Bronchiolitis and Asthma in Children - PowerPoint Presentation

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Bronchiolitis and Asthma in Children

Susanne Meghdadpour, FNP-BC; PhDDivision of Allergy, Immunology, Pulmonary, and Sleep MedicineDuke UniversityDurham , NCDecember 2018

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Bronchiolitis and Current practice guidelines

Definition and etiologyEpidemiologyPathophysiologyPresentation in young childrenGuidelines

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Definition and Etiology

An inflammation of the bronchiolesThe most common lower respiratory tract illness in infants and young children –usually due to a viral infectionRSV (respiratory syncytial virus) is the virus most often isolated, but rhinovirus, influenza, human metapneumovirus, adenovirus as well as non-viral mycoplasma can all be infecting agents

CDC data; www.cdc.gov

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Epidemiology

Most children have been infected by RSV by age 2 and about 40% develop a lower respiratory tract infectionIt contributes to over 100,000 hospitalizations in the US each year, costing more than an estimated $ 1.7 billion1.2 million outpatient visits in children under age 5In 2017 the season ranged from mid-September to mid-May in all regions except Florida (had an earlier onset and longer duration)

Wright, Mullett, Piedmonte; Therapeutics and Clin Risk Management; 2008: 4(5)

American Academy of Pediatrics; 2014; pediatrics.aappublications. org

CDC Respiratory Syncytial virus; Trends and Surveillance 2017;

https://www.cdc.gov/rsv/research/us-surveillance.html

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Pathophysiology

The infecting virus affects airway epithelium resulting in inflammation, edema and some necrosis (sloughing of cells)This leads to bronchiolar plugging, with associated bronchospasm and increased mucous productionIn infants the infection is usually limited to airways (not usually the alveoli)

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The very small airways, or bronchioles, of young children account for about ½ the airway resistance in their lungs

Because of this, even small degrees of obstruction can lead to increases in bronchiolar resistance and cause more significant symptoms.

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Presentation in infants and young children

Often begins with symptoms of a “cold”This can progress to increased work of breathing, cough, wheezing, and irritabilityIt can cause respiratory distress with grunting, retractions, and accessory muscle useApnea is not uncommon, especially when the affecting virus is RSV If child is immunocompetent, it should clear within about 2 weeks.

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American Academy of Pediatric Guidelines, 2014

2014 guidelines were a revision of those published in 2016 and apply to children from 1 to 23 months of ageThey are categorized (based on the evidence of studies reviewed) as “strong”, “moderate”, or “weak” recommendationsThere are 14 in total with some sub-categories and they’re divided into Diagnosis,

Treatment

, and

Prevention

sub-headings.

Access at: http://pediatrics.aappublications.org/content/pediatrics/early/2014/10/21/peds.2014-2742.full.pdf

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Diagnosis

recommendations 1a. Diagnose based on physical exam and history (strong evidence)1b. Assess risk factors such as age <12 weeks, history of prematurity, history of underlying cardio-pulmonary disease, immunodeficiency (moderate evidence)

1c. Radiographic and lab studies should not be routinely obtained (moderate evidence)

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Treatment

recommendations2. Do not administer albuterol (strong evidence)3. Do not administer epinephrine (strong evidence)4a. Nebulized hypertonic saline should not be administered in the ED (moderate evidence)4b. Clinicians may administer hypertonic saline in the hospital (

weak evidence

, based on RCT –randomized controlled trials-- with inconsistent findings)

5. Do not administer systemic corticosteroids in any setting (strong evidence)

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6a.

Clinicians can choose not to administer oxygen if oxygen saturation is > 90 (weak evidence based on low level evidence)6b. Clinicians may choose not to use continues pulse oximetry (weak evidence based on low level evidence)7. Do not use chest PT (moderate evidence)

8. Do not administer antibiotics unless there’s a concomitant bacterial infection or a strong suspicion of one (strong evidence)

9.

Do

administer NG or IV fluids for infants who cannot maintain oral hydration (strong evidence)

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Prevention

10a. Do not administer Synagis (pavlivizumab) to otherwise healthy infants with gestational age = or > 29 weeks (strong evidence)10b. Do administer pavlivizumab to infants with heart disease or chronic lung disease of prematurity. It may be needed by some children with neuromuscular disease or who are transplant recipients (moderate)

10c. Pavilivizumab should be given as 5 monthly doses during RSV season in the first year of life (moderate evidence)

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11a.

