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Selection from: Comprehensive Management of Pediatric Asthma: Using the Guidelines to Develop Effective, Long-Term Plans

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Comprehensive Management of Pediatric Asthma: Using the Guidelines to Develop Effective, Long-Term Plans (Slides With Transcript)  CME

Andrew Liu, MD   Disclosures

Slide 1.

Hello, my name is Dr. Andy Liu. I am a pediatric allergist at the National Jewish Medical and Research Center in Denver. Welcome to today's program on the Comprehensive Management of Pediatric Asthma: Using the Guidelines to Develop Effective, Long-Term Plans.

In the United States, we have new national guidelines for the management of asthma published at the end of 2007. They are comprehensive and they work well in achieving asthma control, but in being comprehensive, they are somewhat lengthy.

What are the main messages? What are the keys to achieving, maintaining good asthma control? That will be the main focus of today's program. I will begin with a little bit of background on asthma and spend most of the time talking about these new asthma guidelines and what are the key messages from them to provide great care for asthmatic patients.

Slide 2.

Let's begin with some pediatric asthma statistics briefly. You can see that asthma is very common in children, especially 9 million American children are affected with asthma. It is on the rise, up 75% over the last 15 years. It is a highly morbid condition, a lot of missed school days, a lot of emergency department (ED) visits, hospitalizations; in children, it is the most common cause of missed school days and ED visits and hospitalizations of any chronic condition, and as such, it is costly to us in the United States.

Slide 3.

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I would like to share with you this case study of this 2-year-old child with asthma.

Slide 4.

As you can see, the clinical symptoms of asthma vary. They are intermittent. The types of symptoms vary from individual to individual. Coughing and/or wheezing are common, sometimes with shortness of breath and chest pain as symptoms become more pronounced or progressive. There is daily variation; asthma tends to be worse at night. And it can limit exercise tolerance. Even less common are the exacerbations that are progressive and often occur in asthmatics several times a year. We also ask about frequency of rescue medication or albuterol usage to treat symptoms.

Slide 5.

Underlying this clinical intermittence is a chronic condition of the airways; causing this airway blockage includes smooth muscle bronchoconstriction and an inflammation of the airways that is eosinophilic or allergic in nature. This inflammation makes the airways twitchy or hyperresponsive, and this blockage tends to be reversible in terms of the inflammation and the bronchoconstriction. However, there are also structural changes of the airway's tissue, called airway remodeling, that do not appear so reversible.

Slide 6.

With airway obstruction comes ventilation defects as seen here in these exquisite ventilation scans by MRI. You can see, compared with normal, that as asthma moves from mild to moderate to severe, you can see gross ventilation defects that ultimately end up involving most of the lungs.

Slide 7.

Is the airway obstruction in asthma reversible? Well, yes and no. We can see that some aspects are reversible and we understand how to reverse them, the bronchoconstriction, the mucous secretion, edema, the eosinophilic inflammation, and with the healing of the inflammation, the airway lining also heals. This improves the bronchial hyperresponsiveness. But there are features of the tissues of the airways in asthma that seem irreversible to us at this point in time: the smooth muscle and mucous gland hypertrophy, airway wall thickening, and changes in how the airways are held open. As well, if beginning in early life, this can affect early lung growth and development of the airways.

Slide 8.

I would like to share with you a little background on the natural history and the types of pediatric asthma.

Slide 9.

There are different types of pediatric asthma that are exemplified well in early life. Here seen, the most commons types are described as those who are transient early wheezers and immunoglobulin (Ig) E-associated wheeze or asthma, otherwise called classic asthma.

Slide 10.

These two common types of childhood asthma are well exemplified in this classic study in Tucson where over 1000 children were enrolled from birth and followed for the development of wheezing. What we can see is that in the first 6 years of life, it is as common to have wheezing problems as to never wheeze. Almost 50% of the population experienced some wheezing problems during their early childhood. All together, about 20% experienced a transient type of wheeze, meaning that they became better on their own between the ages of 3 to 6 years. In comparison, 14% of the total population had persistent wheezing problems through these early years of childhood. How do you distinguish these different types of wheeze?

Slide 11.

The risk factors for transient wheeze are listed here. You can see that they are associated with respiratory viral infections and, in particular, the susceptible are those young children who have smaller air passages and smaller airways due to lung size, male gender, low birth weight, and maternal smoking.

Slide 12.

In comparison, we can tease out those young children with early wheezing who are likely to have persistent asthma using this Asthma Predictive Index. In a young child who has had some wheezing problems in early life, those who are likely to persist may have 1 major or 2 minor criteria. You can see that the criteria are largely about allergy. One major criteria might be a parent with asthma or early atopic dermatitis or early sensitization to inhaled allergens; 2 minor criteria, allergic rhinitis, wheezing apart from colds, eosinophilia, or sensitization to foods.

