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

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Slide 31.

Finally, in this section of asthma control, we have some ideas of predictors from first visits of future poor asthma control or patients who perhaps deserve more attention. Those predictors are listed on the left side, and we can see if these predictors are either increasing or decreasing risk by their odds ratio on the right side.

Significant predictors that increase risk include multiple courses of oral corticosteroids, unscheduled visits or hospitalizations for asthma in the past year, as well as smoking, additional chronic obstructive lung disease on top of asthma, and some other demographic features.

Reducing risk includes regular specialist care management for asthma and more than 4 prescribed inhaled corticosteroids canisters in the prior year, as well as increasing numbers of prescribed long-acting beta agonist canisters in the prior year.

Slide 32.

I would like to update you on some of the changes in our understanding of these asthma therapies.

Slide 33.

With long-acting bronchodilators, there is now a black box warning that identifies an increase in the risk of asthma-related exacerbations and deaths when used. Primarily the concern is the use of long-acting bronchodilators with no anti-inflammatory therapy at the same time. Thus, for the most part, long-acting bronchodilators are only used for asthmatics as add-on therapy to inhaled corticosteroids and largely only exist as combination controller therapy at this point.

Slide 34.

The cromones, which include cromolyn and nedocromil, now have a lesser place in asthma management, especially on a controller or a routine basis. They are not recommended in the international Global Initiative for Asthma guidelines, the GINA guidelines, but are still noted in the US national guidelines as an option.

Slide 35.

Leukotriene modifiers have now been available for prescribing for a number of years. We have a lot of experience with their use now in this new version of the guidelines. They have historically had an excellent safety profile. Leukotriene antagonists may be considered as first-line therapies at step 2 as an alternative to inhaled corticosteroids, or as add-on to inhaled corticosteroids in higher step level care.

Slide 36.

Omalizumab is a monoclonal antibody that is injected on a once-every-2-to-4-week basis to block IgE. This is only approved for usage in children older than the age of 12 and adults, and is primarily indicated for difficult-to-control asthma or severe asthma. It has a rare risk of anaphylaxis, which is about 1 in 1000, and thus, post-injection patients need to be monitored for some period of time.

Slide 37.

Inhaled corticosteroid therapy as an asthma controller has now been out for a long time. We have a good understanding of its efficacy, its safety, and its limitations. It is effective in nearly all aspects of asthma impairment and risk and reducing symptoms, improving lung function, reducing airway twitchiness, improving inflammation, and reducing the frequency and severity of exacerbations.

There is the potential for some side effects with long-term treatment that can occur especially when inhaled corticosteroids are used at high dosages. In children, there is a small effect on linear growth, primarily in the first year of inhaled corticosteroid use, that is possibly transient or reverses after the inhaled corticosteroids are discontinued.

Some limitations of inhaled corticosteroids is that they do not seem to affect airway remodeling features in the doses that we currently use or prescribe, and they do not seem to change the likelihood of outgrowing asthma. Thus, inhaled corticosteroid therapy can achieve control but cannot cure.

Slide 38.

We have good information on whether or not inhaled corticosteroids can help to modify or prevent asthma persistence from several studies, perhaps one of the strongest being this Prevention of Early Asthma in Kids study that was sponsored by the National Institutes of Health (NIH). In this study, young children under the age of 3 who met the Asthma Predictive Index criteria for persistent asthma were treated with either inhaled corticosteroids or placebo for a 2-year period.

Following that 2-year period, the inhaled corticosteroid therapy was discontinued and the child was observed for 1 year to see if the inhaled corticosteroid treatment in early life had reduced the prevalence of asthma.

Slide 39.

Here we can see one of the main outcomes. In the inhaled corticosteroid-treated group in blue, we can see that during the 2-year treatment period, the proportion of episode-free days is maintained at a high level and better than the placebo group. But once inhaled corticosteroids are discontinued, within a matter of weeks, those on inhaled corticosteroids dropped to the level of the placebo group. In other words, inhaled corticosteroids can achieve and maintain good asthma control just as it can in older children and adults; however, similarly again, when inhaled corticosteroids are discontinued after 2 years of usage, asthma returns.

