NO PUB #
INTRODUCTION
The Section on Allergy and Immunology of the American Academy of Pediatrics (AAP), through
a cooperative agreement with the US Environmental Protection Agency, is pleased to present
you with this Pediatric Asthma Speaker's Kit. Asthma is one of the most common chronic disease
conditions that affects nearly 5 million children. This kit was designed to help pediatric allergists-
immunologists educate pediatricians to diagnose and manage children with asthma in their
office and become key players to improve asthma management within schools. The materials
in this kit will educate physicians about the factors that cause asthma, how to determine if a
child is an asthmatic, the role of the indoor air environment in asthma (eg, dangers of indoor air
pollution and allergens), and various treatment approaches that should be considered to help a
child manage asthma at home and at school. The Asthma and Schools section is an ideal primer
for a pediatrician with an interest in advocating for improved resources and protocols in schools
for children with asthma.
Members of the Executive Committee of the Section and invited authors spent countless
hours developing this kit. We feel that it provides state-of-the-art information on a variety of topics
related to asthma in children with user-friendly parent handouts and key take-home messages
for physicians to review with parents and children. The kit consists of 7 sections, which can be
used separately or in combination. The final section actually consists of selected slides from the
other 6 modules, to provide the audience with an overview of asthma. Each slide comes with
talking points but we have allowed individual speakers to add, subtract, or modify the slides for
their own purposes. A list of additional resources and references is provided for those who would
like other public education materials, or evaluation measures to measure quality improvement, or
would like to learn more about cutting-edge asthma therapies.
The companion physician and parent handouts in this kit within each section represents
a unique approach to asthma education and may affect a practice change for clinicians. The
handouts should be reproduced for the audience, and time should be spent explaining their
purpose. The "Key Points to Cover With Patients" (physician handout) lists key educational points
related to the module's topic that a clinician should cover with the patient during a child's visit(s).
The parent handout is designed as a take-home for the patient that covers the same educational
issues as the physician handout but a patient's level.
The Section hopes that you find this Speaker's Kit to be a valuable tool in your efforts to
participate in the education of those who care for children with asthma. This is one of many ways
the Section is striving to accomplish its mission to ensure that all children receive the best quality
of allergy and immunology care. To learn more about the Section's programs and initiatives,
visit http://www.aap.org/sections/allergy, or contact us at soai@aap.org.
/ftu/
Paul V. Williams, MD, FAAP Michael J. Welch, MD, FAAP
Editor, Pediatric Asthma Speaker's Kit Chairperson, AAP Section on Allergy and Immunology
SPEAKER'S KIT
LB-l
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ACKNOWLEDGMENTS
On behalf of the American Academy of Pediatrics, the Section on Allergy and Immunology
gratefully acknowledges the invaluable assistance provided by the following individuals who
contributed to the preparation of the Pediatric Asthma Speaker's Kit.
Paul V. Williams, MD, FAAP, Editor Luis Saca, MD, FAAP
Allen Adinoff, MD, FAAP Brian Smart, MD, FAAP
James E. Gern, MD, FAAP Michael J. Welch, MD, FAAP
David S. Pearlman, MD, FAAP Robert A. Wood, MD, FAAP
Technical Reviewers
Michelle S. Howenstine, MD, FAAP, Section on Pediatric Pulmonology
Janice J. Kim, MD, MPH, FAAP, Committee on Environmental Health
Howard Taras, MD, FAAP, Committee on School Health
US Environmental Protection Agency
AAP Board of Directors Reviewer
Jon R. Almquist, MD, FAAP
Editorial Board
Section on Allergy and Immunology Executive Committee, 2002-2003
Michael J. Welch, MD, FAAP, Chairperson
A. Wesley Burks, MD, FAAP
James E. Gern, MD, FAAP
John M. Kelso, MD, FAAP
Lynda C. Schneider, MD, FAAP
Diane Schuller, MD, FAAP
Paul V. Williams, MD, FAAP
Laurie Smith, MD, FAAP, Immediate Past Chairperson
AAP Staff
Pamela T. Kanda, MPH
Department of Committees and Sections
Sue Romo
Department of Marketing and Publications
SPEAKER'S KIT
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TABLE OF CONTENTS
I. Introduction
A. Acknowledgments
B. Speaker's Tips
II. Sections
Each section contains slides, slide notes, parent handouts, and physician handouts.
A. Origins of Asthma: Environmental Factors
B. The Diagnosis of Asthma in the Pediatric Patient
C. Non-pharmacologic Approaches to Asthma Management
D. Pharmacologic Management of Asthma
E. Management Aids
F. Asthma and Schools
G. Pediatric Asthma Overview
III. References
IV. Additional Resources
DEDICATED TO THE HEALTH OF ALL CHILDREN"
American Academy of Pediatrics
*" SPEAKER'S KIT
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SPEAKER'S TIPS
SIX GOOD IDEAS
Perhaps the most important—but most difficult—aspect of public speaking is keeping the
audience's attention. Here are some suggestions.
Speak up! Talk a little louder than you think you should. Most people speak too softly and the result
is often mumbling. Speaking up can also make you feel less nervous.
Use illustrations. Force the audience to visualize. The listener's mind is hungry for pictures.
Give them something to "see."
Use "first person" stories when possible. The audience perks up for phrases like "The other day...,"
"I have found from my own experience...," or "A friend of mine once told me...."
Pause occasionally. Pauses are perhaps the most effective technique for regaining the attention of
the audience. Most speakers neglect this powerful idea because the silence is deafening to them;
however, the pause is welcomed by the audience. Try it and you'll see all eyes looking back at you
for your next statement.
Save handouts until after your presentation. If you give people materials at the beginning of your talk,
they'll read instead of pay attention to you.
Throw in some rhetorical questions, like, "What would you think if...?" This usually forces people to
respond mentally, hence keeping them on track with you.
SPEAKER'S KIT
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SPEAKER'S TIPS
TIPS FOR EFFECTIVE PRESENTATIONS
Here are some tips to make your presentation more effective—regardless of whether you are
meeting with 5 parents or TOO community group members.
Persuade your audience. Remember your primary goal in most instances is to alert your listeners
to the problem and motivate them to take action, support legislation, and/or get involved at the
community level.
Use statistics sparingly. Round off numbers, making them easier to understand. For example, use
"close to half" instead of 58.5% or "4 out of 5" instead of 80%.
Make your presentation personal. Use examples and anecdotes from your own experience to
illustrate the facts that you present. People are more persuaded by experience than statistics.
Present a local or statewide perspective if possible. A problem that hits close to home is more
compelling than one miles away.
Answer questions briefly and concisely. You do not have to know everything about this issue to make
an effective presentation. If you do not know the answer to a question, offer to find the answer
and get back to the questioner.
Show sensitivity to the interests of your listeners. When preparing for a presentation, think about
how the particular audience will respond to what you are saying, based on their own priorities.
If you show sensitivity to the interests of your listeners, you are much more effective than if you
speak only from your perspective as a pediatrician. Community groups will have many parents
and grandparents in the audience. They will want to know how this affects or could affect them
personally, if it directly affects their family or anyone else they know, and then they will focus on
how it affects their community. Representatives from the business community will focus on the
bottom line for their company and employees.
Encourage your audience to become active on the issue. Urge them to inform others and take positive
action to address the problem.
SPEAKER'S KIT
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Origins of Asthma:
Environmental Factors
Copyright © 2003 American Academy of Pediatrics
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Overview
* Pathophysiology of asthma
- Inflammation
- Airway remodeling
* Epidemiology of asthma in childhood
* Environmental factors and the increase
in childhood asthma
- Allergen exposure
- Pollution
- Infections
- Microbial exposure
Copyright © 2003 American Academy of Pediatrics
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Pathogenesis of Allergy and Asthma
Rhinitis
Copyright ©2003 American Academy of Pediatrics
Environment
• Allergens
• Infections
• Microbes
• Pollution
Allergic inflammation
Asthma
Most cases of asthma begin in
childhood. A number of genetic
factors have been identified,
particularly those associated with the
regulation of immune responses. There
are data suggesting that overproduction
of TH2 cytokines may be important in
asthma pathogenesis and that this may
be regulated in part by genetics. It is
also likely that lung-specific factors will
be identified. Environmental factors also
influence the development of allergies
and asthma. These include exposure
to allergens, infections, microbes, and
pollution. Age may be a third critical
factor and several studies have identified
infancy as an important period for lung
development and for environmental
exposures to affect the development of
the immune system. The net result of
these 3 factors can be the development
of allergic inflammation. In some children
this manifests as allergic rhinitis, while
others go on to develop asthma.
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Pathogenesis of Allergic Inflammation
TH cells
Sensitized
Mast Ceil
III
Copyright ©2003 American Academy of Pediatrics
Eosinophils
Allergens are proteins that interact
with antigen-presenting cells (ARC).
Once presented to naive T cells,
these cells then differentiate into either
TH1 cells, which secrete interferon gamma,
orTH2 cells, which can secrete cytokines
such as IL-4, IL-13, and IL-5. IL-4 and IL-
13 are both factors that cause isotype
switching in B cells for the production
of IgE, which ultimately can sensitize
mast cells. On the other hand, IL-5 is
a potent growth and differention factor
for eosinophils.
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Airway Morphology In Asthma
Goblet cell
hyperplasia
Increased
permeability/
microvascular
leakage
Mucus
Collagen
deposition
Adapted from tutorial Asthma Etesian an<3 Prevention Program Expert P&mffte&ort &t
Asfam Bethes^,MD Natiomi fn^a^ss^f Wealth; 1981
Copyright © 2003 American Academy of Pediatrics
Epithelial
damage
Increased
smooth
muscle mass
Inflammatory
cell
infiltration
Angiogenesis
fce Dtagnm®
The net result of airway inflammation
is the production of changes in
airway morphology in asthma that
lead to airway obstruction. Changes
that have been seen in association
with airway inflammation include goblet
cell hyperplasia, increased vascular
permeability, mucus production, collagen
deposition, damage to the epithelium,
increased smooth muscle mass, and
the production of new blood vessels
within the airway wall. These features
contribute to airway obstruction and also
to airway hyperresponsiveness, which is
defined as an increase in the sensitivity of
airways to bronchoconstriction in response
to inhaled irritants.
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Airway Inflammation and
Remodeling in Asthma
Epithelial Cell
Denudation
Fibrosis
Inflammatory
mediators
-»v Goblet C«U
*» i Hyperplasa
Matrix
Metalloproteinases
Thickened Laminar
Reticularis
Myofibroblast
Smooth muscle >:>-.""; -,
hypertrophy and ^ ci.'^ -
hyperplasia
Copyright © 2003 American Academy of Pediatrics
A relatively new concept in the
pathophysiology of asthma is that
of airway remodeling. Remodeling
is a process in which chronic airway
inflammation causes structural changes
in the airway. These include damage to
the epithelial cells and replacement of
some epithelial cells with goblet cells that
secrete mucus. These changes appear to
be driven by inflammatory cell activation
in the airway. In addition to causing
changes in the epithelial layer, airway
remodeling is associated with proliferation
of myofibroblasts, which can change the
composition of matrix proteins through
the release of proteases and by inducing
increased synthesis of collagen. In addition,
over time, smooth muscle hypertrophy and
hyperplasia can occur.
