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Pediatric Asthma PowerPoint Presentation

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Description : This medical presentation titled ""Pediatric Asthma"" talks about asthma as the most common chronic disease of childhood.

Tags : Allergy, Asthma, exposure to pathogens, Pediatric, indoor air pollution, Pathophysiology, Chronic inflammatory lung disease, Cough, wheezing, dyspnea, chest tightness, Airway narrowing, Remodeled airway, edema, Inflammation, Hyperresponsiveness, Evaluation, Diagnosis, Breathlessness, chest tightness, chest pressure, chest pain, Impulse Oscillometry, Bronchoprovocation Testing, Chest x-ray

Published on : Apr 24, 2021 | Views : 3833 | Downloads : 18

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Slide 1-

Pediatric Asthma Kimberly D. Watts MD, MS Pediatric Pulmonary Medicine
Slide 2-

Why the increasing numbers? Improved hygiene Less exposure to pathogens disrupting innate immunity Increased indoor air pollution Caused by increase in energy efficient building Increased incidence of early onset viral infections Increase in host susceptibility Small lungs due to prematurity or maternal smoking Increased recognition and awareness
Slide 3-

Pathophysiology
Slide 4-

Definition of Asthma Chronic inflammatory lung disease Cough, wheezing, dyspnea and chest tightness Airway narrowing that is partially or completely reversible Increased airway responsiveness to stimuli
Slide 5-

Asthma Pathophysiology Overview Inflammation Narrowed airways Constricted muscles Airway hyper-reactivity Remodeled airway
Slide 6-

The wet dry asthma cough Airways edema Cellular infiltration Eosinophils Activated helper T cells Mast cells +/- neutrophils Increased airway secretions Secreted mucus Desquamated lining cells Intraluminal eosinophils
Slide 7-

Inflammation Chronic inflammation occurs even in the most mild of symptomatic patients Bronchoalveolar lavage of asthmatics demonstrates Neutrophils, eosinophils, lymphocytes and mast cells Cytokines including leukotrienes Alterations in innate lung immunity Impaired glutathione homeostasis Decreased capacity to reduce reactive oxygen species
Slide 8-

Reversible Airflow Obstruction Reduced expiratory airflow by spirometry FEV1 < 80 % predicted and a reduced FEV1 / FVC ratio of < 0.80 Significant reversibility is an increase of >12% in FEV1 from baseline
Slide 9-

Airway Hyperresponsiveness Degree to which airways narrow in response to stimuli Methylcholine Cold Air Histamine Viral upper respiratory infections Allergens Air pollutants
Slide 10-

Normal vs. Asthma Airway
Slide 11-

Evaluation and Diagnosis
Slide 12-

Clinical Presentation Most common cause of chronic cough in children older than 3 years old is asthma Not always accompanied by wheezing 80 % of children with asthma develop symptoms before 5 years of age Breathlessness, chest tightness, chest pressure and chest pain Poor school performance and fatigue
Slide 13-

Cough Cough lasting more than 3 weeks Night time cough Cough to specific exposures Dry and hacking cough Productive with clear / white sputum Usually eosinophils With activity
Slide 14-

Wheezing Polyphonic Tends to be expiatory but can be inspiratory Monophonic wheezes need further evaluation Rings/slings Malacia When albuterol makes it worse
Slide 15-

Symptom Patterns Intermittent exacerbations on a asymptomatic baseline Chronic symptoms with worsening on exacerbations Morning “ dipping” Worsening of symptoms in the morning corresponding to the physiologic dip in pulmonary function September epidemics Viral infections, mycoplasma pneumoniae or Chlamydia pneumoniae infection
Slide 16-

Precipitating Factors and Risk Factors Weather, second hand smoke, allergens and irritants Wood fires, kerosene space heaters, room deodorizers 30 % children with food allergy have asthma Higher rate of intubation Children of asthmatic parents odds ratio 2.6 ( 1 parents) and 5.2 ( 2 parents) Sleep disordered breathing 3.6 fold increase risk for severe asthma Higher BMI associated with greater asthma severity
Slide 17-

Diagnosis - Spirometry National Asthma Educations and Prevention Program recommends spirometry to be performed in patients older than 5 years old FEV1 < 80% predicted FEF 25-75% less than 65% correlated with reversible airflow obstruction in children with normal FEV1 Before and after bronchodilator Increase in 12 % ( maybe 9% in children) Normal spirometry or the lack of reversibility does not exclude the diagnosis of asthma
Slide 18-