As you can see from these criteria, it is not that a child needs to have most or all of these criteria to be at increased risk, just 1 major or 2 minor criteria.

Slide 13.

Now let's turn our attention to the new national guidelines for asthma management.

Slide 14.

The US national guidelines are now in their third major iteration over the last 20 years and continue to be divided into the 4 major components of asthma management: the first, how asthma is diagnosed, assessed, and monitored; the second, how we best work with our patients to be most effective and efficient in achieving good asthma care; the third, control of environmental factors and comorbid conditions that affect asthma, primarily those that promote inflammation in the airways; and the fourth, optimal pharmacotherapy to control asthma and to treat exacerbations or increased symptoms.

Slide 15.

In these new guidelines, asthma management is first assessed when diagnosed based on its severity in order to initiate therapy. Subsequently, in all follow-up visits, asthma control is assessed, and this is a new element of this new version of the national guidelines and is perhaps its biggest change and a very helpful one at that.

Both asthma severity and control are assessed by similar parameters and those parameters are divided into impairment and risk parameters.

Slide 16.

The parameters in the new national guidelines for assessing asthma severity and control can be divided into parameters of impairment and risk.

Listed on the left, impairment is assessed by asking about daytime symptoms, nighttime awakening, albuterol usage to treat symptoms, and impairment of daily activities, missed work or school, exercise limitation; as well, lung function can be measured in the office as a helpful measure of impairment.

The main risk category is that of asthma exacerbations, a helpful one especially when working with children. Exacerbations may be defined as requiring oral corticosteroids to treat a progressive flare or urgent visits, ED visits, or hospitalizations. When assessing asthma control, additional risk measures include continuous obstruction as measured by lung function, or treatment-related adverse effects.

Slide 17.

Here is the heart of asthma assessment for the new guidelines, these new tables. There are tables that differ for asthma severity assessment as well as asthma control, and they also differ by age, a younger age group, here as you can see 0 to 4 years of age, but also different tables for those children 5 to 11 years of age, and those 12 years of age and older including adults. While these tables differ, they are very similar in how they are used. I will spend most of my time on this first table and then I will show you in subsequent tables how they differ from the first.

When initially assessing asthma severity, once asthma is diagnosed, you can see that asthma severity is divided across the top into 4 main categories, just as prior guidelines have been: intermittent, mild, moderate, and severe persistent asthma.

To determine how severe asthma is, we use the parameters listed on the left column divided into those of impairment and risk, asthma symptoms during the day, nighttime awakenings, albuterol use to treat symptoms, interference with normal activities, and highlighted in yellow is this new criteria, asthma exacerbations. There are different degrees for each of these parameters that help to define their level of severity.

Finally, it is worth noting that the single parameter that rates the worst is the one that is used to define the level of severity. Let me just give you an example. Let's take a young child who is having essentially no current problems, no symptoms, nighttime awakenings, or albuterol usage. However, this child has had 3 significant asthma exacerbations in the past year. This child would rate as having at least mild asthma based on the parameter of exacerbation risk.

Slide 18.

The second table of asthma severity assessment differs only from the first table in that it is applied to the slightly older child, ages 5 to 11 years of age. The main way in which this table differs is that it adds to the impairment assessment, a measure of lung function by spirometry.

Children younger than 5, are unable to perform spirometry, hence, the addition of this new parameter for assessing impairment in the slightly older child.

Slide 19.

The third table for assessing asthma severity is now, as you can see, for the child who is 12 years of age and older, including adults. In this case, we can see that this table differs from the earlier tables in that lung function is adjusted by age. As you can see on the far left side under impairment, normal lung function is given, and as we age, there is a slight decline in what is considered normal lung function.

Slide 20.

One of the main reasons why we assess and rate asthma severity in patients is because it helps guide us as to what controller therapy to begin with in order to achieve and maintain control.

The controller therapies, as you can see here, are referred to as a step ladder such that with intermittent disease, step 1 is appropriate; mild disease, step 2; moderate, step 3 or 4; and severe, step 5 or 6. It is a 6-step ladder that is also used to help manage and control asthma, and we will be going over those in a few slides.

Slide 21.

But first, let's talk about assessing asthma control, which is probably the main change in the new guidelines.

Slide 22.

The goal of asthma management is to achieve control, to reduce impairment and risk, to achieve and then subsequently to maintain good asthma control. This is aided by periodic assessments at about 1- to 6-month intervals and is a combination of clinician assessment and patient self-assessment in order to help determine how well or inadequately asthma is controlled.