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Epidemiology of Asthma
• f incidence
• Global distribution
* Associations with environmental factors
Copyright © 2003 American Academy of Pediatrics
In the remainder of the talk, we will
review the epidemiology of asthma
including the rise in asthma incidence,
the global distribution, and, in particular,
associations with specific environmental
factors.
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Asthma Prevalence in Children, 1980-1996, United States
o
o
o
Q>
re
01
redesign of the National Health Interview Survey—United States MMWft Moth Manai Wkiy Rep 2000:49:909-911
Copyright ©2003 American Academy of Pediatrics
It has been recognized that for many
years the prevalence of asthma has
increased in children in the United
States and many other western countries.
These data from a recent MMWR report
suggest that asthma prevalence in US
children has steadily increased through
at least 1996. The methods for the
reporting of asthma prevalence were
changed at that time, making historical
comparisons more difficult.
According to the latest data from the
National Health Interview Survey (2001),
12.6% of children 0 to 17 years of age
(9.2 million) reported that they had had
a diagnosis of asthma made by a health
professional at some time in their lives.
Eight-point-seven percent of children
(6.3 million) of the same ages reported
that they still had asthma. This contrasts
to 6.9% of adults. The rate of current
asthma prevalence was 9.9% for boys
and 7.4% for girls, a difference of 30%.
About two thirds of the children with
current asthma had at least one asthma
attack in the year prior to the survey,
which serves as a crude indicator for
uncontrolled asthma.
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ISAAC Survey: 13- and
14-year-olds
Wheezing in the Past 12 Mo
" «*'..
Figure reprinted with permission from European Respiratory Society Journals Ltd (Ear Respir J. 1998, 12:315-335]
Copyright ©2003 American Academy of Pediatrics
As part of a global study of respiratory
health called the ISAAC study,
wheezing in 13- and 14-year-old
school children during the past 12 months
was ascertained by a carefully standardized
survey. It showed a wide range in the
prevalence of wheezing in different
countries around the world. The highest
rates of wheezing have been found
in westernized countries such as the
United Kingdom, United States, Australia,
and New Zealand. Notably, in many
underdeveloped countries such as China
and Eastern Europe, the frequency of
wheezing is much lower. These findings
strongly suggest that wheezing and
asthma in children are driven by local
environmental factors, and high rates
of asthma in westernized countries may
be related to lifestyle.
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Association of Allergy
With a Western Lifestyle
* Uneven global distribution
- Most prevalent in Western Europe, United
States, Australia, New Zealand
* Immigrant studies: f incidence in
- Pacific islanders who move to Australia
- Indians who move to the United Kingdom
* German reunification
- Increased Incidence of asthma in the former
East Germany
Copyright ©2003 American Academy of Pediatrics
This association of allergy with a
western lifestyle is also suggested
by several other types of studies.
In particular, emigrants who have moved
from pacific islands to Australia, as well as
individuals from the Indian subcontinent
who moved to the United Kingdom, have
noted a dramatic increase in the prevalence
of allergic diseases and asthma. A similar
phenomenon has been noted in the former
East Germany since reunification occurred.
There was an immediate increase in
the prevalence of allergies in children
followed by an increase in asthma several
years later.
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What caused the recent
epidemic of allergic
diseases and asthma?
• Pollution
• f Allergen exposure
* Changes in exposure to childhood
i 11 nesses/pathogens
• Changes in exposure to microbes
- Endotoxin or LPS
Copyright ©2003 American Academy of Pediatrics
This raises questions about what
specific environmental influences
have led to increases in allergic
diseases and asthma. Some of the
factors that have been evaluated include
pollution, allergen exposure, changes
in exposure to childhood illnesses and
pathogens, and changes in exposure to
microbes or microbial products such as
endotoxin or lipopolysaccharides (LPS)
in the environment.
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Asthma: East vs West Germany
* Schoolchildren (ages 9-11) in East
(n=2,623) & West {n=5,030) Germany
-Munich
-Halle: high-sulfur coal
* Questionnaire
* Skin tests
* Cold air challenge
Copyright @ 2003 American Academy of Pediatrics
Again referring to data from Germany
before and after reunification, a
large study was conducted involving
school children in East and West Germany.
Notably, rates of pollution were much
higher in the East German city (Halle),
where there was common use of a
high-sulfur coal to provide heat, compared
with the west German city, Munich. The
incidence of allergies and asthma were
ascertained by questionnaire, and skin
tests and cold air challenges were also
performed to objectively confirm the
diagnosis of allergies and/or asthma.
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Asthma in Germany: Results
West
East
Atopy
Asthma
36.7%
5.9%
18.2%
3.9%
After controlling for sensitization to dust mites, cats,
and pollen, the differences in asthma prevalence were
not significant.
Copyright © 2003 American Academy of Pediatrics
The results showed a fairly dramatic
difference in the prevalence of
atopy in asthma between East and
West Germany. In both cases, atopy and
asthma were more common in West
Germany; this is despite the highly polluted
environment in East Germany. This has
raised some doubts about the role of
outdoor air pollution on the prevalence of
asthma; however, the major pollutant in the
comparator city in East Germany was sulfur
dioxide. There are indications that other
types of pollutants, such as diesel exhaust
particles, may play a role in promoting
allergic sensitization and asthma.
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Outdoor Pollutants Implicated
In Asthma
• Ozone
- Pulmonary function test decrements in
healthy subjects
- Exacerbation of asthma
- Increased nonspecific and specific AHR
- Long-term exposure assoctated with adult-
onset asthma
* Particulate matter
- Decreased growth of lung function
Copyright © 2003 American Academy of Pediatrics
Nonetheless, there is concern about
the effects of outdoor air pollutants
on asthma. Acute exposure to
ozone has been associated with a decline
in forced vital capacity (FVC) and forced
expiratory volume in 1 second (FE\A) in
healthy volunteers, increased neutrophilic
inflammation, increase in nonspecific
airway hyperresponsiveness (AHR),
and increase in responsiveness to mite
challenge in patients sensitized to dust
mites. Findings concerning lung function
growth in children and ozone have been
mixed. One study did not find a correlation,
whereas a recently published large cohort
study in southern California noted an
association between peak flow growth
and ozone pollution. This same group
found significant correlations between
lung function growth and acid aerosols and
particulate matter. The Children's Health
Study from the University of Southern
California (USC) noted an increase in the
development of asthma in a subgroup of
young children involved in heavy exercise
in communities with high ozone.
A prospective cohort study of 3,000
nonsmoking adults found that the ambient
ozone concentration averaged over a
20-year period was associated with doctor
diagnoses of adult-onset asthma.
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Outdoor Pollutants
Implicated in Asthma
Sulfur dioxide
-Potent bronchoconstrictor in people with
asthma
Diesel exhaust particles
- Increased TH2 response
- Increased IgE
Copyright © 2003 American Academy of Pediatrics
Most people with asthma are very
sensitive to the bronchospastic
effects of ambient levels of
sulfur dioxide.
Diesel exhaust particles have been found
to increase IgE production locally and
increase the TH2 response, following
challenge. Epidemiologic data show
an increase in the diagnosis of asthma
associated with the distance one lives
from a major roadway.
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Indoor Air Pollution: Biological
* Furry animals
-Cats
-Dogs
- Rodents
- Horses
- Birds
* Cockroaches
* Oust mites
* Endotoxins
Copyright ©2003 American Academy of Pediatrics
Fungi or molds
Houseplants
Pollen
Infectious agents
- Rhinovirus
-RSV
- Chlamydia
- Mycoplasma
In the late 1990s, the Environmental
Protection Agency (EPA) sought the
guidance of the Institute of Medicine
(IOM) in evaluating the quality and nature
of the scientific data relating constituents
of indoor air and the occurrence or
exacerbation of asthma.
This slide lists the biological exposures
evaluated by the IOM.
RSV=respiratory syncytial virus
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Indoor Air Pollution: Chemical
NO2, NOX (nitrogen
oxides)
Ozone
Pesticides
Particulate matter
SO2(SOX (sulfur
oxides)
ETS
Plasticizers
Volatile organic
compounds
Formaldehyde
Fragrances
Copyright ©2003 American Academy of Pediatrics
T
his slide lists the indoor chemical
exposures evaluated by the IOM.
ETS=environmental tobacco smoke
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Tobacco Smoking and Asthma
Smoking during pregnancy
- Low birth weight -» wheeze in infancy
- independent effect to promote asthma
Postnatal smoke exposure
- Probably not much effect on incident asthma
- Strong effect on asthma disease activity
Copyright © 2003 American Academy of Pediatrics
There has been a great deal of
research investigating the indoor
environment and what effect it may
have on asthma incidence and prevalence.
In particular, tobacco smoking can have
several harmful effects that can lead
to increased risk of asthma. Smoking
during pregnancy has been associated
with low birth weight, and this is a risk
factor for wheezing in infancy. Tobacco
smoke exposure in the perinatal period
also promotes asthma through a second
mechanism, independent of effects on
birth weight. Details of this mechanism
remain to be elucidated. Postnatal smoke
exposure probably does not have much
effect on asthma incidence, but it does
provoke acute attacks of asthma in
affected individuals.
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Indoor Chemical Pollutants and Asthma
Development of asthma
- No adequate evidence other than ETS
(pre-school-aged children)
Exacerbation of asthma
-Sufficient evidence of an association: NO2
- Limited evidence: formaldehyde, fragrances
- Inadequate evidence: pesticides, plasticizers,
volatile organic compounds
Copyright © 2003 American Academy of Pediatrics
The Institute of Medicine (IOM) report
could not find sufficient evidence of
a causal relationship between any of
several indoor chemical pollutants and the
development of asthma, with the exception
of Environmental Tobacco Smoke (ETS) in
infants. There was sufficient evidence of
an association between exposure to N02
and NOX and exacerbations of asthma.
There was only limited or suggestive
evidence that formaldehyde, fragrances
and ETS (school-aged children and adults)
were associated with exacerbations.
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What caused the recent
epidemic of allergic
diseases?
* Pollution
* f Allergen exposure
• Changes in exposure to childhood
illnesses/pathogens
• Changes in exposure to microbes
-Gut flora
- Endotoxin or LPS
:
Copyright ©2003 American Academy of Pediatrics
N
ext, we will evaluate the role of
allergen exposure on the recent
epidemic of allergies and asthma.
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Allergen Exposure and
Increased Allergy/Asthma
* Asthma is strongly associated with sensitization
to indoor allergens.
