Pediatric Asthma - PowerPoint Presentation

Slide1

Pediatric Asthma Practice Essentials

Shannon

Hogate

MSN, FNP-BC

&

Pamela Jimenez MSN, FNP/PNP-BC

Slide2

Objectives

Provide understanding of the diagnosis of pediatric asthma and subsequent treatment goals.

Identify “best practice” recommendations & guidelines for practice management of childhood asthma.

Identify potential complications that prevent effective management of asthma.

Identify opportunities to implement clinical “best practices” in your practice setting.

Identify the roles schools have in Asthma compliance

Slide3

Healthy People 2020 National Goal

Seven national goals:

Reducing the rate of deaths due to asthma among children and adolescents

Reducing hospitalization rates for children and adolescents with asthma

Reducing the rates of hospital emergency room visits due to asthma

Reducing the number of school days missed due to asthma

Increasing formal patient education

Increasing appropriate asthma care

Increasing the number of states with comprehensive asthma tracking systems.

Slide4

Overview

Chronic inflammation of the airway

Episodic in nature and usually associated with widespread, variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment

Evoked by various stimuli

Caused by continuous underlying inflammation

Characterized by:

Wheezing

Breathlessness

Chest tightness

Nighttime or early morning coughing

Slide5

Etiology

Development of asthma is multifactorial and depends on the interactions among multiple susceptibility genes , environmental triggers, diet and perinatal factors

NO ABSOLUTE

markers available to predict the prognosis of an individual child.

Asthma can develop at

ANY AGE

Slide6

Pathophysiology

The pathophysiology of asthma is complex and involves airway inflammation, intermittent airflow obstruction, and bronchial hyper-responsiveness

.

Slide7

History

Median age of onset is 4 years of age

Strong family history

History of other inflammatory markers diagnosed by a provider

60% resolve by young adulthood

50% remitted by adolescence will return in adulthood

Early history of RSV with family history of asthma

Often difficult to differentiate

Slide8

Triggers/Clinical Manifestations

Viral infectionSecond hand smokeExposure to allergens/irritantsExerciseStress/excitementWeather changesGERD

Intermittent dry cough

Expiratory wheezing

Shortness of breath/fatigue

Chest tightness/pain

Poor exercise compliance

Prolonged expiratory phase

Decreased or absent BS

Use of accessory muscles/nasal flaring

Difficulty keeping up with peers in physical activities

Slide9

Viral Respiratory Infections In Children

May mimic asthma or be an early sign of asthma

Both can follow a seasonal pattern Fall, Winter, Spring and have an abatement of symptoms in the summer

Signs typically begins within the first 1-2 years of life

Symptoms include: cough or wheeze that progresses to respiratory distress brought on by a “Cold” (Respiratory Illness), can last for days or weeks

Asymptomatic between illness

Parent often reports

“ Every time he/she gets a cold it goes right to her chest”

Slide10

Asthma or Reactive Airway

Difficult to provide diagnosis in children between 0-4 years

Reactive airway or wheezing often associated with respiratory illness

Preschoolers average 7 “colds” per year with 15 % experiencing 12 or more colds per-year

Confusion arises as child generally has the appearance of continuous symptoms !

50-80% of children with develop asthma show symptoms before the age of 5 years old.

Two general patterns to help differentiate

:

1. A remission of symptoms before Kindergarten

2. Persistence of Asthma symptoms through childhood

Slide11

Classification for treatment

Intermittent: EIB or occasional flare < 2 days/

wk

and no nights responds to SABA PRN

Mild persistent: 3-6 days/week and 1-2 nights/month- minor limitations - step 2: low dose ICS

Moderate persistent- Daily problems and 3-4 nights/month – some limitations step 3 : medium dose of ICS and short burst of OCS

Severe persistent- throughout the day and > 1 night/

wk

- significant limitation- medium ICS with possible change or addition of LABA

Slide12

Diagnostic criteria: 0-4 yrs

Children under 4 with

:

four or more episodes of wheezing in the past year lasting > than 1 day and affecting sleep are significantly likely to have persistent asthma after the age of 5 years if they also have either :

One of the following:

parental history of asthma, a physician diagnosis of atopic dermatitis, or evidence of sensitization to aeroallergens,

OR

Two of the following

: evidence of sensitization to foods, ≥4 percent peripheral blood eosinophilia, or wheezing apart from colds

Symptoms occurring

With and without illness

(exercise, allergens, crying, change in weather, irritant exposure exc.. )

Slide13

Diagnostic criteria : 5-11years

Weed out differential diagnosis

Know that seasonal patterns maybe more “clear”, indicating allergic asthma

Virus induced asthma still common in this age group

Evaluate response to treatment. If poor or symptoms are atypical refer to a specialist!

