Empowering your Teens: Asthma Updates and Management - PowerPoint Presentation

1. Empowering your Teens: Asthma Updates and ManagementSpeakers: Eduardo Fox, MD; Shilpa Patel, MD, MPHAdvancing Asthma Care: A PHN InitiativeEducational Webinar # 5

2. 2A few notes about today’s webinar:All lines are muted throughout the presentation.Please use the Q&A function to ask questions or make comments during the presentation We will be recording the session.Today’s recording and materials will be posted to the PHN’s virtual collaboration site, Glasscubes, following the presentation.

3. 3SpeakersNo conflicts to disclose:No financial or business interest, arrangement or affiliation that could be perceived as a real or apparent conflict of interest in the subject (content) of their presentation.No unapproved or investigational use of any drugs, commercial products or devices.Eduardo Fox, MDShilpa Patel, MD, MPH

4. 4Learning ObjectivesReview updated guidelines around therapeutic management of patients 12 and over with persistent asthma.Review options for medications and delivery devices for adolescents with asthma.Discuss factors which influence asthma control and self-management during adolescence.Identify some strategies to promote adherence to guidelines and care by providers and adolescent patients.

5. 5Child Teen Increasing impact of:obesity, hormones, anxiety/depression, smoking/inhaling/vapingAsthma more common in teen girls than boysHigher mortalityQuality of Life:sleep, school absenteeism, sportsDelay in DiagnosisAdherence (parental understanding, stress, worry re: side effects, technique)School absenteeism, behaviorAsthma more common in boys than girlsViral respiratory infectionsPoor Adherence (decreased routine visits, teen in charge of own medications)Challenges of Adolescence: autonomy, invincibility, embarrassment

6. 6Pediatric Asthma: Disparities

7. 7Increasing mortality rate over the 12-year period despite increasing inhaled steroid use*Note disparitiesJ Allergy Clin Immunol Pract. 2018 May-Jun; 6(3): 1034–1036.

8. Guidelines for 12 years and older:A brief review

9. Inhaled Steroids: Joey12yo and older with persistent asthma (mild)14 yo with mild persistent asthma, well controlled. Here for a follow up visitCurrently using fluticasone 44 mcg 2 puffs BID for maintenance therapy. Uses albuterol for quick-relief when his asthma symptoms flare and prior to exercise in cold weather.His dad heard about the guidelines update and wonders if there will be any change in his treatment / action plan. Usually has more symptoms during winter and required oral steroids last February.

10. 10CURRENTAs-needed SABA for quick-relief therapy+ Daily ICS 2020 UPDATE (2 Options)Continue current treatmentor Intermittent as-needed SABA and ICS used one after the other for worsening asthma. (ie, 2–4 puffs of albuterol followed by 80–250 mcg of beclomethasone equivalent every 4 hours prn) TARGET POPULATION12 years and older with MILD PERSISTENT asthma on Step 2 therapy

11. Inhaled Steroids: Joey12yos and older with persistent asthma (mod/severe)A month later, Joey returns to see you following an ED visit 2 days earlier for an asthma exacerbation. He took his second dose of dexamethasone yesterday and is feeling better but still using his albuterol every 4 hrs. You and his mom develop and discuss a plan to address his acute symptoms. You also advise that Joey step up his maintenance therapy. You review the guidelines updates with them and make your recommendation.

12. 12CURRENTIncrease his ICS dose, change to low-dose ICS/LABA, or add LTRA.  2020 UPDATE Preferred treatment is a single inhaler with ICS-formoterol (“SMART”) used both daily and as needed. TARGET POPULATION12 years and older with MODERATE to SEVERE PERSISTENT asthma (on low or medium dose ICS)