-House dust mite
- Cockroach
-Cat
* There is no convincing evidence that allergen
exposure has increased over the past 30 y.
* Time indoors has increased,
Copyright ©2003 American Academy of Pediatrics
There is no doubt that asthma is
strongly associated with sensitization
to indoor allergens such as house
dust mite, cockroach and cat; however,
there is no convincing evidence that
allergen exposure has increased over
the past 30 years. However, children
are spending more time indoors and
may be increasing exposure to allergens
in that way.
Exposure to these same allergens, with the
exception of cat, has been associated with
sensitization. It has been more difficult,
however, to directly link exposure to the
development of asthma. In its report,
the Institute of Medicine (IOM) did find
sufficient evidence of a causal relationship
between dust mites and the development
of asthma.
Several recent studies have indicated
that the presence of cats or dogs in
the environment may protect against
sensitization in the child who has not yet
developed sensitization.
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Cockroaches and Inner-city Asthma
Increased risk of sensitization.
Sensitized and exposed to
cockroach.
- Doctor-diagnosed asthma in
preschoolers.
- Increased asthma disease
activity.
Eradication from multifamily
housing is problematic.
Copyright © 2003 Ameri can Academy of Pediatrics
The morbidity associated with asthma
in the United States is greatest in
inner cities. In these environments
cockroaches have been strongly implicated
in asthma pathogenesis. In particular,
individuals who are both sensitized
and exposed to cockroaches have had
a documented increase in asthma at
preschool age and also have increased
asthma disease activity. Children sensitized
and exposed to high allergen levels had 3.4
times the incidence of hospitalization for
asthma and a 78% increase in unscheduled
office visits in the Inner City Asthma Study.
Unfortunately, eradication of cockroaches
from multifamily housing is problematic,
although there are continuing efforts to
apply new technologies to this problem.
High levels of cockroach allergen have
been found in school dust as well.
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What caused the recent
epidemic of allergic
diseases?
• Pollution
* f Allergen exposure
• Changes in exposure to childhood
ill nesses/pathogens
• Changes in exposure to microbes
- Gut flora
- Endotoxin or LPS
Copyright ©2003 American Academy of Pediatrics
Next, we will evaluate changes in
exposure to childhood illnesses and
pathogens and the possible effects
on allergies and asthma.
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Relationships Between Viral
Infections and Asthma
Healthy infant
R$V
PIV
Wheezing Illness
\Atopy
\
Resolution
Child or adult
with asthma
Rhinovirus
infections
J
Exacerbation of asthma
* Hospitalization
Asthma • Emergency room visits
Copyright © 2003 American Academy of Pediatrics
Viral infections can affect asthma in
several different ways. First of all,
in healthy infants viruses such as
RSV and parainfluenza (PIV) can cause
acute wheezing illnesses. In most infants
these resolve with no sequelae related
to lung health. However, in a subset of
individuals chronic asthma can develop
later in childhood. Atopy appears to be
a risk factor for the progression of recurrent
wheezing in infancy and childhood asthma.
There are data to suggest that the number
and type of infections that are acquired
in infancy may affect the risk of
developing other atopic disorders;
this evidence will be reviewed in the
next few slides. Finally, viral infections
can affect asthma disease activity in
children or adults with established asthma.
The viruses most commonly implicated
are common cold viruses such as
rhinovirus. In individuals with asthma,
rhinovirus infections can cause
exacerbations of asthma leading
to hospitalization or use of emergency
room facilities.
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RSV LRl and Subsequent Wheezing'
• 888 children
• Physician
diagnoses LRl
• Virology: RSV (207)
•RSV group age 11
* f wheeze
• More likely to
respond to p-
agonist
Figure reprinted with permission
from Elsevier (Tfce Lancet. 1999;354:S41-545)
Copyright ©2003 American Academy of Pediatrics
"Adjusted odds ratios.
It has been recognized for many years
that RSV lower respiratory infections
(LRIs) can produce wheezing in infancy
and, in many ways, these wheezing
illnesses resemble asthma. Recently,
RSV has been implicated as a possible
risk factor for asthma later in childhood.
In the Tucson Childrens' Respiratory
Study, lower respiratory infections with
RSV were documented in 207 infants.
By age 11 the group of children who
had an RSV LRl had an increase in the
frequency of wheezing, reductions in
FEVi, and were more likely to respond
to beta-agonists. This relationship was
no longer present by age 13, suggesting
that the effect of viral infection in infancy
may wane with time and that other factors
may be more important in determining
asthma later in childhood.
The diamonds represent children without
documented RSV infection; the circles,
children with RSV. Note that the 2 groups
converge at age 10.
RSV=respiratory syncial virus
FEV^forced expiratory volume in 1 second
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Can some viral infections protect
against allergies and asthma?
Copyright ® 2003 American Academy of Pediatrics
In contrast to the effects of severe RSV
infection, there have been a number
of recent studies that suggest that
some viral infections may protect against
allergies and asthma.
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Hay Fever and Household Size
> 17,414 British children born in March 1958 (National
Child Development Study)
• Self-reported hay fever during the past 12 mo at age 23 y
Adjusted Prevalence (%)
Number of older children in household (under 211 at age 11 v
01 234
20.4 15.7 11,6 9.6
Stralchan DP. Hay (ever, hygiene, and household size. BMJ. 1989;299:1259-1260
Copyright © 2003 American Academy of Pediatrics
6.5
This idea has grown out of
observations that were originally
made by David Strachan and
colleagues in a large study involving
more than 17,000 children in Great Britain.
In this study, self-reported hay fever during
the past 12 months was ascertained at age
23 and was compared to the number of
older children in the household at age 11.
There was a striking inverse relationship
between the number of children in the
household and the risk of hay fever in
these young adults.
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The Hygiene Hypothesis
Child care
Older siblings
Many infections
(TH1 stimuli)
Birth
V
> Allergen
exposure
Only child
Few infections
V
Healthy
Copyright © 2003 American Academy of Pediatrics
Still
Allergies
Asthma
This led to the hygiene hypothesis,
which suggests that some of the
increase in allergies and asthma may
be caused by an overly hygienic lifestyle.
According to this hypothesis, the immune
system is skewed toward TH2 responses
at birth and this immature immune system
requires continued stimulation during
infancy to develop TH1 responses and a
balanced immune system. Infections that
are acquired in child care or from older
siblings may help this development to
occur. In contrast, children who grow up
with few infections retain an immature
immune system. As a result, when
allergen exposure occurs these children
are at greater risk for developing allergies
and asthma. Several studies have been
conducted to test this hypothesis.
-------
Viral Infections in Infancy and the
Subsequent Risk of Allergies and Asthma
RSV
f Asthma
Hepatitis A
I Allergies
| Asthma
Copyright ©2003 American Academy of Pediatrics
Different viruses
may have different
effects.
-Virus-specific
immune
modulation
- Route of
infection
The net result of these studies is that
if single infections are considered,
it is evident that different viruses
may have different effects on allergies
and asthma. As reviewed previously, RSV
infection is associated with an increased
risk of asthma in childhood. Whether this
virus is associated with greater allergen
sensitization is controversial. In contrast,
hepatitis A infections during childhood
have been associated with reduced
allergies and asthma, both in Europe and
in studies performed in the United States.
The effects of these different viruses may
have to do with factors that are specific
to the particular virus or route of infection.
It is possible that severe LRIs at an early
age, such as those that can be produced by
RSV infection, may affect the development
and/or growth of the lungs.
-------
Orofecal vs Airborne Microbes
in Relation to Atopy and Asthma
Italian military recruits
- Case control, 240 per group
Serologic diagnosis of enteric pathogens vs
airborne viruses
Allergy evaluation
-Skin tests, allergen specific and total IgE
- Diagnosis of allergic asthma or rhinitis
Copyright © 2003 American Academy of Pediatrics
Data from Matricardi and colleagues
also suggest that the route of
infection is important in determining
the effects of viral infections on allergies
and asthma. This group studied Italian
military recruits in a case-control study
and used serologic methods to diagnose
enteric pathogens versus airborne viruses.
Allergies were evaluated through skin
tests, allergen-specific and total IgE, as
well as physician diagnose of allergic
rhinitis or asthma.
-------
Orofecal vs
Airborne
Microbes in
Relation to
Atopy
Orofecal
Respiratory
Figure reprinted with permission from
BMJ Publishing Croup (BMJ. 2000:
320:412-417)
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1 *? 1
fri*« 91 mpasttM ts TgontSi.
Hpyt&t ,*rf tefWWS 4 v»ii$
345
emmifis. mtmu.
anil herpi
Copyright © 2003 American Academy of Pediatrics
In these studies the odds ratio (OR)
for developing atopic diseases was
inversely related to the number of
infections that were acquired via the
orofecal route. In contrast, respiratory
infections were not associated with
protection from atopic disease.
-------
Cases {%) of Asthma* According to
Exposure to Orofecal Microbes
Index of Exposure to
Orofecal/Foodborne Pathogens
0
n=796
38
(4.8%)
1
n=618
21 (3.4%)
2 or 3
n=245
1 (0.4%)
(P< 0.002)
'Asthma not related to exposure to airborne viruses.
Figure reprinted with permission from BMJ Publishing Group
(BMJ. 2000; 320:412417)
Copyright © 2003 American Academy of Pediatrics
In this study the effects on asthma
were also evaluated. Rates of asthma
were significantly lower in individuals
who had developed orofecal or foodborne
infections. In contrast, the number of cases
of asthma was not related to exposure to
airborne viruses.
-------
Effects of Child Care on Infections,
Wheezing, and Asthma
Short term -» More infections with
- Respiratory viruses
• Rhinovirus (UR1)
• RSV (Bronchiolitis)
- Enteric viruses
- Bacterial infections (otitis media)
Copyright © 2003 American Academy of Pediatrics
Child care centers provide an excellent
opportunity to evaluate the effects
of recurrent infections on wheezing
and asthma. There is no doubt that in
the short term, children who attend
child care centers in infancy have more
infections with respiratory viruses such
as rhinovirus or RSV as well as enteric
viruses and bacterial infections of the
upper respiratory tract.
URI=upper respiratory infection
-------
Child Care and Risk of Asthma
1,035 children in Tucson Respiratory Study
Age 6: questionnaire for child care
Pediatrician diagnosis of asthma
at 6,8,11,13 y
Early child care:
Age at
Entry Into
Child Care
Relative
Risk
P value
asthma
>12 mo 1.0
7-12 mo 0.9
0-6 mo 0.4
Copyright © 2003 American Academy of Pediatrics
Copyright 92000 M.S««chu»«Hs Mmtail Socirty
AH rjgUti rescrvid. Adapted wfth pwm teflon from
MMBtchusMti M«dic«l Socwty (N Ei«f J Mm.
2000:313:538-5«)
.88
.03
The effect of child care on the risk of
asthma has been evaluated in the
Tucson Childrens' Respiratory Study.