Specialists have objective measurement PFT, Peak flow to help in the diagnosing and treatment of asthma

Always Consider other causes

Goal:

improved outcomes

Slide14

Teens and Asthma

Asthma onset during adolescents nonallergic or allergic

May be reluctant to take medicines or follow “rules”

Adolescent might be totally in charge of taking medications at home.

Discuss how to take medication and ways to remember medication

Once a day dosing

Discuss importance of Medicine

Be aware of risks: Sports, smoking, poor nutrition, lack of medical care

Sports increase competition needing tighter asthma control

Slide15

Differential Diagnosis

Upper airway: Sinusitis, Allergic Rhinitis

Obstructions of large airway: foreign body, vocal cord dysfunction, vascular rings, laryngeal webs,

laryngotracheomalacia

, tracheal stenosis,

bronchiostenosis

, enlarged lymph nodes or tumors

Obstruction of small airway: Cystic fibrosis, bronchiolitis

Other causes: GERD/aspiration, congenital heart disease, pneumonia

Slide16

9.9%

6.9%

8.4%

Childtrends.org

Prevalence

Slide17

Slide18

CDC.gov

Burden to Healthcare system

11/16

Slide19

Delaware’s Trend

Highest peak in 2013- 26.3%

Steady decline to 21.6% in 2015Mild rise-projected

Delaware Health tracker 2017

Slide20

National Ambulatory Medical Care Survey 2011/2012

Primary Care 2012

10.5 million visits to primary care offices with asthma as the primary diagnosis

Emergency Department 2011

1.8 million ED visits with asthma as a primary diagnosis

Slide21

Hospitalizations and lost days from school

3rd –ranking cause of hospitalizations in childrenNearly 44% of all asthma hospitalizations are for childrenEstimated nearly 8 million days/year are restricted to bed due to asthmaOver 14 million school days/year lost for asthma ( 8days/child) 80% increased death rate for children < 18 since 1980

Asthma tracker 2016

Slide22

Radiology/Labs

Chest X-ray often appears normal or reveal hyperinflation

Typically used to rule out other disease states masquerading as Asthma or coexisting conditions such as pneumonia , foreign body, congenital abnormality

Labs:

CBC with differential

Eosinophils

Total

IgE

Specific

IgE

testing-

RAST (

Radioallergosorbent

testing)-Example:

IgE

pet dander, dust mite, pollens, weeds, molds, exc.

Slide23

ALLERGY TESTING & Immunotherapy

80 % of school age children with Asthma have allergic sensitivity

Immunotherapy can help prevent the progression from allergic rhinitis into allergic asthma

Children < 2 less likely to have allergic asthma & need referral to pulmonary

Chronic allergen exposure over time can trigger increased frequency in asthmatic symptoms, require more medicine, increased missed days of school, & disturb sleep

RAST and Or Skin testing preferred. Immunotherapy SCIT, SLIT drops and tablets

Immunotherapy can: induce allergen specific tolerance, improve clinical symptoms of allergic symptoms/asthma, improve allergy tolerance for years following discontinuation of therapy, prevent new allergen sensitization, and prevent progression to severe asthma.

Slide24

Pulmonary Function TestThe Basics

Asthma is the most common reversible obstructive airway disease.

Spirometry can be used in ages as young as 5-6 years old

Abnormal finding indicating airway obstruction:

FEV1 <80% of predicted FEV1/FVC ratio <80% predicted

Spirometry maybe normal in mild or well controlled asthma

Pre and Post Bronchodilator >12 % increase for all ages or >200ml older kids

Slide25

Pharmacology: A Brief History

EARLY 1900 smoking Jimsonweed plant. Contained a atropine like a bronchodilator.

