Basics of Pediatric Asthma Management
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Basics of asthma treatment including trigger exposure reduction, controller , reliever meds & step up/ down ladder.
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Basics of Pediatric Asthma Management
- 1. Basics of Pediatric Asthma Management Fatima Farid Ped Resident Yr 4 ENTER
- 2. Contents Medications Long term controllers & short term relievers Treatment Plan Stepping up & down therapy Introduction Principles of management Trigger Mx Recognition & exposure reduction 01 02 03 04
- 4. Core Concepts Pharmacologic Treatment Short term relievers & long term controllers Trigger Reduction Recognition & lifestyle changes to avoid exposure Follow- up Monitoring for symptom and lung function changes Education Enabling self- management skills by child & care- givers 01 02 03 04 ICS: Inhaled corticosteriods; LT-A: Leukotriene antagonists; LABA: Long acting B2 agonists; SABA: Short acting B2 agonists
- 5. Goals of Mx ● Our end goals in asthma treatment: 1. Reduce disease symptoms 2. Decrease asthma exacerbations 3. Minimize medication side effects ● “It is expected that a person with well-controlled asthma should be able to participate in work, school, play, and sports without limitation due to breathing” - UpToDate 01 02 03 04
- 6. Trigger Mx Recognize & reduce exposure 02. 01 02 03 04
- 7. 01 02 03 04 Can you spot 7 triggers?
- 8. 01 02 03 04 Can you spot 7 triggers? Animal dander Viral URTI Indoor Mould Cockroach allergens Wood smoke Dust mites Tobacco smoke
- 9. Exposure reduction strategies Viral URTI • Avoid contact with sick family members • If needs daycare, try to choose one with fewer children • Annual influenza immunization for children with persistent asthma • No smoking around the child • Help parents and caregivers quit smoking • Eliminate wood stoves and fireplaces • Do not leave food or garbage exposed • Use boric acid traps for cockroaches • Reduce indoor humidity to < 50% • Avoid vaporizers (increases the mould) • Fix leaky faucets and pipes Smoke Hygiene 01 02 03 04
- 10. Pictures 01 02 03 04 Wood stove (bad) De- humidifiers (good) Boric acid (good) Vaporizers (bad)
- 11. Dust Mite Exposure Reduction Strategies ● Essential Actions: ○ Encase pillow, mattress and box spring in allergen- impermeable encasement ○ Wash bedding in hot water weekly ● Desirable Actions: ○ Avoid sleeping or lying on upholstered furniture (those with a soft padded covering) ○ Minimize number of stuffed toys in child’s bedroom ○ Reduce indoor humidity to < 50% ○ If possible, remove carpets from bedroom and play areas; if not feasible, vacuum frequently 01 02 03 04
- 12. What does hypoallergenic mean? ● The fabric is tightly woven and made of a textile that is less likely to retain indoor allergen particles ● This protects the user from allergens by creating a barrier between the skin and bedding surface ● Hypoallergenic fabrics are typically breathable and promote a cool environment in which mould and bacteria cannot grow ● Usual natural fabrics used are cotton, bamboo, silk & eucalyptus ● Synthetic fabrics like microfiber can also be hypoallergenic but they are not as breathable and may contain materials that are irritating to the skin 01 02 03 04
- 13. Pictures 01 02 03 04 Hypoallergenic mattress cover Hypoallergenic pillow cover
- 14. Pictures 01 02 03 04 Upholstered sofa (bad) Upholstered bed (bad)
- 15. Animal Dander Exposure Reduction Strategies ● Remove pet from the home or keep outdoors if removal not possible ● Keep pet out of bedroom ● Use a filter on air ducts in the child’s bedroom 01 02 03 04