In these studies child care attendance
was evaluated by questionnaire at age
6 years. This was compared to doctor-
diagnosed asthma at the ages of 6, 8, 11,
and 13 years. These studies indicate that
early entry into child care is associated
with a reduced risk of asthma throughout
childhood. The same relationship did not
occur if infants were exposed to child
care centers after the age of 7 months.
This suggests that there may be a critical
time during immune system development
during which infections may protect
against the development of asthma.
-------
Health Effects of Child Care
0-2 yr
1 Infections
•LRI
• RSV bronchiolitis
* URI, sinusitis
* Otitis media
• PE tubes
* Adenoidectomy
• Gastroenteritis
Copyright © 2003 American Academy of Pediatrics
3 yr-school age
Recurrent
wheezing
7 y and older
4 Asthma
This slide sums up effects of child
care on respiratory health throughout
childhood. There is no doubt that
attendance at child care centers in infancy
leads to an increase in the number of
infections and can have adverse health
effects such as recurrent otitis media,
the need for PE tubes, or adenoidnectomy.
In the preschool years child care
attendance is also associated with
recurrent wheezing. However, at 7 years
and older there appears to be a beneficial
effect in that the prevalence of asthma
is lower. What particular types of infections
or exposures associated with child care
lead to this protective effect have not yet
been determined.
LRI=lower respiratory infections
RSV=respiratory syncial virus
URI=upper respiratory infection
-------
What caused the recent
epidemic of allergic
diseases?
• Pollution
* f Allergen exposure
* Changes in exposure to childhood
illnesses/pathogens
* Changes in exposure to microbes
- Endotoxin or LPS
Copyright ® 2003 American Academy of Pediatrics
Finally, we will evaluate the relationship
of changes in exposure to microbes
to the recent epidemic of allergic
diseases and asthma.
-------
The Updated Hygiene Hypothesis
Birth
Child care
Older siblings
Animals
Microbes
Allergen
exposure
Only child
few infections
infections
Tolerance
Healthy
Copyright © 2003 American Academy of Pediatrics
Stiff TH2
Allergies
Asthma
Recently, the original hygiene
hypothesis has been updated to
include several new concepts.
First, in epidemiologic studies there
has been an inverse relationship noted
between contact with animals and/or
microbial exposure and the risk of
developing allergies and asthma. Secondly,
the hygiene hypothesis now includes
the concept of tolerance. While allergen
exposure that produces a TH2 response
has been associated with allergies and
asthma, allergen tolerance means that
the immune system does not react to
the allergen at all. Production of tolerance
may have to do with what types of signals
are delivered to T cells and what sorts of
cytokines (eg, IL-10) are synthesized in
response to allergens.
-------
Rural Lifestyle and
Reduced Allergy and Asthma
• 9,082 school children ages 12-19 y
» Survey:
- 802 children raised on a farm
- 397 nonfarming controls
* Allergy/asthma evaluation
- Skin tests
- Spirometry
- Methacholine reactivity
Copyright ©2003 American Academy of Pediatrics
Several studies have provided
evidence of a link between a rural
lifestyle and reduced allergies
and asthma. In this study, published
by Ernst and colleagues, more than
9,000 school children between the ages
of 12 and 19 responded to a survey about
whether they were raised on a farm.
Allergy and asthma evaluations were
performed, including skin tests, spirometry,
and methacholine reactivity.
-------
Rural Lifestyle and
Reduced Allergy and Asthma
Outcomes
OR Adjusted*
Wheeze
AHR
Asthma
+ Skin tests
0.72 (0,56-0,99)
0.80 (0.56-0.87)
0.71 (0.37-0.98)
0.62 (0.48-0.80)
* Adjusted for gender, current smoking,
and number of siblings.
Copyright © 2003 American Academy of Pediatrics
In these studies a rural lifestyle
was associated with significantly
lower rates of wheeze, airway
hyperresponsiveness, asthma, and positive
skin tests. These relationships persisted
after the odds ratio (OR) was adjusted for
gender, current smoking, and the number
of siblings.
-------
Rural Lifestyle: Potential
Protective Factors
Contact with animals
-Stable
-Pigs
— Cats and dogs
Exposure to high levels of endotoxin (LPS)
Consumption of fermented beverages
Copyright © 2003 American Academy of Pediatrics
Additional studies have been
performed suggesting that contact
with animals may be a key factor
associated with a rural lifestyle for
protection against allergies and asthma.
These studies have been bolstered
by recent findings that household pet
exposure in infancy may also provide
a protective effect. Both of these
exposures have been linked to high
levels of endotoxin within the household.
In addition, consumption of fermented
beverages, which provides another
type of exposure to microbes in the
environment, may also protect against
allergies and asthma.
Endotoxin is another term for LPS
(lipopolysaccharide), which is a component
of the cell wall of gram-negative
organisms. This is an immune stimulant
felt to encourage the development of
the TH1 immune response.
-------
Endotoxin
Levels in
Various
Homes
«.
4
Figure Copyright >§2000
American Medical Association.
All rights reserved. (JAMA. 2000: 284:1652-1653)
Copyright © 2003 American Academy of Pediatrics
Recently, endotoxin levels have been
determined in various household
settings. In suburban homes in
Denver, Co, endotoxin levels are quite
low; however, progressive increases in
endotoxin were found in farm homes in
the United States, rural homes in India and
Peru, and barns in the United States. These
levels seem to show an inverse correlation
with the prevalence of asthma in urban
versus rural environments as reported in
other studies. Data from European cross-
sectional studies linked contact with
livestock and poultry, specifically in stables
or barns, with a decreased incidence of
allergic disease.
-------
Endotoxin
and Allergy
Skin-Test
Results
Figure reprinted with permission from
Elsevier (The Lancet. 2000:355:1680-1683)
Copyright © 2D03 American Academy of Pediatrics
Moreover, environmental endotoxin
levels appear to be inversely
related to the risk of developing
positive skin-test results. These data by
Gereda and colleagues compare endotoxin
levels in the homes of skin-test positive
and skin-test negative individuals.
-------
Summary: Infections,
Allergies, and Asthma
Effects of viral infections on asthma
- Timing (age)
- Type of infection (enteric vs
pneumonitis)
RSV infections—distinct sequelae
- Reduced lung function
- Severe infections -» asthma
Microbial products
- Effects may depend on time and
quantity of exposure
Copyright © 2003 American Academy of Pediatrics
In summary, certain infections in infancy
may have effects on the subsequent
development of allergies and asthma.
These effects may be dependent on the
age of exposure and type of infection.
Severe LRIs may predispose toward
asthma in childhood. Respiratory syncytial
virus (RSV) appears to be the most likely
virus to cause these effects. In contrast,
exposure to microbes in the environment
may provide a protective effect against
the development of allergies and asthma.
These effects may also depend on time
as well as the quantity of exposure.
-------
What caused the recent
epidemic of allergies and
asthma?
• Pollution
* t Allergen exposure
* Changes in exposure to childhood
illnesses/pathogens
* Changes in exposure to microbes
-Gut flora
- Endotoxin or LPS
Copyright © 2003 American Academy of Pediatrics
This brings us back to the central
question: what caused the recent
epidemic of allergies and asthma?
During this lecture, we have looked at
studies that have separately evaluated
the potential effects of pollution, allergen
exposure, childhood infections, and
exposure to microbes.
-------
Understanding the
increases in Asthma
Animals
Copyright © 2003 American Academy of Pediatrics
In future studies it will be important
to study the potential interactions
between these factors to determine
which combinations of factors and
interactions between environmental
exposures are key to the development of
asthma. It is likely that there are distinct
sets of environmental factors that are
responsible for the high prevalence of
asthma in different geographic locations
(eg, US inner cities versus New Zealand).
-------
-------
Origins of Asthma
What Is Asthma?
Asthma is a chronic disease of the tubes that carry air to the lungs. These airways become
narrow and their linings become swollen, irritated, and inflamed. In patients with asthma,
the airways are always irritated and inflamed, even though symptoms are not always
present. The degree and severity of airway inflammation varies over time.
Children with asthma can have symptoms start or worsen when they are exposed to many indoor
substances such as
• Dust and dust mites
• Cockroaches
• Animals such as cats and dogs
• Molds
• Secondhand cigarette smoke
Children with asthma may also be sensitive to colds and other viral infections, cold air, and
particles or chemicals in the air. Ongoing exposures to these substances will not only worsen
asthma symptoms, but also continue to aggravate airway inflammation.
Inflammation of the airways causes them to be oversensitive and "twitchy," often called
"hyperreactive." When the airways are hyperreactive, they can go into spasms, causing blockage
and symptoms of wheezing, chest tightness, and shortness of breath.
Who Gets Asthma?
Asthma is a common condition in childhood. In the United States, 10% to 15% of children in grade
school have or have had asthma. It can cause a lot of sickness and result in hospital stays and
even death. The number of children with asthma is increasing, and the amount of illness due
to asthma may also be increasing in some parts of the country. The reasons for these increases
are not exactly known; however, outdoor air pollution and increased exposure to allergens are not
likely causes.
Recent studies suggest that how often and how early a child is exposed to certain infections and
animals can influence the development of asthma. For example, children who come from large
families, live with pets, or spend a considerable amount of time in child care in the first year of life
are less likely to develop asthma. This early exposure to common allergens may actually protect
against the development of asthma.
Studies have also shown that a child's exposure to infections early in life can determine whether
he develops allergies or asthma. Some infections seem to decrease the risk of developing asthma,
whereas one infection, respiratory syncytial virus, increases the risk.
-------
How Is Asthma Treated?
Any child who has asthma symptoms more than twice per week should be treated. One of the
most important treatments of asthma is to control the underlying inflammation of the airways.
This can be done with medications or by avoiding environmental factors that cause or aggravate
airway inflammation.
Knowing the causes and triggers for asthma can allow families to reduce or avoid these triggers
and reduce ongoing airway inflammation and hyperreactivity. This can reduce the severity and
frequency of asthma symptoms and, hopefully, the need for as much asthma medication.
American Academy of Pediatrics
DEDICATED TO THE HEALTH OF ALL CHILDREN^
Copyright © 2003
-------
Origins of Asthma
Key Points to Cover With Patients
• Asthma is a common childhood disease with increasing prevalence, morbidity, and mortality.
• Asthma is a chronic inflammatory condition of the airways that causes airway obstruction and
intermittent bronchospasm, leading to the symptoms of wheezing, coughing, and shortness
of breath. This inflammation can sometimes lead to airway remodeling. Treatment of this
inflammation is important in the management of asthma.
• Exposure to allergens such as house dust mite, cockroach, cat, or molds may be responsible for
the development or exacerbation of asthma in sensitized individuals, but it is unlikely that there
has been a significant increase in allergens to account for the increase in prevalence of asthma.