1940’s Theophylline was available for treating asthma

1956 First meter dose inhaler made by 3M and first beta adrenergic bronchodilator was introduced.

Isuprel

HELPED but caused tachycardia and occasional myocardial injury

1960’s We differentiated beta 1 receptors found in heart vs. beta 2 receptors found in bronchial smooth muscle and albuterol was developed

1960-1970 theophylline/ephedrine: side effect Jittery Anxious

1970-1980-Slow release Theophylline one brand name Theo-dur

1970 First Inhaled Corticosteroid: Beclomethasone each inhalation 50mcg

1980 Patients were asked to take ICS 4-8 puffs 4 times a day

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We Have Come a Long WAY !

Slide27

Therapeutic medication trial of bronchodilators

Commonly practiced and often very informative.

Bronchodilator initiated for use with chronic cough, wheeze, or shortness of breath.

Absolutely no help-

think of evaluating technique of inhaler, medication or think of other causes. If still thinking possible asthma refer to specialist.

Partial help-

Ask more questions and add a ICS or LM (singular)

Still in limbo refer to specialist

Definitely helps

– think Asthma

Peak flow monitoring:

Cheap $20 per meter. Can do at home with and without symptoms.

Use with symptoms and Check response to medicine . Looking for 20% change in predicted or patient average green zone value.

Slide28

TODAYS GUIDELINESKey Points to Discuss with Caregivers

SABAs ALONE not enough, ICS are the most effective medication for management of Asthma

Safety and Benefits

:

Known and welled studied clinical reduction of symptoms, restores normal activity, reduces hospitalization and emergency visits

given in

MICROgrams

instead of

MILLIgrams

1mg of Prednisone is 1000mcg ICS

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But I don’t want my Child on Steroids !STEROID PHOBIA

Common Caregiver Fears and Misconceptions

:

Not anabolic steroids (muscle building steroids)

You can not get “immune” or addicted to these steroids

Antihistamines do not treat asthma inflammation

Under the Supervision of a provider you can stop them at any time. No tapering needed.

Once my child starts steroids she will have to take them forever? N

Slide32

ICS and linear Growth

Discuss with caregivers: Other factors that effect growth Normal short-term changes in growth ratePubertal changes Use of systemic steroidsOther medical conditions and medicationsReassure parents minimally effected

Slide33

Effect of ICS on Linear Growth

Childhood Asthma Management Program

(CAMP)

Clinical trial: largest prospective randomized study to follow children until they reached final adult height.

1041 participants of CAMP trial ages 5-12 years old 1993-1995

Compared :

Budesonide (400mcg per day), Nonsteroidal

Nedcromil

, and Placebo

Evaluated Asthma Control, Lung Development, Growth

Slide34

CAMP STUDY Results

Results showed

Nedcromil

group and placebo had similar results

Children on ICS budesonide (400mcg ) had fewer symptoms, fewer acute attacks, hospitalization, and reduced airway hyper-responsiveness

ICS Improve ASTHMA CONTROL !

Budesonide group mild reduction in growth in first year of treatment half inch on average. The effect persisted but did not increase over duration of trial

Slide35

FOLLOW UP STUDY

Researchers re-recruited 943 of the original 1041 CAMP participants and tracked height, weight, and lung function yearly for 12 years until the average participant reached 25 years

FOLLOW UP FINDINGS:

Observed .47 or half inch difference in average height

The effect on height during initial treatment DID NOT progress and was not cumulative but did persist into adulthood

Slide36

Leukotriene Blockers

Singulair (

montelukast

): Mild persistent asthma, once a day, not a steroid, generally well tolerated, also treats allergic rhinitis, easy to take, used for exercised induced asthma

Singulair

is pregnancy category B, infant 6 months older

Accolate

(

zafirlukast

) twice a day, must give 1 hour before or 2 hours after meals >5

yrs

Zyflo

CR 2- 600 mg

b.i.d

1 hours after meals > 12

yrs

Can cause hepatotoxicity: Must monitor LFT’s, drug interaction beta blocker,

warfin

, theophylline

Slide37

Xolair (omalizumab)

