daily (morning and night) using auxiliary equipment The control of childhood asthma can be achieved in almost all such as a mask (Table 8). Leukotriene receptor antagonistspatients. Successful control is defined as follows: (i) a minimal (LTRA) and/or disodium cromoglycate (DSCG) are used aloneTable 8 Long-term asthma management (6–15 years) Step 1 Step 2 Step 3 Step 4Basic Symptomatic therapy ICS ICS ICS (FP or BDP (FP or BDP 100–200 mg/day) (FP or BDP 200- 400 mg/day) 100 mg/day) or plus one or more • LTRA† • LTRA† and/or • Sustained-release theophylline (p.o.) • DSCG • DSCG • LABA (tape, p.o. or LABA inhalation) Or SFC (100/200 mg/day) onlyAdditional • LTRA† Sustained-release plus one or more Glucocorticosteroids (p.o.) theophylline (p.o.) and/or • LTRA† (Short-term consideration) • DSCG • Sustained-release theophylline (p.o.) Hospitalization at a medical institution • DSCG (consideration) • LABA (tape, p.o. or LABA inhalation) or SFC (50/100–100/200 mg/day) only † There are anti-allergic drugs such as histamine H1 antagonists and Th2 cytokine inhibitors other than LTRA. BDP, beclomethasone dipropi-onate; DSCG, disodium cromoglycate; FP, fluticasone propionate; ICS, inhaled corticosteroids; LABA, long-acting b2-agonists; LTRA, leukotrienereceptor antagonist; p.o., per os; SFC, salmeterol/fluticasone propionate combination. © 2010 Japan Pediatric Society
  6. 6. 324 N Kondo et al.Table 9 Long-term asthma management (2–5 years) Step 1 Step 2 Step 3 Step 4Basic Symptomatic • LTRA† ICS (FP or BDP 100–150 mg/day , ICS (FP or BDP 150–300 mg/day, therapy and/or BIS 0.5 mg/day) BIS 1.0 mg/day) • DSCG‡ plus one or more or • LTRA† ICS (FP or BDP • DSCG‡ 50–100 mg/day, BIS 0.25 mg/day) • Sustained-release theophylline (p.o.)§ • LABA (tape, p.o. or LABA inhalation)Additional • LTRA† • Sustained-release plus one or more theophylline (p.o.)§ and/or • LTRA† • DSCG • DSCG‡ • Sustained-release theophylline (p.o.)§ • LABA (tape, p.o. or LABA inhalation) † There are anti-allergic drugs such as histamine H1 antagonists and Th2 cytokine inhibitors other than LTRA. ‡If necessary, + b2-agonists(0.05 mL–0.1 mL). §Be careful of side-effects. BDP, beclomethasone dipropionate; BIS, budesonide inhalation suspension; DSCG, disodiumcromoglycate; FP, fluticasone propionate; ICS, inhaled corticosteroids; LABA, long-acting b2-agonists; LTRA, leukotriene receptor antagonist;p.o., per os.or in combination with others, based on symptoms.17,18 Sustained- (BIS) should be used. If a poor response to these therapies isrelease theophylline (SRT) is recommended as an option. observed, SRT should be considered (Table 9). The treatment for In younger children (aged 2–5 years), LTRA, 50–100 mg/day infants <2 years old is shown in Table 10. LTRA and/or DSCGFP or BDP or 0.25 mg/day budesonide inhalation suspension are used as first-choice medication. In the JPGL 2008 as well asTable 10 Long-term asthma management (<2 years) Step 1 Step 2 Step 3 Step 4Basic Not necessary • LTRA • ICS (FP or BDP 100 mg/day, • ICS (FP or BDP 150–200 mg/day, (symptomatic and/or BIS 0.25–0.5 mg/day) BIS 0.5–1.0 mg/day) therapy) • DSCG (2–4 times/day)† plus one or more • LTRA • DSCG (2–4times/day)†Additional • LTRA • ICS (FP or BDP 50 mg/day, plus one or more • b2-agonists (tape or p.o.) and/or BIS 0.25 mg/day) • LTRA • Sustained-release theophylline‡ • DSCG • DSCG (2–4times/day)† (consideration) (6 months<) (2–4 times/day) • b2-agonists (tape or p.o.) (serum conc. 5–10 mg/mL) • Sustained-release theophylline‡ (consideration) (6 months<) (serum conc. 5–10 mg/mL) † If necessary, + b2-agonists (0.05 mL–0.1 mL). ‡Exercise caution. Steps 3 and 4 should be carried out by the pediatricians specializing inallergies. BDP, beclomethasone dipropionate; BIS, budesonide inhalation suspension; DSCG, disodium cromoglycate; FP, fluticasone propionate;ICS, inhaled corticosteroids; LTRA, leukotriene receptor antagonist; p.o., per os.Table 11 Apparent severity and actual severity of asthmaApparent severity Actual severity (severity considering current therapies administered)determined on the basis ofcurrent symptoms Step 1 Step 2 Step 3 Step 4Intermittent P Intermittent P Mild P Moderate P Severe PMild P Mild P Moderate P Severe P Severe PModerate P Moderate P Severe P Severe P Very severe PSevere P Severe P Severe P Severe P Very severe P P, persistent.© 2010 Japan Pediatric Society