• Outdoor air pollution is unlikely to be the cause of the increase in asthma prevalence because
pollutant levels have declined over the last few decades, and asthma prevalence rates are
higher in more developed areas with cleaner air.
• Indoor air pollution may be important in the increase in asthma, but many factors need to be
studied further. Environmental tobacco smoke, however, is one indoor pollutant that has been
associated with wheezing in infancy and the exacerbation of asthma in children of all ages.
• Recent studies suggest that the frequency of exposure to certain infections and animals early
in life can influence the development of allergies and asthma. Children who come from large
families or who spend considerable time in child care in the first year of life tend to have less
asthma. Children who develop certain infections in early life tend to have recurrent wheezing
later in life. Children who are exposed to animals early in life, such as living on a farm or having
cats or dogs in the house, also tend to have less asthma.
American Academy of Pediatrics |P
DEDICATED TO THE HEALTH OF ALL CHILDREN'"
Copyright © 2003
-------
-------
The Diagnosis of Asthma
in the Pediatric Patient
Copyright © 2003 American Academy of Pediatrics
-------
Outline
• Definition of asthma
* Diagnostic elements of history and physical
examination
* Differential diagnosis
• Associated diseases
• Diagnostic testing
* Testing for associated diseases
• Asthma phenotypes and prognosis
• Summary
Copyright © 2003 American Academy of Pediatrics
The diagnosis of asthma can be
challenging, especially in pediatric
patients. This discussion will cover
the most important considerations in the
diagnosis of asthma including the definition
of asthma, important elements of the
history and physical examination, the
differential diagnosis, the consideration of
associated diseases, diagnostic testing,
and, using information about the history,
physical, and diagnostic testing, asthma
subtypes and prognosis.
-------
Definition of Asthma
A chronic inflammatory disease of the airways
with the following clinical features:
• Episodic and/or chronic symptoms of airway
obstruction.
• Bronchial hyperresponsiveness to triggers.
* Evidence of at least partial reversibility of the
airway obstruction.
* Alternative diagnoses are excluded.
Copyright © 2003 American Academy of Pediatrics
Asthma is defined as a chronic
inflammatory disease of the
airways with
• Episodic and/or chronic symptoms of
airway obstruction (eg, cough, wheeze,
shortness of breath, tachypnea).
• Bronchial hyperresponsiveness to
triggers. Triggers may be specific,
such as airborne allergens in sensitized
patients, (the most common of which
are pets, mold, dust mites, and pollen),
or nonspecific, such as irritants (eg,
cigarette or wood smoke).
• Evidence of at least partial reversibility of
the airway obstruction. This concept will
be expanded later in this presentation,
but is classically defined as a 12%
increase in forced expiratory volume
in 1 second (FEV-,) after bronchodilators
or a course of oral corticosteroids.
The diagnosis of asthma involves fulfilling
these diagnostic criteria and excluding
alternative diagnoses.
-------
Diagnostic Approach to Asthma
Clinical suspicion
Clinical history with focus on symptom patterns
Confirm diagnosis with objective measurement
Copyright © 2003 American Academy of Pediatrics
Most of the rest of this presentation
will focus on the diagnostic
approach to asthma. There are
3 main elements to establishing this
diagnosis: clinical suspicion (if the patient's
initial presentation suggests the possibility
of asthma, suspect asthma), clinical history
(focused largely on symptom patterns), and
confirmation (by objective measurement
and response to treatment).
-------
Consider Asthma
Consider asthma in patients who have repeated diagnoses
of respiratory illnesses such as
* Reactive airway disease
* Bronchitis
* Croup
• Pneumonia
* Bronchiolitis
Always maintain a high index of suspicion for asthma.
Copyright © 2003 American Academy of Pediatrics
Asthma is a common disease in
pediatric patients and it is important
to maintain a high index of suspicion
for this diagnosis. When patients are seen
by a number of different physicians, such
as in a large group practice or in the case
of patients who commonly visit urgent care
centers or emergency rooms, it may be
difficult to "connect the dots." Therefore,
it is very useful to critically review past
physician notes for every health care
encounter. The age of the child might
influence the index of suspicion.
-------
Wheezing—Asthma?
Wheezing with URIs is very common in small children but
* Many of these children will not develop asthma,
• Asthma medications may benefit patients who wheeze
whether or not they have asthma.
All that wheezes is not asthma.
Copyright © 2003 American Academy of Pediatrics
There are important pitfalls in the
diagnosis of asthma. For example,
wheezing with upper respiratory
infections (URIs) is very common in
small children but not all of these children
will develop asthma. On the other hand,
asthma is commonly under-diagnosed
in children and asthma medication may
benefit small children who wheeze
with URIs, whether they eventually
develop asthma. Related observations
are that wheezing does not always mean
asthma and many patients with asthma
do not wheeze.
-------
Cough—Asthma?
Consider asthma in children with
• Recurrent episodes of cough with or without wheezing
* Nocturnal awakening because of cough
• Cough that is associated with exercise/play
Cough may toe the ontf symptom
present in patients with asthma.
Copyright © 2003 American Academy of Pediatrics
The clinical presentation of asthma
may be subtle. Recurrent cough or
nocturnal awakening because of
cough are usually associated with asthma,
even if other typical asthma symptoms,
such as wheeze or shortness of breath,
are not present.
-------
Medical History
• Symptoms
- Frequency and severity of symptoms
- Exacerbating factors
* Medications—frequency and response
* Allergic diseases
• Family history
Copyright © 2003 American Academy of Pediatrics
I
mportant elements of the medical
history include
• Presence of symptoms such as cough,
wheeze, shortness of breath, or chest
tightness
- Frequency of symptoms: less than
weekly, more than twice weekly, daily,
or continuous
- Severity of symptoms, including
nighttime awakening, missed school
and other limitations to activities such
as sports, emergency room visits,
and hospitalizations
- Exacerbating factors for symptoms,
such as exercise, URIs, pets,
and smoke
• Need for and response to medications,
especially short-acting bronchodilators
• Personal history of other atopic disease,
such as atopic dermatitis and allergic
rhinitis
• Family history of asthma or other atopic
disease
-------
Differential Diagnosis
Vocal cord dysfunction
Mechanical airway obstruction
Cystic fibrosis
Upper airway noise or congestion
Congestive heart failure
Copyright © 2003 American Academy of Pediatrics
The differential diagnosis for asthma
in pediatric patients is broad. Some
useful distinguishing features of
common masqueraders are as follows:
• Vocal cord dysfunction—never occurs
during sleep.
• Mechanical airway obstruction, which
includes vascular ring and foreign
body—exacerbation of symptoms during
feeding, abnormal chest x-ray film
may be noted with vascular ring, and
abnormal inspiratory/expiratory chest
x-ray film may be found in foreign body
obstruction.
• Cystic fibrosis—often there are other
clinical features, such as failure to
thrive, clubbing, history of constipation
as an infant, nasal polyps, or frequent
respiratory infections.
• Upper airway noise or congestion—
is usually distinguishable on careful
physical examination by auscultation
of the upper airway.
• Congestive heart failure—tachypnea
and poor perfusion may be noted in
addition to an abnormal cardiovascular
examination.
-------
Differential Diagnosis
• Bronchopulmonary dysplasia
• Croup
• GERD/aspiration
• Habit cough
* Sinusitis
• Pertussis
Copyright © 2003 American Academy of Pediatrics
• Bronchopulmonary dysplasia—history of
prematurity and mechanical ventilation.
• Croup—inspiratory stridor versus (in
asthma) expiratory wheeze, in addition
to barky cough and hoarse voice.
• Gastroesophageal reflux disease
(GERD)/aspiration—relaxation of the
lower esophageal sphincter during
increased respiratory efforts such as
rapid breathing or coughing can lead
to reflux and aspiration. This aspiration
leads to airway injury, an increased effort
to breathe, and further aspiration. Infants
with recurrent aspiration can present
with wheezing.
• Habit cough—Usually presents as a
chronic cough that is loud, often barky,
and very disruptive. The cough does
not increase with exercise or at night;
characteristically, it disappears after
the child falls asleep.
• Sinusitis
• Pertussis—both pertussis and asthma
can cause a paroxysmal cough in young
children, possibly making it difficult to
distinguish between the two. Response
to a short course of prednisone and
bronchodilators might be helpful in
making the distinction.
-------
Objective Evaluation of Asthma
• Physical examination
> Pulmonary function
• Broncnoprovocation
Copyright © 2003 American Academy of Pediatrics
The objective evaluation for asthma
includes the physical examination,
objective monitoring of pulmonary
function (ideally with spirometry initially),
and, in some cases, evaluating the
response to bronchoconstrictive tests
or agents.
-------
Physical Examination
Respiratory examination
* Evidence for obstructive respiratory disease
• May be normal in patients with asthma
General examination
• Evidence for atopic disease
* Absence of clubbing
Copyright © 2003 American Academy of Pediatrics
I
mportant elements of the physical
examination include
Evidence for obstructive respiratory
disease such as wheezing, cough,
dyspneic speech, accessory muscle
use, tachypnea, increased ratio of
expiratory-to-inspiratory times, and
increased anterior-posterior diameter
of the chest wall. Note that the
respiratory examination may be
normal in patients with clinically
significant asthma.
Evidence for atopic disease such as
pale and edematous nasal mucosa,
rhinorrhea, conjunctival injection, and
eczema.
Presence of clubbing suggests other
pulmonary disease such as congestive
heart failure (CHF) or cystic fibrosis.
-------
Spirometry
Abnormal findings indicating airway obstruction
• FEV1 <80% predicted
• FEV^FVC ratio <80%
Spirometry may Jferrorraal in
mild or well-controlled asthma
Copyright © 2003 American Academy of Pediatrics
Spirometry is useful for monitoring
and diagnosing asthma, but is
difficult or impossible to perform
in many children younger than 5 years.
Even though spirometry is more difficult
for young children to perform than
peak flow measurement, it should
be attempted after age 4. Spirometry
is preferred over peak flow measurement
because it yields information about
lung volumes and air flow in a much
more detailed and consistent manner.
Peak flow measurement largely reflects
on large airway function and is much
more vulnerable to artificially high or
low readings.
Typical spirometric findings in asthma
include
• FEV, <80% predicted
• FEVi/FVC ratio <80% predicted
(FEVi - forced expiratory volume in
1 second; FVC = forced vital capacity)
Spirometry may be normal in patients
with mild asthma or those with well-
controlled asthma, just as the physical
examination may be normal. In such cases,
the diagnosis is made tentatively based
on the history of symptoms and response
to therapy. In essence, the diagnosis is
only confirmed with objective evidence
of reversible airway obstruction, either as
clearing of wheezing or improvement in
spirometry following treatment.