Spirometry loops
Slide 19-

Diagnosis – Peak Flow More variable and effort dependent Wide variability in published predicted peak expiratory flow reference values Can alter brand to brand Peak flows should not be used to diagnose asthma More helpful to monitor a patient’s response over time for a subgroup of patients
Slide 20-

Other Diagnostic Modalities Impulse Oscillometry Passive cooperation Evaluates resistance pre and post bronchodilator Bronchoprovocation Testing Methylcholine, histamine , cold air , exercise If patient fails empiric trial of asthma medsications Chest x-ray Congential malformations Airspace disease Signs of asthma
Slide 21-

Other Diagnostic Modalities Sweat Chloride Barium Swallow TEF, reflux, vascular anomolies Negative study cannot exclude GER Allergy testing Limited to seasons and suspect exposures Exhaled nitric oxide Levels elevated in patients with asthma Chornic exposere to passive smoking may falsely decrease the levels
Slide 22-

Treatment
Slide 23-

Acute management
Slide 24-

Short Acting Beta Agonists Relaxes smooth muscle Overuse or regular use is associated with poor control Theoretical concern regarding down regulation of beta receptors with chronic use Can impact medication needed for urgent care
Slide 25-

Short acting medications Albuterol MDI with spacer or nebulizer No role for oral albuterol given side effects Levalbuterol R- enantiomer – active isomer only Approved MDI > 4 years old and neb > 6years old Hospitalization rate lower among childrens who received levoalbuterol in the ER vs. albuterol but studies are mixed Comparable, no evidence for superiority
Slide 26-

Ipratropium Bromide Anti-cholinergic Bronchodilator through smooth muscle relaxation Adjuvant for albuterol in the ER Reduce hospital admissions Improve lung function in severe asthma Also can use as an alternative agent to albuterol Tracheomalacia MDI not administered to soy or peanut allergy patients Contains soy lecithin
Slide 27-

Steroids 2007 NAEPP expert panel no longer recommends doubling dose of inhaled steroids for quick relief during acute exacerbations Not found effective in reducing severity or progression of exacerbation Higher dose ( > 2 times the normal dose) may be an alternative to oral steroids in mild exacerbations if patient does not tolerate oral steroids Short course of oral steroids in addition to short acting beta agonists for acute exacerbations
Slide 28-

Chronic Management
Slide 29-

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Slide 30-

Who should get controller therapy? 0 to 4 years old Greater than 4 episodes of wheezing Parental history of asthma Patient with atopic dermatitis or allergies Food allergies with eosinophilia or wheezing without colds Require albuterol more than two days per week Experiences severe illness < 6 weeks apart 2 rounds of steroids in 6 months Intermittent disease with severe exacerbation
Slide 31-

Controller therapy 5 years and older For any persistent asthma Any symptoms > 2 days a week Night time symptoms greater than 2 times a month Albuterol more than 2 days a week Any interference with normal activity Requires oral steroids more than once a year Severity and interval of exacerbations
Slide 32-

Intermittent - - - > Step 1 Mild - - -> Step 2 Moderate - - -> Step 3 Severe - - -> Step 3 or 4
Slide 33-

Starting controller therapy Two to six week interval is needed to assess response Adherence with current regimen needs to be assessed before escalating therapy Included assessment of barriers When controlled for 2 to 6 months can begin reducing regimen
Slide 34-

Inhaled Corticosteroids Inhibiting steps in the inflammatory cascade Associated with reduction in Symptoms Irreversible decline in lung function Asthma exacerbations Functional limitations Side effects from other medications Reduction in parameters better than with leukotriene antagonist First line control therapy for persistent ( or step 2 or greater ) asthma
Slide 35-

Inhaled Corticosteroids Fraction of the dose than systemic steroids Minimal side effects Almost all the trivial amount of drug absorbed is deactivated after one pass through the liver Differences in medications
Slide 36-

Inhaled Corticosteroids Minimize risk of adverse side effects Step down treatment to lowest possible dose to maintain control Optimize adherence to lowest dose possible Optimize delivery Evaluate for complicating factors Avoid triggers
Slide 37-

Inhaled Steroids and Disease Progression Did not alter disease progression Patients 2-3 years old with > 4 episodes of wheezing- - > fluticasone or placebo Fluticasone fewer symptoms and exacerbations At the last observational year no significant differences Early , intermittent intervention had no effect on disease progression from episodic to persistent wheezing 411 infants first thee years of life ICS or placebo At 5 years of age no difference between lung function or symptoms or asthma medication use between placebo group or ICS group
Slide 38-