13. 13“SMART” Therapy: Single maintenance and reliever therapy Maximum number of puffs per day (based on 4.5 mcg formoterol/inhalation): Ages 4-11: 8 puffs (36 mcg formoterol) Ages 12 years and older: 12 (54 mcg formoterol) Note: formoterol is the only LABA studied for use in SMART therapyINDICATIONSDOSINGStep 3 (low-dose ICS) and Step 4 (medium-dose ICS) treatment.Patients poorly controlled on ICS-LABA with SABA as quick relief1–2 puffs once or twice daily for maintenance and 1–2 puffs as needed for asthma symptoms. Maintenance dosing and frequency depends on age, asthma severity, and ICS dose in the ICS-formoterol preparation

14. 14“SMART” TherapyPotential benefits: Reduced asthma exacerbations, unscheduled medical visits or systemic corticosteroidsMay improve asthma control and quality of lifePotential risks: No difference in documented harms compared to daily ICS, or ICS-LABA, with SABA as quick relief therapy. Other considerations: There may be a lower risk of growth suppression among those taking SMART versus daily higher-dose ICS treatment (4-11 yo).Need to consider cost, formulary considerations, or medication intolerance. 1-month supply may not last a month if the inhaler is used for reliever therapy in addition to maintenance.

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16. 16ConsiderationsManagement:Continue to emphasize step-wise approach to therapyMore options and greater flexibilityFocused updates to the 2007 guidelines Billing and coverageInsurance coverage for new regimens FDA review/formulary Changing documentationEMR integration/ templatesChanges to asthma action planGradual implementationResources: Please refer to PHN Asthma Toolkit

17. 17Long-Acting Muscarinic Antagonists (LAMA)12 Years and Older with Uncontrolled Persistent Asthma LAMA: Pharmacologic class of long-acting bronchodilatorsKey Points:Adding a LABA rather than a LAMA to an ICS is recommended when asthma is not controlled by ICS alone.If a LABA cannot be used, adding a LAMA to an ICS is an acceptable alternative (small potential benefit)If already on ICS-LABA, adding a LAMA is recommended for many individuals (may improve asthma control and quality of life, small potential benefit). Potential risks: Do not use in those with glaucoma or at risk for urinary retention.No more benefit than adding a LABA to ICS controller therapyMay increase the risk of harm (based on a single real-world study in Blacks)

18. Asthma Medications and Devices

19. 19MedicationsShort-acting beta-agonists (SABA)Inhaled corticosteroids (ICS)Leukotriene inhibitors (LTRI)Combo ICS/ long-acting beta-agonists (LABA)Long-acting muscarinic antagonist (LAMA)Biologics

20. 20The Evolution of Inhaler Technology: Journal of Asthma: Vol 31, No 1https://www.tandfonline.com/doi/pdf/10.3109/02770909409056770?needAccess=trueHow it started…

21. Where we are…Lots of choices in many colors, sizes, and doses

22. To purchase: Respiratory Inhalers-at-a-Glance and Other Posters in Our Online Store | Allergy & Asthma Network (allergyasthmanetwork.org)

23. 23Insurance Formularies(audible audience groan- even on Zoom with everyone muted!)Change often and without noticeInconsistencies between formulary and pharmacy feedbackMay limit options for individual patientsFormulary preferences may not be appropriate for agePHN has been able to provide advocacy with payersFamiliarity with devices is key

24. 24MDI/ HFAMDI (metered-dose inhaler)HFA  (hydrofluoroalkanes)Spacers (valved holding chamber or VHC)With mouthpieceWith mask (different sizes)Many different products on the market; insurance coverage issuesVideos on how to use spacer with inhalershttps://vimeo.com/channels/impactdc

25. 25DPI (dry powder inhaler)Consider for 6 yo and older“Hacking” is sometimes an option but not “approved”Some devices are approved down to 4 yo but not easy to useVideos:IMPACT DC siteManufacturer videosYouTubeDiskusRespiclickTwisthalerRedihaler

26. 26Other DevicesNebulizersPerceived “gold standard”; used in the ED and hospitalMDI’s equally effectiveMore expensive than MDI’sAssociated with more frequent side effectsPeak Flow MetersIndividualizedRequires education and practiceVariable evidenceSpirometry