-------
Peak Flow Measurement
More useful for monitoring
Peak flow logs may be helpful
Spirometry is preferred for diagnosis
Copyright © 2003 American Academy of Pediatrics
Peak flow measurement is a more
useful tool for monitoring than for
diagnosing asthma. Peak flow logs
may be useful, however, to establish
asthma diagnosis in some situations
by documenting, for example, large
changes (>20%) with triggers or large
diurnal variations (>20%). Peak flow
variability, however, is more useful
in determining asthma severity, not
in making a diagnosis. Spirometry is
preferred to peak flow monitoring in
the diagnosis and evaluation of asthma
because the data it yields are greater in
descriptiveness and reproducibility and,
therefore, give a better indication of a
patient's true lung function. By age 4,
most patients can be taught to perform
the peak flow maneuver and some may
be able to perform Spirometry. After age
5, most patients can perform spirometry.
-------
Response to Bronchodilators
Findings consistent with asthma include
* 12% or greater increase in FEV1 (all ages)
•exclude asthma.
Copyright © 2003 American Academy of Pediatrics
Spirometry before and after
bronchodilators is very useful in
diagnosing or confirming the clinical
impression of asthma. Findings that are
consistent with an asthma diagnosis
include an increase in FEVi of greater
than 12% (in all ages) or 200 ml (in
older children and adults). Note that
a normal pre-bronchodilator FE\A
does not preclude the presence of
bronchodilator responsiveness (there
may still be a 12% or 200 ml rise), and
the lack of a 12% or 200 ml_ increase
in post-bronchodilator FE\A does not
rule out the presence of asthma.
FE\A = forced expiratory volume in
1 second
-------
Typical Spirometric Curves
Graphs courtesy of the National Institutes of Health.
Copyright © 2003 American Academy of Pediatrics
There are 2 types of spirometry curves
typically used for asthma diagnosis:
the volume-time curve and flow-
volume loop. The figure on the left is a
volume-time curve, which plots volumes
versus time. This curve allows for easy
estimation of the FVC and FEVi. The
figure on the right is a partial flow-volume
loop. The complete loop would also
show an inspirator/ section, to form
a loop. This curve measures flow rates
versus volumes.
These curves are typical for asthma. Note
the post-bronchodilator improvement in
FEV! of greater than 12% and 200 ml.
The concave nature of the downslope of
the flow-volume loop is typical of airway
obstruction.
FVC = forced vital capacity
FEVi = forced expiratory volume in
1 second
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Bronchoprovocation
* Generally not needed
• Reasons to perform
- Diagnostic dilemma
• Vague history
* Poor response to therapy
- Research
• False + and -
Copyright © 2003 American Academy of Pediatrics
Bronchoprovocation refers to
techniques used to evaluate the
degree of airway hyperreactivity
(AHR) in an individual. Airway hyper-
reactivity is a characteristic of asthma
and refers to the tendency for the airways
to react to stimuli in a more rapid and
severe fashion than normal airways.
Bronchoprovocation is usually not
necessary to diagnose asthma, but can
be helpful in patients who present with
a diagnostic dilemma because of a history
that is not characteristic or when response
to therapy has been poor in patients
who have histories suggestive of asthma.
It can be used in clinical practice in some
situations, such as occupational asthma.
Bronchoprovocation is used extensively in
research to document therapeutic effect,
and often in epidemiologic studies.
Not all individuals with increased AHR have
asthma, however. Airway hyperreactivity
can be present in those with a recent viral
respiratory infection, in those with past
asthma, and during the pollen season in
individuals with seasonal rhinitis.
-------
Types of Bronchoprovocation
• Exercise
* Methacholine
• Histamine
• Hypertonic saline
• Allergens
• Cold air
* Adenosine
Copyright © 2003 American Academy of Pediatrics
This slide lists the various techniques
used for bronchoprovocation. Some
of the stimuli used are pharmacologic,
such as histamine and methacholine,
which trigger bronchoconstriction by
direct stimulation of receptors or muscles.
The other stimuli are physiologic, which
work more like natural stimuli, releasing
mediators and indirectly stimulating airway
smooth muscle.
The exercise challenge is one of the most
commonly performed bronchoprovocative
tests. Exercise is a common trigger for
patients with asthma and may, in the case
of exercise-induced asthma, be the only
trigger. It is often used for patients who
have respiratory symptoms exclusively
when they exercise and normal baseline
spirometry.
There is a standardized protocol for all
of these challenges, including exercise.
All of these tests have false positive and
negative results. A normal test result
does not always exclude the diagnosis
of asthma, especially a negative result
from an exercise challenge. The more
one deviates from the standardized
protocol, such as when exercise tests
are performed in the pediatrician's office,
the more likely it is to have false-negative
results from challenges.
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Allergy Testing
Evidence for allergy common in pediatric
patients with asthma
May help guide environmental control
Skin testing (prick with or without intradermal)
the "gold standard"
In vitro (RAST) testing an alternative in some
situations
Copyright © 2003 American Academy of Pediatrics
Because evidence for allergy is found
in up to 85% of pediatric patients
with asthma, allergy testing may
be useful as a part of their evaluation.
If sensitization to allergens can be
demonstrated, asthma may be improved
by control of exposure. In the case of dust-
mite-sensitive patients with asthma, for
example, asthma severity improves with
control of dust mite exposure.
Allergy testing may have prognostic value
in younger children. Young children who
wheeze are more likely to have persistent
disease if they are atopic.
Skin testing (prick with or without
intradermal testing) is the "gold standard"
of allergy testing, but radioallergosorbent
testing (RAST) may be an alternative in
some situations. For example, RAST
may be preferred in patients with severe
dermatitis or who are unable to tolerate
skin testing or refrain from taking
antihistamines. Radioallergosorbent
testing is considered less sensitive than
skin testing. Newer forms of RAST (the
so-called CAP RAST) do provide some
quantitative value, especially in food
testing. The standardization of RAST
can vary significantly from laboratory
to laboratory.
Positive skin-test results also can be
a significant predictive factor for the
diagnosis of asthma in patients with
chronic lower respiratory symptoms.
-------
Asthma and Skin Test Reactions
Copyright S: 1989 Massachusetts Medical Society- At rights reserved.
Figure reprinted with permission from Massachusetts Medical Society. (N EnglJ filed 1389,320:271-277)
Copyright © 2003 American Academy of Pediatrics
This study demonstrates that the odds
ratio for having asthma increases with
the number and strength of positive skin-
test reactions to individual allergens.
The skin-test index represents the sum
of individual graded scores (0-4) for skin
prick responses to 5 different allergens.
Positive skin-test results also can be
a significant predictive factor for the
diagnosis of asthma in patients with
chronic lower respiratory symptoms.
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Other Possibly Useful Tests
• Chest x-ray film and CT
• Sweat chloride
• Sinus CT
• pH probe
• Rhinolaryngoscopy
• Bronchoscopy
Copyright © 2003 American Academy of Pediatrics
Based on the index of suspicion for
other diseases that may mimic
asthma, a number of useful tests
may be obtained. These tests include
radiographic evaluation of the chest and
sinuses, sweat chloride, esophageal pH
probe, and direct airway visualization by
rhinolaryngoscopy and bronchoscopy.
The index of suspicion for other diseases
may increase with a poor response to
asthma medications or the presence
of signs and symptoms not typical for
asthma (eg, clubbing). Some centers,
however, routinely obtain chest x-ray film
and sweat chloride because these tests
are inexpensive, easy to obtain, and may
reveal the presence of unrecognized
diseases such as cystic fibrosis, anatomic
abnormality, or congenital heart disease.
CT = computed tomography
-------
Asthma Phenotypes
Transient early wheezing
Non-atopic wheezing
Atopic wheezing/asthma
Copyright © 2003 American Academy of Pediatrics
The Tucson Children's Respiratory
Study has provided a great deal of
useful information about childhood
asthma and allergic disease. It was
originally established as a long-term,
longitudinal, prospective study of the risk
factors for acute lower respiratory tract
illnesses in early childhood and chronic
obstructive airways disease in later life.
A total of 1,246 newborns were enrolled
into the study between May 1980 and
January 1984. Subjects from the study
have been extensively evaluated. One
important finding of the study is the
identification of several different asthma
phenotypes in pediatric patients: transient
early wheezing, non-atopic wheezing, and
atopic wheezing/asthma.
This study has demonstrated that not all
children who wheeze in early childhood will
develop asthma. Many of the children who
wheeze in the first 3 years of life do not
have the classic asthma inflammation and
may not respond to the same treatments
as children with persistent asthma. These
children usually are no longer wheezing
by age 6. Such phenotypes are not easy
to identify with certainty clinically, and
there may be some overlap. It is important
to remember that children who go on to
develop persistent asthma also start before
age 3 and the outcome may depend on
early recognition and therapy. Because
there are no single markers to differentiate
children who are transient wheezers from
children who are persistent wheezers,
careful follow-up with attention to historical
features and signs of persistent disease
is crucial.
-------
Transient Early Wheezing
Resolves by age 3
Not associated with atopy
Small airways
Risk factors include prematurity, exposure to
siblings, and maternal smoking during pregnancy
Copyright © 2003 American Academy of Pediatrics
Transient early wheezing resolves by
age 3. This phenotype is usually not
associated with evidence for atopy
or family history of allergic disease. The
primary risk factor appears to be reduced
lung function. This reduced lung function
is due to small airway size, rather than
inflammation or increased airway lability.
For example, these children have no
increase in methacholine responsiveness
or peak flow variability at age 11. Risk
factors for this phenotype include
prematurity, exposure to siblings and
children at child care centers, and maternal
smoking during pregnancy.
-------
Non-atopic Wheezing
Associated with lower respiratory infection before
age 3, especially RSV
Increased risk for wheezing until age 13
History of RSV is not associated with atopic disease
Copyright © 2003 American Academy of Pediatrics
The phenotype of children with
non-atopic wheezing is usually
associated with viral infection,
especially respiratory syncytial virus (RSV).
Respiratory syncytial virus lower respiratory
infection before age 3 has been identified
as a risk factor for persistent wheezing for
much of childhood. By age 13, the prior
history of RSV appears to no longer be
a risk factor for wheezing. No relationship
has been demonstrated between RSV
infection and atopy.
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Atopic Wheezing/Asthma
Onset of symptoms before age 3 and the
presence of atopy
Persistent disease
Increased severity of disease and abnormal
pulmonary function growth
Copyright © 2003 American Academy of Pediatrics
More than 50% of ail cases of
persistent asthma begin before
age 3. While most children who
wheeze before age 3 do not develop
persistent asthma, the onset of disease
before age 3 in those who do develop
persistent asthma is associated with a
more severe course. The development
of abnormal pulmonary function can
occur during this age as well, before it
can be measured routinely in the office.
Therefore, it is important to try to identify
those children who will develop persistent
asthma in the preschool years, and perhaps
to begin early therapy.