Slide 40.

Now let's turn our attention to managing asthma exacerbations.

Slide 41.

Asthma exacerbations are defined as acute or subacute progressive episodes of asthma.

Slide 42.

The management of these exacerbations, the treatments are primarily short-acting bronchodilators such as albuterol, oral corticosteroids, and oxygen.

The best management strategy is to provide patients with education that such exacerbations can occur and an action plan of stepwise intervention to try to keep these exacerbations from getting worse.

Slide 43.

This table from our new national guidelines describes the management approach to asthma exacerbations based on their severity. As you can see from the left side column, asthma exacerbations can be rated as mild, moderate, severe, or life-threatening.

For signs and symptoms, you can see that the main parameter that helps define the exacerbation severity is the level of dyspnea or shortness of breath.

It also helps to define the usual clinical course, that being for mild with mild dyspnea, these exacerbations can usually be managed at home; if they progress to moderate, these exacerbations usually require an urgent office visit or an ED visit; if it progresses to severe, these exacerbations usually require an ED visit and a likely hospitalization; and if life-threatening, hospitalization and an intensive care unit (ICU) visit are often the norm.

In the middle are peak flow criteria that can be used to help distinguish asthma exacerbation severity. I would provide one caution, and that is if an exacerbation is moderate to severe or worse, measuring a peak flow is not necessary and can actually provoke an asthma exacerbation.

Slide 44.

Here we provide some additional notes of managing exacerbations in infants. Primarily, infants can get in trouble more easily because they have less respiratory reserve, they have less development of accessory muscles, a more pliable ribcage. All of this makes it more difficult for them to breathe when they are having an asthma exacerbation.

When oxygenation drops, such as that measured by oxygen saturation, to less than 90%, this is actually a late sign in an exacerbation for asthma, and this is actually what we are trying to avoid by the early intervention on asthma exacerbations. With infants, lack of therapeutic response is often an indication for hospitalization to assure that the exacerbation is not only controlled but that control can be maintained.

Slide 45.

Now let's shift our attention to common comorbidities associated with asthma.

Slide 46.

Asthma can be viewed along with other common allergic childhood diseases as part of the allergic march of early childhood. In the allergic march, young children, especially infants, often present with food allergies and eczema, and then subsequently present with persistent asthma and allergic rhinitis or the airways allergic diseases.

Slide 47.

The prevalence of rhinosinusitis in asthmatics is very high, about 60% to 80%, compared with 10% to 20% in the general population.

The linkage between atopic dermatitis and asthma is also strong, especially with severe atopic dermatitis. For those who have severe atopic dermatitis, almost 100% will develop inhalant allergen sensitization and 75% develop allergic respiratory disease in subsequent years.

Slide 48.

There is also a developing understanding of the link between food allergies and asthma. We know that food allergies are more common in people with asthma than in the general population. We know that for those who have food allergies, that a significant number of people will have asthma symptoms as part of their food reaction. More recently, we can see that food allergies are especially common in those who have severe asthma exacerbations.

Slide 49.

Treatments for asthma and allergic rhinitis may overlap in that certain treatments can improve both conditions. Our approach to environmental control measures is key to both conditions.

Intranasal corticosteroids that are used to treat allergic rhinitis also improve asthma symptoms. Especially in patients with mild asthma, treatments with antihistamines and especially treatments with leukotriene antagonists can be useful in addressing not only symptoms of allergic rhinitis but also asthma. Allergy immunotherapy is also a helpful treatment for allergic rhinitis and asthma.

Slide 50.

Here we see another common comorbid condition with asthma: gastroesophageal reflux disease or GERD.

Asthma and GERD often occur together; and are most commonly seen in asthma patients who are difficult to control in part because their GERD has not been addressed. It seems to be particularly common in children with asthma; may go asymptomatic from a GERD standpoint; and is often associated with nocturnal wheezing.

Slide 51.

This feature requires the newest version of Flash. You can download it here.

I would like to share with you this case of a teenage cheerleader with exercise-induced asthma problems.

Slide 52.