Slide 23.

What is well controlled asthma? Well, the new guidelines do an excellent job of defining asthma control as achieving and maintaining all of these parameters: minimal day symptoms; no limitations of activities including exercise; nocturnal symptoms or awakening from asthma should be very rare, no more than once a month; minimal need for reliever treatment such as albuterol for asthma symptoms; normal or near-normal lung function; and no more than 1 asthma exacerbation per year.

Slide 24.

This definition of well controlled asthma can also be seen in these tables for assessing asthma control. This is the table that is applied to the youngest aged child, and we can see now across the top that asthma control is categorized into 1 of 3 levels: well controlled, not well controlled, or very poorly controlled asthma.

The parameters that we use to assess asthma control, those parameters of impairment and risk, are again familiar as they were for asthma severity: day symptoms, nighttime awakening, interference with normal activities, and albuterol usage to treat those symptoms. There is also the familiar new exacerbation criterion which is very helpful, and there is one more added, which is treatment-related adverse effects.

So we can see now that under well-controlled asthma, that the goal of control is well defined.

Slide 25.

The second of these asthma control assessment tables is for the slightly older child, ages 5 to 11 years. Again, this table differs from the control assessment for younger children simply by the addition of lung function criteria.

Lung function in the older child and adult are used to assess asthma impairment but are also used to assess asthma risk. What this means is that spirometry or measurements of lung function are considered helpful on a continuous basis to make sure that continuous obstruction is not occurring or developing in an occult way in some asthmatics.

Slide 26.

In the older child, 12 years of age, and the adult, we can see again that the table is familiar. However, there is the addition of new validated questionnaires that can help us assess asthma control. They are listed here in the impairment category, ATAQ, ACQ, asthma control test ACT, and I will be showing you an example toward the end of how these validated questionnaires can be used to simplify your life and clinical assessment with asthma.

Slide 27.

To summarize briefly, the goals of asthma therapy are to decrease impairment and reduce risk of asthma by normalizing the symptoms, the lung function, and physical activity and decreasing the risk of exacerbations and progressive airflow obstruction.

Slide 28.

Once we have assessed a level of asthma severity and control, how do we achieve good control? That information helps us apply these stepwise tables for asthma management. Here you can see in the middle a 6-step ladder of increasing intensity of asthma controller therapy that can be used to achieve asthma control.

Let's use the example of asthma severity first. As you might recall, in those tables for intermittent asthma, step 1 therapy is applied; that is albuterol on an as-needed basis only. But with mild-persistent asthma, step 2 therapy is appropriate. We can see that there is a preference of low-dose inhaled corticosteroids that is highlighted, but there are also alternatives that are acceptable: cromolyn or montelukast. For moderate asthma, step 3 or step 4 therapy is appropriate, and for severe asthma, step 5 or step 6 level therapy is appropriate as a starting place.

The ladder is also helpful in that initially, we start at a certain step to achieve control, but once control is achieved, then we can step down to maintain control. If control is not achieved, we step up the ladder. And so, with these progressive follow-up visits, we see that we can apply this ladder by stepping up or stepping down in the level of asthma therapy needed to maintain asthma control.

The other important elements as seen here include consultation with a specialist if asthma is difficult to control or step 3 level care is needed, as well, patient education and environmental control considerations at every step.

Slide 29.

The assessment and control algorithm for management in the slightly older child, age 5 to 11 years, is shown here and differs slightly from that applied to the younger child.

Step 1 and step 2 level care looks similar. At step 3, there is a slight difference: for the younger child, step 3 care is preferably inhaled corticosteroids at a higher dosage; here we can see that for step 3 care, that is one of the options, but as well, combination controller therapy is an early option. Combination controller therapy is considered add-on to inhaled corticosteroids with either a long-acting bronchodilator, a leukotriene antagonist, or theophylline. Stepping up to step 4 or step 5 provides a preferred alternative primarily of increasing the inhaled corticosteroid dosage. There are also alternatives that are provided.

Slide 30.

Finally, for the older child 12 years of age and older to adulthood, we can see again that there is only a slight modification in the stepwise approach to care. That modification exists primarily at the step 3 level where we can see that there is a preference for either combination controller therapy with low-dose inhaled corticosteroids plus long-acting bronchodilator, or medium-dose inhaled corticosteroids.

One other change in this algorithm for the older child and adult is for the severe asthmatic, or the difficult-to-control asthmatic, at step 5 or step 6 where one option is the addition of omalizumab therapy; this is an anti-IgE monoclonal antibody therapy that is approved for use in children older than 12 and adults.

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