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Predictive Index for Asthma
• >3 episodes of wheezing in first 3 y and 1 of the
following:
- Physician diagnosis of asthma in a parent
- Physician diagnosis of atopic dermatitis in the child
• OR 2 of the following:
- Physician diagnosis of allergic rhinitis in the child
-Wheezing apart from colds
- Peripheral eosinophilia
Copyright © 2003 American Academy of Pediatrics
Clues to the development of
persistent asthma include a family
history of asthma, atopy in the
child, more than 3 episodes of wheezing,
and wheezing without URI, especially in
children older than 2 years. Predictive
indices have been developed by the Tucson
group; the following index is able to predict
with greater than 75% accuracy which
children who are early wheezers will have
asthma at school age:
• More than 3 episodes of wheezing in the
first 3 years of life combined with 1 of
the following:
- Physician diagnosis of asthma in
a parent
- Physician diagnosis of eczema in
the child
• Or 2 of the following:
- Physician diagnosis of allergic rhinitis in
the child
- Wheezing apart from colds
- Peripheral eosinophilia
URI = upper erspiratory infection
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Classification of Asthma Severity
Intermittent
Symptoms <2x/wk
Nighttime symptoms
<2x/mo
FEV<, or PEF >80%
predicted
PEF variability <20%
Copyright © 2003 American Academy of Pediatrics
Mild Persistent
Symptoms >2x/wk but
<1x/d
Nighttime symptoms
>2x/mo
FEV! or PEF >80%
predicted
PEF variability
20%-30%
It is valuable to classify asthma
according to severity at presentation.
This information may be used to
select appropriate therapy as well as
help predict the course of disease. This
slide describes symptoms and objective
findings in mild persistent and intermittent
asthma. The classification of children
who are unable to perform spirometry or
peak flow measurement is based largely
on symptoms.
It is important to remember that children
can have severe intermittent asthma
exacerbations and be totally symptom
free with normal pulmonary function
between exacerbations. These children
would still fall under the category
"intermittent" as defined by the National
Heart, Lung, and Blood Institute Expert
Panel Report 2: Guidelines for the
Diagnosis and Management of Asthma
and Pediatric Asthma: Promoting Best
Practice—Guide for Managing Asthma
in Children. Children with significant
exacerbations more often than every 6
weeks should be considered for treatment
as persistent asthmatics.
A useful way to identify those children
who have persistent asthma and need
ongoing controller therapy is the Rule
of 2s: wheezing more than 2 times per
week, waking with asthma more than
2 times per month, and using more than
2 rescue inhalers per year.
PEF = peak expiratory flow
-------
Classification of Asthma Severity
Moderate Persistent
• Symptoms daily
• Daily use of
bronchodilators
• Nighttime symptoms
>1x/wk
• FEV1 or PEF >60%
and <80% predicted
• PEF variability >30%
Copyright © 2003 American Academy of Pediatrics
Severe Persistent
Continual symptoms
Frequent nighttime
symptoms
Limited physical
activity
FEV1 or PEF <60%
predicted
PEF variability >30%
This slide describes symptoms and
objective findings in moderate
persistent and severe persisitent
asthma. The classification of children
who are unable to perform spirometry
or peak flow measurement is based largely
on symptoms.
FEV, = forced expiratory volume in
1 second
PEF = peak expiratory flow
-------
Summary—Asthma Diagnosis
in the Pediatric Patient
Asthma is a chronic inflammatory disease leading to
signs and symptoms of obstructive lung disease.
Diagnosis is based on history, examination, and testing.
Alternative diagnoses need to be considered.
Lung function testing is and allergy testing can be
important in the evaluation of pediatric asthma.
Classifying asthma is useful in treatment and prognosis.
Copyright © 2003 American Academy of Pediatrics
The diagnosis of asthma in pediatric
patients can be challenging,
especially in very young patients.
In considering whether a patient has
asthma, it is important to remember
that asthma is a chronic inflammatory
disease leading to signs and symptoms
of obstructive lung disease. The search
for supportive features in the history,
examination, and testing follow from this
understanding of the pathophysiology of
asthma. It is also important to consider
alternative diagnoses that, in some cases,
need to be excluded. In addition, because
atopy is so clearly linked with asthma in
many pediatric patients, allergy testing may
be an important part of the evaluation of
these patients. Finally, using information
from the history, examination, and testing,
asthma can be classified several different
ways. This classification is useful in
the treatment and prognosis of patients
with asthma.
-------
-------
Diagnosis of Asthma
How Is Asthma Diagnosed?
It is often difficult, especially in young children, to be entirely certain that asthma is the
diagnosis. After a careful physical examination, your pediatrician will need to ask you specific
questions about your child's health. The information you give your pediatrician will help
determine if your child has asthma. Your pediatrician will need information about
• Your child's symptoms, such as wheezing, coughing, and shortness of breath
• What triggers the symptoms or when the symptoms get worse
• Medications that were tried and if they helped
• Any family history of allergies or asthma
It is very important that your pediatrician test your child's airway function. One way to do this
is with a pulmonary function test using a device called a spirometer. This device measures the
amount of air blown out of the lungs over time. Your pediatrician may also want to test your child's
pulmonary function after giving her some asthma medication. This helps confirm that the blockage
in the air passages that shows up on pulmonary function tests goes away with treatment.
Some children do not find relief from their symptoms even after using medications. If that is
your child, your pediatrician may want to test your child for other conditions that can make
asthma worse. These conditions include allergic rhinitis (hayfever), sinusitis (sinus infection), and
gastroesophageal reflux disease (the process that causes heartburn).
It is important to remember that asthma is a complicated disease to diagnose, and the results of
airway function testing may be normal even if your child has asthma. Also keep in mind that not
all children with repeated episodes of wheezing have asthma. Some children are born with small
lungs, and their air passages may get blocked by infections. As their lungs grow they no longer
wheeze after an infection. This type of wheezing usually occurs in children without a family history
of asthma and in children whose mothers smoked during pregnancy.
/&&
American Academy of Pediatrics |P
DEDICATED TO THE HEALTH OF ALL CHILDREN™
Copyright © 2003
-------
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Diagnosis of Asthma
Key Points to Cover With Patients
• Asthma is a chronic inflammatory disease of the airways with the following features: episodic
symptoms of airway obstruction, bronchial hyperresponsiveness to triggers, and evidence of
at least partial reversibility of the airway obstruction.
• The diagnosis of asthma depends on a careful clinical history showing certain patterns of
symptoms, with confirmation by objective testing that may include pulmonary function testing
and allergy testing. The best form of pulmonary function testing for the diagnosis of asthma
is spirometry. In children who are too young to perform objective testing, response to trials of
medications may confirm the diagnosis.
• The diagnostic suspicion should be high in any child with recurrent lower respiratory symptoms
such as cough, wheeze, and shortness of breath. Children with recurrent "bronchitis,"
"pneumonia," "bronchiolitis," or "reactive airway disease" may have asthma. Cough that
wakes the child at night or increases with exercise is often a symptom of asthma.
• Not all children with wheeze have asthma, but increasing frequency of wheezing beyond infancy,
particularly without an upper respiratory infection, is highly suspicious for asthma. Most children
who wheeze in the first 3 years of life may not continue to wheeze after that time. Historical
clues and physical findings help to differentiate other causes of wheezing, but additional testing
may be necessary to rule out other conditions.
American Academy of Pediatrics
DEDICATED TO THE HEALTH OF ALL CHILDREN
Copyright © 2003
-------
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Non-pharmacologic Approaches to
Asthma Management
General strategies
1. Asthma education
2. Environmental control (eg, allergens, irritants)
3. Immunotherapy
4. Other (eg, exercise, chiropractic)
Copyright © 2003 American Academy of Pediatrics
While pharmacologic management
is necessary for all patients
with asthma, it is also important
to consider possible non-pharmacologic
approaches. These may allow for improved
asthma control with lower doses of
medication and are therefore logical and
appealing to patients and their families. The
following 4 strategies will be discussed:
1. Asthma education—important and
necessary for all patients.
2. Avoidance of allergens and nonspecific
irritants—this should be employed
for all patients. Even those without
allergies can have symptoms triggered
or exacerbated by exposure to irritants,
especially environmental tobacco
smoke (ETS).
3. Immunotherapy—appropriate for
selected patients, especially those with
clear allergic triggers.
4. Other (eg, exercise, chiropractic)—
limited data that these are effective.
-------
Asthma Education
• Critical to effective asthma management
• Primary caregivers should provide regular
follow-up and education on
- Asthma signs and symptoms
- Expectations of asthma treatment
- Medications and their administration
- Written action plans, peak flow meters
- Environmental control measures
Copyright © 2003 American Academy of Pediatrics
As part of ongoing asthma care,
practitioners should take time to
educate their patients about asthma
facts and therapy. Teach what asthma
symptoms and signs are, such as cough
without colds, cough at night, cough
with exercise, chest tightness, and
throat tightness.
The goals of asthma therapy are well
outlined in the National Heart, Lung, and
Blood Institute (NHLBI) Expert Panel
Report 2: Guidelines for the Diagnosis and
Management of Asthma released in 1997.
These goals include
• Minimal symptoms of asthma (rescue
inhaler use less than twice per week)
• Full participation in physical activity
• Minimal school absences
• No emergency department visits or
hospitalizations
• Minimal adverse effects from
medications
• Near-normal pulmonary function
The types of medications used and their
purposes need to be reviewed. Patients
often are non-adherent to medication
programs because they do not understand
the purpose of a medication.
Written action plans may be helpful in
asthma self-management programs
and should specify when to use rescue
medications, adjustments to controller
medications during exacerbations, and
when to notify the health care provider.
According to the National Asthma
Education and Prevention Program "Expert
Panel Report Guidelines for the Diagnosis
and Management of Asthma—Update
on Selected Topics—2002," there are
inadequate data to support the use of
peak flow meters over symptom-based
management plans. Nonetheless, peak-
flow-based management plans may be
helpful in patients with moderate or severe
asthma and may improve physician-patient
communication. They are also particularly
helpful for patients who do not recognize
significant degrees of airway obstruction.
Avoidance of triggers of asthma are as,
if not more important than medication
use, and details will be provided throughout
this presentation.
-------
Asthma Education
• Books, pamphlets, Internet sites, and other materials
should be provided or recommended.
• Specialist referral can be invaluable.
• Support groups and others should be recommended
for support and educational materials and programs.
- Allergy and Asthma Network/Mothers of Asthmatics (www.aanma.org)
- American Academy of Allergy, Asthma, and immunology (www.aaaai.org)
- American Academy of Pediatrics (www.aap.org)
-American Lung Association (www.lungusa.org)
- Asthma and Allergy Foundation of America (www.aafa.org)
Copyright © 2003 American Academy of Pediatrics
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Classification of Environmental Triggers
Allergens
• Indoor
- Mites, animals,
cockroaches, molds
• Outdoor
- Pollens (eg, trees,
grass, weeds)
- Molds
Copyright © 2003 American Academy of Pediatrics
Irritants
• Tobacco smoke
* Air pollutants
• Odors, fragrances
- VOCs
Molds can be triggers both indoors
and outdoors. However, molds do
not ordinarily occur indoors to a
significant extent unless there are ongoing
problems with moisture, such as leaking
roofs or previous significant water damage.