Hand hygiene– disinfect hands before and after contact with patients (strong evidence)11b. Use alcohol based rubs for hand decontamination when caring for children with bronchiolitis, or soap and water when not available (strong evidence)12a. Ask about exposure to tobacco smoke (moderate evid.)12b. Counsel about smoking cessation (strong evidence)

13. Encourage exclusive breastfeeding for at least 6 months (moderate evidence)

14. Educate personnel and family members on evidence based diagnosis and prevention (moderate evidence)

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Perspectives and actual practice

Some differences of opinion have been published (Western Jrnl of Emer Med; XV1, 1, 2015)After the 2006 guidelines were published a large study of 41 freestanding children’s hospitals found a relationship between the guidelines being published and a decrease in diagnostic testing and corticosteroid and bronchodilator therapy. There was no difference in use of antibiotics or RSV testing. (Pediatrics 2014, 133, e1)

A 2013 study of EDs showed a decrease in CXRs but no decrease in bronchodilator or corticosteroids or antibiotics

.

(Pediatrics 2013, 131 (suppl1)

Practices are likely to determine some of their own policies especially when the recommendation was weak or moderate. A number of ED physicians say they use a single dose trial of Albuterol to check response, but don’t continue if there isn’t any.

Are there populations where bronchodilators and oral steroids (used to be mainstays of treatment) might work?

Yes! In children with underlying atopy and asthma



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Pediatric Asthma

DefinitionEpidemiology EtiologyPathophysiologyPresentation in different age groups of childrenDiagnosisTreatment guidelines– NAEPP (National Asthma Education and Prevention Program) and GINA (Global Network on Asthma)

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Definitions

From NIH – NHLBI (National Heart, Lung, Blood Institute)A chronic lung disease that inflames and narrows the airways. Asthma causes recurring periods of wheezing, chest tightness, shortness of breath, and coughingFrom GINA (Global Initiative for Asthma)Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation

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So… we know that it is:

A heterogeneous disorder with many phenotypes – in children they include:Transient infant wheezingNon-atopic wheezing in toddlersIgE-mediated (allergic) wheezing/asthma

Later-onset childhood asthma

Chronic and persistent

Characterized by airway inflammation and episodic airflow obstruction in response to various triggers

Airflow obstruction is caused by inflammation, constriction and excess mucous production

(Bel, Curr Opin Pulm Med 2004 Jan;10(1):44-50); (Fitzpatrick et al, JACI, 2011, 127, 2)

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Epidemiology

Asthma is the most common chronic condition among childrenIn the US, 25 million people are known to have asthma and 6-7 million are children under age 183 million suffered from an asthma attack in 2015Between 4 and 6000 people still die from asthma every year ALA factsheet; Feb 2017; http://www.lung.org

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Etiology

Asthma has different characteristics (mild, moderate severe– intermittent vs persistent) and these characteristics seem to be influenced by:Triggers shown in the prior slide (inflammatory factors, irritants, pollutants, reflux, tobacco exposureBut also:Genetics-- more prevalent in some families Infections such as RSV which predispose children to asthma,

Reduced exposure to microbial burden which may have led to us having abnormal responses to allergens/viruses

Different chemicals released by lung tissue can mediate the process

Martinez, 2008 Respiratory Care; Kendig's Disorders of the Resp Tract in Children, 2006; Piedimonte & Simons, Eur Resp, 2002

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The primary medical treatment has been short acting bronchodilators for intermittent asthma, and inhaled steroids for persistent disease.

But… we now know that some people don’t seem to respond well to steroids. Why? The disease is multidimensional and much more heterogeneous than we used to assume it was. Primary phenotypes seem to be driven by: Eosinophilic asthma with Th2 cytokines proposed as regulating this form (usually corticosteroids responsive) versusNon-eosinophilic asthma where we don’t really understand the molecular mechanisms responsible (poor response to corticosteroids). High neutrophil counts have been noted in non-eosinophilic presentations.

These differences have changed asthma research and will likely change treatment in the future

(Fahy, AJRCCM, 2010)

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T2 High Asthma

Master regulators ↓TH2 and ILC2 cells ↓IL-4, IL-5, IL-13

Mechanistic View

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Diagnosis

Symptom pattern is *episodic* but recurrentDoes the child have more than one symptom? Airway constriction is at least partially

*

reversible

*

using short acting bronchodilators or steroids

When pulmonary function testing can be done we look to see if a bronchodilator relieves airway obstruction

Is there mucous hyper-secretion?

The obstruction and constriction lead to cough, wheezing (expiratory>inspiratory), chest symptoms (tightness, pain) and dyspnea

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Impairment & Risk domains of asthma severity

p 307EPR-3 NAEPP, 2007

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1. Treatment

Reduction or avoidance of triggersMedication -- focus is on long-term controlInhaled steroids – reasonably effective, but not in all patients

Mast cell/leukotriene stabilizers

Oral steroids for acute exacerbations

Bronchodilators (primarily beta-agonists)

For patients with significant allergic triggers either allergy vaccine or biologics like Xolair (omalizumab) or Nucala (mepolizumab – just approved) may be indicated – for older children/teens with severe disease

Muscarinic antagonists

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Avoidance of triggers

Reduction of allergens in homesAvoidance of smoke and smokersAttention to moldPet allergiesModerating cold air exposurePre-treatment or altered choice of exercise

Recognition and treatment of exacerbating conditions including chronic sinusitis, GE reflux, chronic otitis

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Medications

Appropriate use of controller medicationsNeed to be given consistentlyNeed to be given regularlyTimely use of rescue medications

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Use a step-wise approach to titrating medication

Controller vs. rescueShow me!