Intermittent Use of ICS Con Intermittent inhaled budesonide at 400 mcg BID x 7 days less effective than daily ICS in children 5-10 years old No difference in placebo vs. high dosed ICS for 3 days at the first signs of a viral URI with wheezing Pro Budesonide 1 mg BID for 7 days at first onset of symptoms as effective as budesonide 0.5 mg qhs for 12-53 month old patients Meta-analysis no difference in daily ICS vs. intermittent in need for oral steroids but daily ICS better control and more symptoms free days
Slide 39-

Leukotriene Receptor Agonists Cysteinyl leukotrienes found in BAL in asthmatic patients Inhibit production at various points in the cascade Adjuvant therapy to ICS in patients > 1 year old No evidence to support use as first line controller agent or as intermittent therapy Can be used to step down therapy from ICS or in mild patient who cannot tolerate ICS
Slide 40-

Montelukast VS. Placebo 2-5 years olds Intermittent asthma associated with viral symptoms Better than placebo with a reduced rate of exacerbations and decreased use of ICS Vs. ICS Meta-analysis in mild to moderate persistent asthma children ICS had better pulmonary function and better asthma control ICS more cost effective
Slide 41-

Response variability Double cross over ( 6-17 years old) – Fluticasone and montelukast 17 % responded to both medications 23 % responded to fluticasone only 5% to montelukast only 55% to neither Inhaled steroids as the first line controller agent Intermittent use of moneltukast was associated with some improvement but not difference from placebo in hospitalizations, albuterol use or oral steroids use More studies needed
Slide 42-

Long Acting Beta Agonists Used as an adjuvant to ICS Should not be used for acute exacerbations Once control is obtained, effort should be made to go to a single agent ICS Reserved for patients who “ fail” medium dose ICS Black box warning May increase the chance of severe asthma episodes and asthma related deaths
Slide 43-

Anti IgE ( Omalizumab) Monoclonal anti IgE Moderate to severe asthma Not controlled on ICS Elevated IgE levels Approved if > 12 year old in US IgE levels 30 -700 Positive allergy testing
Slide 44-

Chronic Oral Steroids Severe persistent asthma Long term effects Adrenal suppression Weight gain Diabetes Hypertension Cataracts Delayed growth Immune suppression Osteoporosis Behavioral effects Lowest possible dose, every other day administration, trying all other modalities is preferable
Slide 45-

Other Therapies Cromolyn Systemic review found no clear therapeutic effect vs. placebo No evidence to sport the concurrent use of cromolyn with ICS Theophylline Use limited secondary to potentially serious short term side effects ( arrhythmia, seizures and death) Needs frequent serum monitoring as well as monitoring with drug interactions
Slide 46-

Barriers to Care
Slide 47-

Unequal burden of asthma About 1 in 6 or (17%) of non-Hispanic black children had asthma in 2009 In 2001-2009 the greatest rise in asthma rates was among black children with an almost 50 % increase About 40% of uninsured people with asthma reported not being able to afford their medications About 11% of insured people can not afford their asthma medications
Slide 48-

Affects of Poverty and Race on Pediatric Asthma Prevalence Definitions of poor, near poor and non-poor are based on federal poverty levels that take into account annual/ monthly income and family size Prevalence data 2006-2008 MMRW, Jan. 14, 2011 Asthma Prevalence in the US
Slide 49-

Differences in Prevalence African American = 12.7 % Puerto Ricans = 25.7 % Mexican Americans = 6.6% Whites = 8.8% Higher among children Living below the poverty threshold Living in an urban setting Northeastern portion of the US
Slide 50-

Signs of Poor Control Utilization of ER Frequency of hospitalizations Repeated use of oral glucocorticoids School absenteeism Inability to participate in physical activity
Slide 51-

Poor Response to Asthma Medications Non-adherence Inadequate inhaler technique Ineffective drug dose or dosing interval Complicating medical problems Substitution of inappropriate treatment Response variability to certain medications
Slide 52-

Psychosocial Factors affecting adherence Family disagreement about diagnosis Peer rejection Concern about adverse side effects of controllers Financial consequences Disruption of family routines Fear of inability to obtain health insurance with a pre-existing condition Limitations of social interactions because of triggers
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Slide 54-

Take Home Points from National Asthma Education and Prevention Program Expert Panel Report All patients should receive Asthma action plan Initial assessment of asthma severity Review of asthma level of control at follow-up visits at least every 6 months Assessment of exposure to allergens and triggers Asthma education by a qualified health professional Referral to an asthma specialist when appropriate Education regarding dangers of over use of beta agonists Information regarding risk factors for death of asthma