NEW Pediatric Indication in the last year ages 6 years-12 years old

Moderate to Severe persistent allergic asthma

Positive skin test or RAST to perennial allergen

For patients with Symptoms not controlled with ICS/allergic asthma

Serum IGE 30-1300 IU/ML

Slide38

Slide39

Nucala (mepolizumab)

For Patients 12 years or older with Severe Asthma, Eosinophilic phenotype

Anti-Interleukin 5 Treatment : IL-5 is the major cytokine responsible for the growth and differentiation, recruitment, activation, and survival of eosinophils

Current Therapy: High dose ICS with or without oral steroids defined >880mcg fluticasone per day

Exacerbation history : 2 or more in the prior 12 months

Blood Eosinophil: obtain by CBC with differential: Eosinophils >150 cells/

uL

Slide40

Slide41

ASTHMA ACTION PLAN

Survey of caretakers at an Inner City Pediatric clinic revealed: 75% had Asthma Action Plans

9 out 10 reported using the AAP to manage exacerbations at home.

Stop Light Approach: Green, Yellow, Red. EASY TO READ

Peak flow monitoring: Objective measurement help care givers make intervention.

Symptomatic Treatment plan: helps caregivers decide when to intervene

Slide42

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YELLOW ZONE TREATMENT

Start SABA EPR #3 guidelines

Short burst of STEROID EPR # 3 guidelines

Intermittent use of ICS at the start of a Illness “1

st

sign of COLD”

Increasing dose of daily ICS. Quadruple the dose. Doubling not as effective.

Add ICS to ICS/LABA(age appropriate for combo therapy) for example

Pulmicort

plus

Symbicort

. (Quadrupling ICS) or add another ICS to current ICS example

Qvar

plus

Flovent

so patient dose not run out of daily med.

Slide44

Quadruple: That’s a lot of Steroid !

Typical systemic steroid dose 1-2mg/kg/day30 to 60 mg per day for 5 day dosing Or Moderate Inhaled Corticosteroid 500mcg X 4 =2000mg=2mg per/day

Slide45

References Yellow Zone treatment

Management of acute loss of asthma in the yellow zone a practice parameter Annual Allergy, Asthma, Immunology 113 (2014).Quadrupling the dose of corticosteroid to prevent asthma exacerbation: a randomized, double blind, placebo controlled, parallel group clinical trial (2009)Early Intervention with high dose inhaled corticosteroids for control of acute asthma exacerbation at home and improved out comes: a randomized controlled trial (2012)Pediatric Asthma Controller Trial PACT

Slide46

Yellow ZONE: The Grey Area

Early identification of asthma flare and intervention: better outcomes

Loss of asthma control differs from occasional asthma flare

False starts-may not need yellow zone treatment

Late start may lead to need for oral steroids

Increasing ICS results in Less systemic side effects versus oral steroids

When reached Red ZONE: Oral steroids but patient can continue yellow zone protocol. Studies have demonstrated symptoms may resolve or decrease and airway inflammation is still present. Plan to continue until the patient is 1 week well

Slide47

Exercised Induced Bronchospasm

In 2010, 50 % of Olympic cross country skiers, hockey players, ice skaters were being treated for EIB.

According to the CDC: 3 out of 5 asthmatics restrict their activity because of their asthma.

2014 National Health Survey:

48% of children under the age of 18

yrs

had 1to 2 asthma attacks in the last year

Slide48

Pregnancy and the Pediatric PatientKEY POINTS

CDC reports

in 2014 almost 250,000 babies were born to women ages 15-19 years old with birth rate of 24 per 1000 women in this age group.

Uncontrolled asthma lead to preeclampsia, low birth weight, and pre term labor

Rule of Thirds:

In a meta analysis of 14 studies, this holds true:

1/3 Asthma same

1/3 Asthma improved

1/3 Asthma worsened

TAKE AWAY MESSAGE FOLLOW PREGNANT ASTHMATICS CLOSELY

Slide49

Pregnancy: Medications Basics

Steroids /SABA

Generally safe BUDESONIDE- Large population-based prospective cohort epidemiological study reviewed data from 3 Swedish registries covering approximately 99% of pregnancies 1995-1997indictate no congenital malformation from use of ICS in early pregnancy

Medications

Class C- many asthma medications are class C. If asthma is uncontrolled and mom is not getting oxygen baby is not getting oxygen.