27. Asthma Self-Management Education

28. Asthma Self-Management: JoeyRecognition of symptoms and signsYellow Zone ManagementAsthma Action PlanMedication adherence and techniqueSMART therapy (when to use Quick Relief - RED ZONE)Medication delivery devices – HFA vs. DPISpacer technique  (switching to mouthpiece)Identification and mitigation of triggersAllergens vs. Irritants

29. 29Resources for Asthma Self-Management EducationIMPACT DC Patient Education Videos on VimeoIMPACT DC Patient Education HandoutsTriggersMedication TechniqueAsthma Care TipsBasics of asthma for practice staff (module)

30. 30Adherence in Teens: Barriers and Possible SolutionsBarriersStrategies/ SolutionsInaccurate symptom perceptionSmoking/VapingDevelopmental StageAdherence

31. Comorbidities in adolescents with asthma

32. Comorbidities32

33. Key Findings to date by Dr. Rastogi’s lab:Obese children with asthma have lower pulmonary function than normal-weight children with asthma Obese children with asthma have evidence of systemic Th1 polarizationTh1 polarization is associated with pulmonary function deficitsCDC42 pathway is up-regulated and associated with Th1 polarization and pulmonary function deficits in obese children with asthma**Content provided by Dr. Deepa RastogiObesity is an independent risk factor for asthmaObesity-related asthma among children is associated with higher disease burden that is not responsive to currently available asthma medications.Obesity and Asthma

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35. Pathogenesis of Asthma in Obese ChildrenProposed mechanismsMechanical fat loadInflammationDixon et.al 2010, Beuther et.al 2006

36. Anxiety, Depression in Children with AsthmaAnxiety, depression, and asthma: New perspectives and approaches for psychoneuroimhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC8502834/#bib27munology research (nih.gov)36 as likely in children with asthmaKaton et al., 2007; Richardson et al., 2006; Vila et al., 2000Increased ED visits/hospitalizationsDecreased adherence3

37. Anxiety, Depression in Children with AsthmaAnxiety, depression, and asthma: New perspectives and approaches for psychoneuroimhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC8502834/#bib27munology research (nih.gov)37Five Things to Know About Inflammhttps://www.psychiatrictimes.com/view/five-things-know-about-inflammation-and-depressionation and Depression (psychiatrictimes.com)

38. Major Depressive Episodes by Age and Asthma Status Past Year Major Depressive Episodes More Common Among Adolescents With Asthma (samhshttps://www.samhsa.gov/data/sites/default/files/report_3047/Spotlight-3047.htmla.gov)

39. Vocal Cord DysfunctionTreatmentEvaluationHistory (of course)Exam (inspiratory noise / wheeze)Pulmonary function testingFlexible laryngoscopy Speech therapy- breathing exercises and relaxation techniquesConsider Heliox in acute setting and Atrovent for exercise-induced symptomsAddress comorbid conditions- counseling for anxiety or other mental health concerns39Abnormal closure of the vocal cords- during inhalation

40. Vocal Cord Dysfunction vs. AsthmaVCDAsthmaAgeAdolescentAny AgeSymptomsSensation of Throat Closing/Throat Tightness Chest TightnessDuration of SxRapid onset and offset, minutes to secondsLonger duration minutes to hoursTriggersExercise, Irritants, Stress/AxietyExercise, Irritants, Stress/Emotions, URI, AllergensExercise Induced SymptomsUsually within minutes of exercise startingUsually after one has been exercising for some timeSleep SymptomsNONE (unless also has asthma and has asthma at night)Often has symptoms during sleepResponse to SABANOYES (unless overall very poorly controlled asthma)Common associationsAnxiety, (can also have asthma)Anxiety

41. 41The PHN Asthma Toolbox – Current Contents

42. 42MOC Part 2 must be claimed within 30 days of the event!CME must be claimed within 90 days of event!

43. 43Thank youIf you have any questions or comments, please email phn@childrensnational.org.