Exercise-induced bronchospasm is essentially the norm for asthmatics, occurring in 90% of patients with asthma. It often indicates poorly controlled asthma, and as such, long-term controller therapy generally helps exercise-induced bronchospasm symptoms.

In addition to good long-term controller therapy, we can also pretreat prior to exercise to help prevent asthma symptoms. Pretreatment can be with bronchodilators or leukotriene antagonists, as well, warming up prior to exercise and breathing in warm air can be helpful to reduce exercise-induced bronchospasm.

Slide 53.

Finally, in this demonstration of comorbidities associated with asthma, I would like to show you these high-resolution CT scan images of asthmatics. The one on the left has some highlighted pixilation in yellow that is actually identifying air trapping in alveoli. This air trapping in alveoli is an interesting measure of airflow obstruction in asthma that is quite distal or down at the end of the airways.

Slide 54.

This peripheral airways obstruction can occur in the absence of changes in the common lung function measure, forced expiratory volume in 1 second (FEV1). Because it is so distal, there is some concern that conventional inhaled corticosteroid therapies, at least some of them, may not reach these small peripheral airways, and that newer inhaled corticosteroids or inhaled medications that have very small particulate, as well as oral systemic therapies, may be one way to reach these peripheral affected airways in asthma.

Slide 55.

I would like to end with a few pointers for asthma management in clinical practice.

Slide 56.

The first point is an example of these validated control assessment questionnaires that can simplify your asthma management in clinical practice.

This asthma control test is a 5-question questionnaire that is supposed to be administered to the patient prior to your seeing them. They complete this on their own, and this is freely available to you through a number of venues. It asks 5 questions that have been validated, and together, they provide an additive score that can help you determine whether your asthmatics are well controlled, not well controlled, or very poorly controlled based on established validated cut points.

This can save you the time in practice of having to ask these questions yourself. It is not 100% foolproof but about 70% to 75% of the time, this asthma control test will give you the right determination for the level of asthma control.

Slide 57.

When patients return to us and their asthma is not being controlled, our goals are not being achieved, what is underlying this problem? We have an understanding of some of the things that contribute to that in most cases.

Commonly, there are differences in perception or expectations of what constitutes good asthma control. Many patients may not understand or believe that their asthma can essentially be normalized as defined in the new asthma guidelines. It is very common in practice if we ask our patients, how is your asthma, they will say, my asthma is good; my asthma is fine. But when we actually ask about the individual parameters, their idea that their asthma is fine may be that they have 4 or 5 exacerbations a year, that they can't exercise, but they are not having multiple daily symptoms or are not having a frank exacerbation all the time. Thus, the new guidelines are helpful in defining the different parameters that we like to see completely controlled or well controlled across the board, not just 1 or 2 of them, and also to the extent that we are looking for normalization.

Poor adherence to treatment regimens is also a common problem. For example, a situation that I commonly see involves patients that are unable to take their inhaled medications correctly. This is something that needs to be revisited especially if you are depending on inhaled medications for good asthma control.

Still, in an ideal world, when there is a good understanding of asthma control and there is good adherence with the management plan, there are still some patients who do not respond to the initially or subsequently prescribed therapy because there is variability in response to treatments and some of that variability can be due to pharmacogenomic issues.

Slide 58.

The last point for clinical practice that I would like to review with you is when to refer a patient to an asthma specialist.

Generally speaking, when patients have life-threatening exacerbations, are difficult-to-control, when additional diagnostic tests are needed, or additional asthma education is needed, when there are problems with adherence and the thinking that additional testing or education may be helpful, allergen immunotherapy, or repeated exacerbations, these are some indications for when an asthma specialist can be helpful in defining a good asthma plan to achieve and maintain control.

Slide 59.

In conclusion of this program, we understand asthma as a common condition beginning in early childhood and that is clinically variable but biologically persistent.

New asthma guidelines are helpful in showing us how to assess, achieve, and maintain asthma control for the larger majority of our patients.

Finally, our management approach should be tailored within the guidelines to meet the individual needs of each patient, and also provide some guidance on when to refer to a specialist on how to achieve good control. Thank you for joining us.

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