Please treat and give pregnant women a RESCUE inhaler.

Recommend follow up with asthma specialist and high risk OB/GYN

Slide50

Four components of asthma care

Assessment and monitoring of impairment and or risks

Education and self-care

Control of environmental factors and comorbid conditions

Pharmacologic treatment based on step wise approach (either up or down)

Slide51

Out patient visits

Interval history of asthmatic complaints, including history of acute episodes

History of nocturnal symptoms

History of symptoms with exercise, and exercise tolerance

Review of medications, including use of rescue medications

Review of home-monitoring data

Patients with good control for at least 3 months can be stepped down

F/U 2-6 week initially then q 4-6 mos.

Patients requiring step two or greater should be referred to specialist

Review technique of MDI

use

Explore reasons for lack of improvement

Slide52

Lack of improvement

Non-adherence should always be suspected in those with poorly controlled asthma.

Poor technique usage of inhalers greatly contributes to lack of control

Wrong diagnosis

Wrong medication

Non-avoidance of triggers

Slide53

Reason for non-adherence

Forgetting to take medication

Parental health beliefs

Lack of understanding of disease, medication or usage

low-level evidence to suggest that adherence decreases as the dosing frequency of prescribed medication increases

Family dysfunction or lacking in routine

Parental concerns or negative perceptions of steroid medication

Slide54

When to refer

History of sudden severe exacerbations

History of prior intubation for asthma

Admission to an ICU because of asthma

Two or more hospitalizations for asthma in the past year

Three or more emergency department visits for asthma in a year

Hospitalization or an ED visit for asthma within the past month

Use of 2 or more canisters of inhaled short-acting beta2-agonists per month

Current use of systemic corticosteroids

R

ecent withdrawal from systemic corticosteroids

Chronic cough, AR or sinusitis

Slide55

5 key points to MDI use

Randomized trial demonstrated the use of video teaching helpful 95% of the time

Failure to use inhalers correctly reduces their benefit

Patients should be taught how to clean and use their inhaler when first prescribed inhaled medication

Technique should be checked at subsequent visits

Individuals’ abilities should be taken into account when selecting inhaler devices

Placebo inhalers can be useful to demonstrate correct inhaler technique

Slide56

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Final thoughts

Assessment and monitoring does work

Early intervention and education is key

Collaboration provide timely, quality care to improve outcomes

Thank you!

Slide59

references

American Academy of Allergy Asthma and Immunology (AAAAI). (2016). Asthma guidelines and treatment. Retrieved from

http://www.aaaai.org/practice-resources/statements-and-practice-parameters

Center for Disease Control (CDC). (2017).

About teen pregnancy.

Retrieved from

https://www.cdc.gov/teenpregnancy/about/index.htm

Center for Disease

Cotnrol

(CDC). (2017). Pediatric asthma. Retrieved from

https://www.cdc.gov/asthma/default.htm

Child trends. (2015). Asthma trends. Retrieved from

https://

www.childtrends.org/wp-content/uploads/2016/11/43_Asthma.pdf

Dinakar

,

C

. (2014).

Management of acute loss of asthma control in yellow zone: a practice

: A

practice parameter.

Retrieved from

Annual

of Allergy Asthma Immunology, 113

, 143-159.

Galaxo

-Smith –Kline (GSK). (2017).

Nucala

. Retrieved from :

www.nucala.com

Genentech/Novartis pharmaceuticals (2017). Xolair in allergic asthma. Retrieved from

www.xolair.com

Hossny

, E. (2016). The use of inhaled corticosteroids in pediatric asthma: update. Retrieved from

http://waojournal.biomedcentral.com/articles/10.1186/s40413-016-0117-0

Light, M. J. (2011). Pediatric Pulmonology. Retrieved from

https://

ebooks.aappublications.org/content/pediatric-pulmonology

Lockett, T. (2014). Optimizing health outcomes for children in Delaware with asthma. Retrieved from https://www.nemours.org/about/mediaroom/press/dv/asthmaoutcomes.html

National

of Heart, Lung, and Blood Institute (NIH). (2017). National asthma control initiative. Retrieved from NIH:

https://www.nhlbi.nih.gov/health-pro/resources/lung/naci/