  7. 7. Jpn pediatric guidelines for asthma 2008 325JPGL 2005, SRT is omitted owing to the possibility of side- erbation of asthma. Respiratory syncytial virus and parainfluenzaeffects, which occur more frequently in infants. Theophylline virus are the most common pathogens of bronchiolitis.21administration is not recommended for children <6 months of age The onset of infantile asthma occurs at <2 years of age, andbecause there is no clear evidence of its effectiveness and safety, the disease may become a chronic condition after its establish-or for children with fever or convulsive diseases. In addition, the ment. Moreover, patients with infantile asthma cannot subjec-recommended dosage of ICS is 50 mg/day FP or BDP, or tively complain of respiratory failure, and symptoms can be0.25 mg/day BIS. If a poor response to these drugs is observed, observed only objectively. Therefore, early diagnosis and inter-the inhalation of a combination of 2 mL of liquid DSCG and vention are required in infancy. The management in a medical0.05–0.1 mL 0.5% salbutamol solution using a nebulizer is rec- facility for acute attacks and the medication plan for long-termommended in younger children or infants. BIS is now available management in infants (infantile asthma) are mentioned above.for younger children and infants. Exercise-induced asthmaTreatment of moderate persistent asthma (step 3 ) Exercise-induced asthma (EIA) is an important symptom to beICS should be used regularly; 100–200 mg/day FP or BDP in aware of in the management of childhood asthma. EIA oftenolder children, 100–150 mg/day FP or BDP, or 0.5 mg/day BIS in occurs in patients with severe or uncontrolled asthma, in responseyounger children, and 100 mg/day FP or BDP, or 0.25–0.5 mg/ to persistent extreme exercise, and its onset can occur in eitherday BIS in infants. In children who have frequent asthma symp- cool or dry air. Children are often very active both at school andtoms despite regular treatment with ICS, additional treatment at home, and the occurrence of EIA may damage their quality ofwith LTRA, SRT, or DSCG (+ b2-agonist, if necessary, in life or may cause them to avoid exercise. It is therefore importantyounger children or infants) should be considered, regardless of that patients, parents, and teachers have a sufficient understand-age. In older and younger children, if symptoms persist, long- ing of the mechanism and characteristics of EIA. It is also impor-acting b2-agonist in the oral or tape forms or long-acting tant to understand that the proper management and theb2-agonist (LABA) inhalation should be administered at continuation of appropriate physical exercise can lead to anbedtime.19 improvement in EIA.22 In older children, salmeterol fluticasone propionate combina-tion (SFC) is also available (Table 8). In infants, if symptoms Asthma during adolescencepersist, a tape or oral b2-agonist is recommended. The characteristics of asthma in the period from adolescence toTreatment of severe persistent asthma (step 4 ) young adulthood include a decreasing response to medicationThe dosage of ICS should be increased in cases of severe asthma. therapy; a risk of transitioning to adult asthma; an adverse effectThe inhalation of 200–400 mg/day FP or BDP in older children, on menstruation; a disturbed lifestyle due to psychological stress150–300 mg/day FP or BDP, or 1.0 mg/day BIS in younger chil- related to family, friendships, school work, and employment;dren, and 150–200 mg/day FP or BDP, or 0.5–1.0 mg/day BIS for lower treatment compliance rates; and an increased mortality rateinfants is recommended. LTRA, SRT, or DSCG (+ b2-agonist, if of asthma.23necessary, in younger children or infants) should be added regu- The check points for clinicians treating patients with adoles-larly as a concomitant treatment, on the basis of the symptoms. In cent asthma are as follows: monitoring the patient to avoid irregu-younger children and older children, LABA (tape, oral, or inha- lar visits to the clinic, attention to lapses in compliance regardinglation) can be administered. In older children, SFC is also avail- medication use, attention to the abuse of b2-agonist metered-able. If symptoms persist in older children, the use of short-term dose inhalers, clarification of the transition period in movingoral prednisolone should be considered. If symptoms persist in from pediatrics to internal medicine, re-evaluation regardinginfants, an oral or tape b2-agonist