Review triggers

Review “AAP”

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B-agonist and anti-cholinergic medications

Short-term, quick acting, beta-agonists– Albuterol, Xopenex, and anti-cholinergic-- Atrovent are directed at relieving acute bronchoconstrictionLonger acting bronchodilators– Serevent, Foradil – were designed to improve the effectiveness of inhaled steroids in an additive way

Can be delivered by compressor nebulizer, spacer or as dry powder

Newer addition:

LAMAs – long acting muscarinic (anti-cholinergic)

antagonists – not on current NAEPP guidelines

May work better for patients with neutrophilic disease

Tiotropium (Spiriva) approved for children and adolescents ages 6 and up– 2.5 mcg/day (2 inhalations of 1.25 mg of Respimat)

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Inhaled steroids

Intended as daily maintenance medicationMay be just an ICS (QVAR, Flovent, Asmanex, Alvesco, Pulmicort) or in combination with long acting bronchodilators (Advair, Symbicort, Dulera)They are packaged in metered dose inhaler (MDI) formulation or as a dry powder inhaler (DPI)Choice of medication driven by severity of symptoms, age of child, family schedule, insurance

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Mast cell and Leukotriene antagonists & inhibitors

Leukotrienes are inflammatory molecules, released by mast cells, which contribute to bronchoconstriction. Singulair (Montelukast) and Accolate (Zafirlukast).. . Leukotriene antagonists….Block receptors on the lung and to prevent the binding and release of leukotrienes. Both initially intended as adjunctive therapy

Singulair–age 6

mos

(for rhinitis) and for 12+

mos

(rhinitis or asthma);

Accolate

age 5

Seem to benefit children with allergies, exercise induced problems

Approved for allergic rhinitis

Zyflo (Zileuton)

– acts “higher up” and blocks the production of certain leukotrienes– so reduces the amount circulating

Approved for children ages 12 and older

Has potential GI and liver side effects

Cromolyn Sodium

– older medication; prevents release of histamine from mast cells

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Oral steroids and Theophylline

Episodic need for oral steroids Intended for acute exacerbationUsually begin with 2 mg/kg x 4-5 days; max dose 60 mg/day; taper after 6 daysChronic need for oral steroids – Unusual in children; more common in adults

Sometimes needed by adolescents with severe asthma

Theophylline

see stepwise guidelines – slide 31

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Not on NAEPP guidelines at present

BiolgicsMonoclonal antibodies -- Target IgE, eosinophils, and cytokines released by T-helper cellsXolair (Omalizumab) age 6 and up (blocks IgE )Nucala (

Mepolizumab

) age 12 and up (binds to IL-5; reduces

eos

production)

Fasnera

(

Benralizumab

) age 12 and up (blocks IL-5 receptor; depletes

eos

; eosinophilic phenotype

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Reflux and asthma

Has been identified as a trigger or a means of asthma exacerbation for many peopleTreatment may be continuous or episodic Eating/drinking patterns Medications – antacids, H2 blockers (Ranitidine) and PPIs

Treatment can significantly help, especially night time symptoms

Studies have been done in children with asthma, using lansoprazole even when specific reflux symptoms were not present, and haven’t always shown improvement in asthma symptoms, but there is some thought that there may be some genetic variability and that dose may make a difference

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Vocal cord dysfunction

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Acute asthma exacerbation in pediatric patient

Keep child calmIf they can drink, warm liquids may helpAlbuterol by nebulizer every 20 mins x 3 dosesWheezing is better than no breath sounds – sometimes it’s a sign of improvementTransport to the ED if not improved, if work of breathing increases, if cannot maintain O2 sats > 92% Dose of Decadron (0.3 to 0.6 mg/kg) if available, or liquid prednisolone if not, with ongoing course of prednisone– 2 mg/kg/day x 4 extra days (max 60 mg/day)

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Medication delivery devices

MDI’s -- especially inhaled steroids, need to be used with spacers, regardless of age of childAdequate delivery of medicationRisk of oral candidiasis with steroidsA variety of spacers are on the marketLeast expensive in Durham: Duke Children’s Health Ctr. Pharmacy, Upchurch Drugs, Costco. Check independent pharmacies locally

Turbohalers/Flexhalers

Nebulizers

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Questions???

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