Asthma in Children October 29, 2002Swedish Family Medicine Jorge Garcia, MD
CASE 1An 7-year old girl has just moved into townand presents to her doctor. She has historyof wheezing and rhinitis and recurrent otitismedia since infancy. Over the past 2 yearsher symptoms have worsened. Shecomplains of coughing and SOB daily andclaims to awaken at least once a week inthe middle of the night by these symptoms.
Her family history consists of maternalasthma, and atopy in both parents.Physical exam finds inflamed nose, mildwheezing, otherwise unremarkable. Thepatients mother states that her daughterwas previously prescribed an albuterolpuffer to use prn, which her daughteruses daily and requires monthly refills.The child is able to remain active. In thepast year she has had 4 courses ofprednisone.
According to the aboveinformation:How would you classify thispatients severity?Mild intermittentMild persistentModerate persistentSevere persistent
Diagnosis of Asthma SeverityDiagnosis Days w/Sx Nights w/Sx PEF(Step) (% personal best) or FEV2 % predicted best)severe persistent(4) Continual Frequent <60moderate persistent(3) Daily >5 / month 60-80mild persistent (2) >2/wk 3 to 4 / month >80mild intermittent (1) <2 /wk <2 per month >80
New Asthma Dx: Confirm with PFT Consider Allergy testing if the child also has significant allergic rhinitis.
With the diagnosis of AsthmaWhat are the findings on PFT?
PFT Increase in forced expiratory volume in one second (FEV1) of 12 percent or more after bronchodilator therapy. variable airflow obstruction (20 percent or more) with serial spirometry or peak expiratory flow (PEF). Not reliable in kids <3-4.
CASE 1: Naomi J.An 7-year old girl has just moved into townand presents to her doctor. She has historyof wheezing and rhinitis and recurrent otitisand sinusitis since infancy. Over the past 2years her symptoms have worsened. Shecomplains of coughing and SOB daily andclaims to awaken at least once a week inthe middle of the night by these symptoms.
Her family history consists of maternalasthma, and atopy in both parents.Physical exam finds inflamed nose, mildwheezing, otherwise unremarkable. Thepatients mother states that her daughterwas previously prescribed an albuterolpuffer to use prn, which her daughteruses daily and requires monthly refills,but the patient is able to remain active.In the past year she has had 4 coursesof prednisone.
What more would you want toknow about your patient?
Obtain a history to rule outtriggers What are some possible triggers of RAD?
Obtain a history to rule outtriggers. What are some possible triggers of RAD?
dust mites and mold spores, pollenanimal dander,cockroaches,indoor and outdoor pollutants,irritants (e.g., tobacco smoke, smoke from wood-burningstoves or fireplaces, perfumes, cleaning agents),pharmacologic triggers (e.g., aspirin or other nonsteroidalanti-inflammatory drugs, beta blockers and sulfites),physical triggers (e.g., exercise, hyperventilation, cold air)physiologic factors (e.g., stress, gastroesophageal reflux,respiratory infection [viral, bacterial] and rhinitis).Kitchen sink.
“Treatment of children with asthmashould begin with the mostaggressive therapy necessary toachieve control, followed by"stepping down" to the minimaltherapy that will maintain control.”
Moderate Persistent Asthma(Step 3) High dose corticosteroid inhaler daily. Long acting daily bronchodilators. Short acting bronchodilator for symptoms.
Asthma treatment by severity: Step 1; mild, intermittent days with symptoms: <2 times per week nights with symptoms <2 per month PEF>80% predicted.
Asthma treatment by severity:Step 1; mild, intermittent No daily preventive meds needed: treat symptoms only. Treatment should be required no more than 2/week. Short acting beta-2 agonist: Albuterol MDI with face mask or spacer. Cost: $30-50/ canister.
Asthma treatment by severity:Step 2; mild, persistent Days with symptoms >2 times per week Nights with symptoms: >2 per month but less than 5 times/month. percent predicted PEF >80%.
Asthma treatment by severity:Step 2; mild, persistent Daily anti-inflammatory medications: Cromolyn (Intal) inhaler $47.00 Nedocromil (Tilade) inhaler $36.00 or Low- to medium dose inhaled corticosteroid [range of prices: Budesonide (Pulmicort Turbuhaler DPI), 200 µg per puff $19.00 to Fluticasone (Flovent), 44 µg per puff $47.00 (13-g canister)]
Asthma treatment by severity:Step 2; mild, persistent Short-acting bronchodilator as needed for symptoms. Intensity of treatment depends on severity of exacerbation: Inhaled short-acting beta2 agonist by nebulizer or spacer/holding chamber and face mask or Oral beta2 agonist.
High dose corticosteroid inhalerdaily. Beclomethasone (Vanceril DS MDI), 84 µg per puff $42.00 Fluticasone (Flovent 220 µg per puff $95.50 Reduce to lower dose once symptoms controlled.
Long acting daily bronchodilators. Salmeterol (Serevent MDI) $42.00 (Serevent Diskus DPI) $43.50 Short acting bronchodilators for rescue only: Albuterol.
Step 4: Severe and persistent Sx Days with symptoms: Continual nights with symptoms: Frequent PEF <60% predicted.
Usually add oral pred to Step 3medications.Treatment can be variable in step 4.
Step 4; severe, persistent Daily anti-inflammatory medications: High-dose inhaled corticosteroid with spacer/ holding chamber and face mask and If needed, add systemic corticosteroids (0.25 to 2 mg per kg per day) and reduce to lowest daily or alternate-day dosage that stabilizes symptoms.
What is the role ofAntileukotrienes ? “In patients with chronic asthma who are symptomatic while receiving moderate-to-high doses of inhaled beclomethasone, the addition of 2 to 4 times the licensed dose of antileukotriene (AL) agents reduces the rate of exacerbations that require systemic corticosteroids. Insufficient evidence exists that AL confers benefit over doubling the dose of corticosteroids or that it has an inhaled corticosteroid- sparing effect.” Cochrane Database Syst Rev. 2002;(1):CD003133
What is the role ofAntileukotrienes ? They are new drugs, and expensive. The doses that seem to work are higher than marketed recommendations. They may help in Step 3 and 4, to reduce exacerbations, and reduce need to increase dose of inhaled steroids. No worrisome side effects…yet.
Home severity monitoring mayhelp keep kids out of the hospital. First, determine their “Personal Best” Ask them to check PF a few times each day, for two weeks, when asthma in good control.
Write out the PF Color Zones PF <50% Red Zone PF 50-80% Yellow Zone PF> 80%: Green Zone
Green Zone: PF > 80% ofpersonal best. No symptoms at all. Good Control. Continue taking regular medications.
Yellow Zone: PF 50%-80% CAUTION! Need rescue meds: Use short acting Beta-2 agonist (Albuterol MDI or nebulizer). Consider increasing dose of medication. Monitor PF more frequently.
Red Zone: PF < 50% Use Short Acting beta-2 Agonist: Albuterol. Call doctor’s office, or seek medical attention.
Who is at risk of dying ofasthma? Severe disease: 1-2% of these kids will die of asthma. Hx: prior hospitalization, steroid need. Symptoms triggered by foods. Self weaning, esp. off steroids. Lack of parental care. Poor, African-American, boys.
However…in large study ofasthma deaths: 33% had mild asthma. 34% had no prior hospitalization. A minority of patients (15-30%) die suddenly, within two hours of onset of dyspnea.
When assessing a sick asthmatic: If they are unable to lie down, the severity is moderate of great, and they will need more aggressive work up and treatment.