can be administered and SRT whether or not to use ICS in patients not currently inhaling ICS,could be considered. However, SRT should be used carefully. and maintenance of the relationship between physician and patients by providing sufficient information on available medica-Infantile asthma tion and medication plans.Infantile asthma, which is defined as asthma in children aged <2 It is important to improve treatment compliance throughyears in JPGL 2008, should be identified because infantile effective patient education with suitable explanations of asthmaasthma patients have special characteristics not only in anatomy and individual treatment plans. Physicians also need to establishbut also in pathophysiology. In comparison to older children, the a good partnership with their patients.internal airway is narrower and there is less lung flexibility andcontractility in younger children.20 Moreover, airflow limitation Asthma deathis more likely in young children than older children owing to The asthma mortality rate in patients aged 5–34 years has risenfactors such as less smooth muscle in airways, hyperplasia of dramatically twice in previous years. The asthma mortality ratemucus secretion, and limited breathing movement owing to a significantly increased in patients aged 10–14 years during thehorizontally oriented diaphragm. Airflow limitation induces rapid 1960s and had a sevenfold increase in male subjects. During theexacerbation of asthma symptoms in younger children. Respira- 1980s the rate increased threefold in patients aged 15–29 years,tory viral infections in infancy influence both the onset and exac- and this increase continued until 1990 before decreasing abruptly © 2010 Japan Pediatric Society
  8. 8. 326 N Kondo et al.in 1995. The asthma mortality rates per 100 000 individuals were methods and same districts. Jpn. J. Pediatr. Allergy Clin. Immunol.0.2 (male) and 0.1 (female) in patients aged 5–19 years 2003; 17: 255–68. 10 Nishima S, Chisaka H, Fujiwara T et al. Surveys on the prevalencein 2007. of pediatric bronchial asthma in Japan: a comparison between the Factors contributing to the increase in asthma mortality rate 1982, 1992, and 2002 surveys conducted in the same region usinginclude delays in receiving medical care, and sudden and unex- the same methodology. Allergol. Int. 2009; 58: 37–253.pected worsening of symptoms. The causes of delays in receiving 11 Hanrahan JP, Tager IB, Segal MR et al. The effect of maternalmedical care include a misunderstanding of asthma severity by smoking during pregnancy on early infant lung function. Am. Rev. Respir. Dis. 1992; 145: 1129–35.patients or families and an excessive dependence on b2-agonist 12 Weiss ST, Tager IB, Munoz A, Speizer FE. The relationship ofpressured metered-dose inhalers.24 respiratory infections in early childhood to the occurrence of increased levels of bronchial responsiveness and atopy. Am. Rev. Respir. Dis. 1985; 131: 573–8.Conclusion 13 Global Initiative for Asthma. Global Strategy for Asthma Manage-The JPGL 2008 is a guideline that provides recommendations for ment and Prevention. NHLBI/WHO Workshop Report. GINA2002. National Institute of Health, National Heart, Lung , and Bloodstandard therapies for childhood asthma under the present con- Institute, Bethesda, 2002.ditions in our country, and we emphasize that it is not a textbook 14 Iikura Y, Matsumoto T, Fujita K et al. Continuous isoproterenolaimed at therapeutic standardization. During asthma treatment inhalation therapy in children with severe asthmatic attack.the individual background and/or living situation of each patient Int. Arch. Allergy Immunol. 1997; 113: 370–72.should be considered. 15 Nishimuta T, Watanabe H, Sato K et al. A study on the usefulness of the Japanese pediatric asthma control program (JPAC). J. Pediatr. Allergy Clin. Immunol. 2008; 22: 135–45.References 16 Itazawa T, Adachi Y, Ito Y et al. [Bronchial Asthma – Long term management: A study on the usefulness of the Childhood Asthma 1 Japanese Society of Allergy and Clinical Immunology. Japanese Control Test (C-ACT)]. Jpn. J. Allergol. 2007; 56: 1055 (in Pediatric Guidelines for the Treatment and Management of Asthma Japanese). 2008, 1st edn. Kyowa Kikaku, Tokyo, 2008. 17 Leung KB, Flint KC, Brostoff J et al. Effects of sodium cromogly- 2 Japanese Society of Allergy and Clinical Immunology. 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