- 17. Medical Mx Controllers 1. Inhaled corticosteroids 2. Leukotriene modifiers 3. Long acting B2 agonists 4. Omalizumab Relievers 1. Short acting B2 agonists 2. Anticholinergic agents 3. Oral corticosteroids 01 02 03 04
- 18. Inhaled Corticosteroids (ICS) ● The most effective anti- inflammatory medications for treatment of chronic persistent asthma ● Preferred therapy when initiating long term control therapy ● Ealy intervention with ICS reduces morbidity but does not alter the natural history of asthma ● Regular usage reduces: ○ Airway hyperreactivity ○ Need for rescue bronchodilator therapy ○ Risk of hospitalization ○ Death from asthma 01 02 03 04
- 19. Inhaled Corticosteroids (ICS) ● Side effects: ○ Dysphonia ○ Oral candidiasis ○ Decreased growth velocity (approx. 1 cm in first year of TTT): non- progressive, reversible ● Low to medium dose ICS usage does not cause: ○ Disturbance of HPA axis or glucose metabolism ○ Subcapsular cataracts ○ Glaucoma 01 02 03 04 ICS side effect Poor asthma control Decreased height velocity
- 20. Inhaled Corticosteroids (ICS) 01 02 03 04 Budesonide (Pulmicort) Beclomethasone (Qvar RediHaler) Fluticasone propionate (Flixotide)
- 22. What are leukotrienes? 01 02 03 04 Leukotrienes are potent mediators of inflammation and smooth muscle bronchoconstriction that are synthesized via the arachidonic acid metabolism cascade
- 23. Leukotriene Modifiers ● Oral daily use medications that inhibit these biologic effects in the airway ● Its two classes include: ○ Cysteinyl leukotriene receptor antagonist: Zafirlukast & Montelukast ○ Leukotriene synthesis inhibitors: Zileuton 01 02 03 04 Montelukast (Singulaire)
- 24. Side Effects • Zafirlukast/ Montelukast: Neuropsychiatric disturbances (black box warning), and rarely allergic symptoms, dyspepsia, deranged liver function • Zileuton: Headache, deranged liver function test, sleep disorders, dyspepsia, myalgia, leukopenia 01 02 03 04
- 25. Montelukast – administration technique 01 02 03 04 Instructions: - May put directly on child's tongue or mix with a spoonful of cold, soft food, such as yoghurt or ice-cream. - Make sure the child takes the whole dose immediately (or within 15 minutes) - CANNOT dissolve the granules in a drink
- 26. Other Controller Medications LABA • Relax airway smooth muscle for 12 hours • Never use LABA without ICS as it can cause a life- threatening asthma attack • Usually given in combination inhalers: Salmeterol + Fluticasone • Humanized anti- IgE monoclonal antibody • Prevents binding of IgE to high affinity receptors on basophils & mast cells • Xolair (brand name) is delivered by subQ injection Q2- 4 weeks Omalizumab 01 02 03 04 Salmeterol + Fluticasone (Seretide)
- 28. Reliever Meds SABA • Short acting B2 agonists relax bronchial smooth muscle within 5- 10 minutes & effect lasts for 4- 6 hours • Side effects: tremors, tachycardia, irritability • Example is albuterol • Bronchodilation, decrease mucus hypersecretion, counteracts cough receptor irritability by binding to M receptors in bronchial smooth muscle • Example is ipratropium bromide • Bronchodilation, reduce mucosal edema and mucus secretion • Prolonged use can result in systemic side effects • Prednisolone is used Anti- cholinergics Oral Steroid 01 02 03 04
- 29. Reliever Meds 01 02 03 04 Salbutamol/ Albuterol (Ventolin) Ipratropium bromide (Atrovent)
- 30. Treatment Plan Step- wise approach 04. 01 02 03 04
- 31. Source: UpToDate – An overview of asthma management
- 32. Source: Nelson Textbook of Pediatrics, twentieth edition
- 33. Source: Oxford Handbook of Pediatrics, second edition
- 34. References ● Nelson Essentials of Pediatrics, seventh edition ● Nelson Textbook of Pediatrics, twentieth edition ● Oxford Handbook of Pediatrics, second edition ● UpToDate- An overview of asthma management 01 02 03 04