Air pollutants come from wood smoke,
automobile exhaust, and volatile organic
compounds (VOCs) in sprays, solvents, and
household cleaners.
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Role of Allergy in Asthma: Clinical Evidence
• Allergy is common in children
(8Q%-90% of school-aged children with asthma).
* Presence of allergy is associated with more severe
and persistent asthma.
* Allergen exposure is associated with
- Increased risk of developing asthma.
- Increased asthma morbidity.
• Allergen avoidance can reduce AHR and asthma
morbidity.
Copyright © 2003 American Academy of Pediatrics
It is clear that allergy plays a significant
role in childhood asthma. When
progressing from early to late childhood,
an increasing percentage of children
with asthma will develop allergic
sensitivities, such that by the age
of 10 years 80% to 90% of children
with asthma will have positive skin-
test results to 1 or more allergens. The
development of allergy is associated with
more severe and persistent asthma, and
allergen exposure has been shown to be
a risk factor for both asthma development
and increased asthma morbidity. On the
positive side, studies have shown that
allergen avoidance can have salutary
effects on the course of childhood asthma,
including reduced symptoms and airway
hyperreactivity (AHR).
-------
1997 NHLBl Guidelines
* For patients with persistent asthma on daily
medications, the clinician should
- Identify allergen exposures,
- Use skin testing or in vitro testing to assess specific
sensitivities to indoor allergens.
- Implement environmental controls to reduce exposure
to relevant allergens.
| "The first and most important step in controlling
I allergen-induced asthma is to reduce exposure to
j relevant indoor and outdoor allergens."
Copyright © 2003 American Academy of Pediatrics
In the 1997 version of the NHLBl Expert
Panel Report 2: Guidelines for the
Diagnosis and Management of Asthma,
much more emphasis was appropriately
placed on the role of allergy and allergen
avoidance. The guidelines now recommend
that any clinician caring for patients with
persistent asthma should
• Identify allergen exposures.
• Use skin testing or in vitro testing to
assess specific sensitivities to indoor
allergens.
• Implement environmental controls to
reduce exposure to relevant allergens.
Further, the guidelines concluded with this
statement: "The first and most important
step in controlling allergen-induced asthma
is to reduce exposure to relevant indoor
and outdoor allergens."
-------
Photo courtesy of the US Food
and Drug Administration.
Dust Mites
* Overall the number one indoor
allergen
* Perennial with seasonal
increases in the summer/fall
* Grow best with moderate
temperatures and >60%
relative humidity
* Two major US species
- Dermatophagoides farinae
- D pteronyssinus
Copyright © 2003 American Academy of Pediatrics
Dust mites deserve their reputation
as the number one indoor allergen
on a worldwide basis.They grow
best with moderate temperatures and
moderate to high relative humidity;
therefore, peak levels are typically seen
in the summer and fall. There are 2 major
species of allergenic dust mites in the
United States—Dermatophagoides farinae
and pteronyssinus.
-------
Dust Mites
* Major allergen is contained in fecai pellets.
* Particle size is relatively large (>20 urn).
• Particles settle quickly after disturbance.
* Grow best in fabrics
- Mattresses - Carpets
- Pillows - Stuffed toys
- Bed linens - Upholstered furniture
• Control measures must focus on these sites.
Copyright © 2003 American Academy of Pediatrics
The major mite allergens are digestive
proteins that are carried on fecal
pellets. These particles are relatively
large by allergen standards, which is
important because particle size influences
airborne characteristics of an allergen
and the environmental control measures
that may or may not be effective.
These particles settle very quickly after
disturbance such that most mite exposure
occurs when we are in intimate contact
with them, such as in our beds and pillows.
Dust mites grow best in fabrics and these
fabric items should therefore be the focus
of any mite avoidance regimen.
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Dust Mite Control Measures
First line (necessary and cost-effective)
* Use mattress and pillow encasements.
• Wash bed linens every 1-2 weeks, preferably
in hot (>130°F) water.
• Remove stuffed toys.
• Regularly vacuum carpeted surfaces.
* Regularly dust hard surfaces.
• Control humidity (dehumidify If possible, but
at least do not add humidity!).
Copyright © 2003 American Academy of Pediatrics
These are the "first-line" measures of
dust mite control. They are first line
because they are necessary and not
terribly expensive or difficult to implement.
There are no industry standards for vacuum
cleaners, although a few studies have
shown that those with High Efficiency
Particulate Air (HEPA) filters or filter
bags leak less allergen particles into
the indoor air.
Dusting should be done with a damp or
treated cloth to pick up the dust. Feather
dusters should not be used.
Dehumidification may be difficult and
expensive in humid environments. Indoor
air conditioning is an effective way to
dehumidify the air, but is expensive if
not already available. It is not known
whether local dehumidification is possible
or effective.
Note: Discuss the issue of American
Academy of Pediatrics policy on hot
water temperatures of 120°F versus
the recommendation of 130°F for dust
mite control.
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Dust Mite Control Measures
Second line (helpful but more costly)
* Remove carpets, especially in the bedroom,
• Remove upholstered furniture.
Third line (limited or unproved benefit)
* Acaricides
• Tannic acid
* Air cleaners
Copyright © 2003 American Academy of Pediatrics
Second-line measures are helpful
but should be considered more
carefully for individual patients
because they may be much more costly.
Third-line measures are of limited or
unproven benefit and are therefore not
routinely recommended. Both acaricides
(a dust mite pesticide like benzoic acid)
and tannic acid (meant to denature mite
allergens without killing living dust mites)
appeared promising in the laboratory but
have proven less effective in homes.
Tannic acid may also stain carpeting or
furniture. Although they are often sold
with claims of dust mite control, air
cleaners/purifiers have little or no role
in the control of mite allergens—because
of the large particle size there is very
little airborne mite allergen available
for filtration.
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Animal Allergens
• Contained in sebaceous secretions,
saliva, and urine (rodents)
• Dry on fur, bedding, carpeting, furniture,
etc, and become airborne with
disturbance
* Carried on small particles such that some
allergens will be airborne at all times
Copyright © 2003 American Academy of Pediatrics
Animal allergens are typically
produced in a liquid form and then
become airborne after drying.
A substantial portion of animal allergens
are carried on small particles that remain
airborne for extended periods.
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Animal Allergy—Why So Important
* 5%—10% of general population.
• 20%-70% of people with allergies/asthma.
* >50% of US homes have at least one cat or dog.
* Homes and public buildings without pets may
have significant allergen levels.
* Other furred animals also are commonly
encountered.
Copyright © 2003 American Academy of Pediatrics
A
nimal allergy is an enormous clinical
problem because
1. Animal allergy is very common.
2. Exposure is widespread because of
the large number of pet-containing
homes and the fact that the allergens
are present even in homes and public
places that do not contain animals. Cat
allergen has been found in significant
concentrations in classrooms, enough
to trigger symptoms in sensitive
asthmatics.
3. When taking a history and performing
allergy testing, it is also important to
inquire about exposure to pets other
than cats and dogs such as gerbils,
hamsters, rabbits, and guinea pigs.
-------
Animal Allergen Control Measures
* Remove source (ie, find a new home for the pet!).
- Reduces allergen in settled dust
- Clinical benefit presumed but never proven.
- Allergen levels fall slowly—benefits not
expected for weeks to months.
- Should be followed by aggressive cleaning to
remove reservoirs of allergen.
- Possible role for tannic acid to augment
allergen removal.
Copyright © 2003 American Academy of Pediatrics
The approach to animal allergy should
be simple—find a new home for
the pet and clean aggressively. You
should remember, however, that even
with these measures allergen levels fall
over a period of weeks to months, so a
clinical benefit should not be expected
immediately.
-------
Animal Allergen Control Measures
• If pet is not removed, the following measures may
help reduce allergen levels:
- Limit access, especially to bedroom.
- Run air cleaners.
- Remove carpeting.
- Use mattress and pillow covers.
- Wash animals (not likely helpful unless done at least
2-3 times a week).
• However, these may not reduce levels enough to
help patients who are highly allergic.
Copyright © 2003 American Academy of Pediatrics
Unfortunately, most families are
unwilling to remove pets from their
homes, even when they are causing
significant disease. A number of measures
have therefore been studied that may help
to reduce exposure even with the pet still
living in the home. These include keeping
the pet out of the bedroom, running air
cleaners, removing carpeting, and using
mattress and pillow covers (because
carpets, mattresses, and pillows are
huge reservoirs of allergen). Washing
cats and dogs has been recommended
but it has now been shown that the
effects of washing are very short-lived—
it would be necessary to wash the animals
2 or more times per week to have any
potential benefit.
It is also very important to note that these
measures are not likely to be effective for
patients who are highly allergic, for whom
the only proper advice is to remove the pet
from the home.
-------
Animal Allergens
Additional issues
* Production varies widely between animals
but cannot be predicted based on breed, hair
length, color, etc.
• Stick to walls, clothing, and other surfaces.
• Transported on clothing, so they are present
in virtually all homes, schools, and other
public buildings.
Copyright © 2003 American Academy of Pediatrics
Some cats and dogs are said to be
hypoallergenic but there are no data
to support this. There is significant
variability in allergen production from
one animal to another but this cannot
be predicted based on the breed or any
other variable.
It has clearly been shown that animal
allergens are spread to most homes and
public places that have never contained
animals; therefore, it is possible to detect
cat and dog allergens in almost any indoor
environment.
-------
Cockroach Allergens
Derived from saliva, fecal material, secretions, skin
casts, body parts.
Highest levels in kitchens; found throughout the
home, including bedroom and bed.
Levels in bedroom may be most associated with
sensitization and disease.
Significant levels found in schools in the inner city.
Airborne particles large (>10 urn), detectable mainly
after disturbance.
Copyright © 2003 American Academy of Pediatrics
Cockroach allergens are found in
saliva, feces, and other secretions,
as well as skin casts and body parts.
The highest levels are found in kitchens
but the allergen is widely disseminated
in the home, with bedroom levels being
most closely associated with asthma
morbidity. Significant exposure may also
occur outside the home, with one study in
Baltimore, MD, demonstrating high levels
in schools in the inner city. Like dust mite,
cockroach allergens are carried on large
particles that are only transiently airborne
after disturbance.
-------
Cockroach Allergy
Cockroach = dominant indoor allergen in many
urban areas.
Cockroach sensitivity is present in 30%-50% of
children with asthma in the inner city.
Combination of cockroach exposure and sensitivity
is the best predictor of asthma morbidity in the
National Collaborative Inner-City Asthma Study
(1997).
Copyright © 2003 American Academy of Pediatrics
Cockroach allergy is very interesting
because it was not even recognized
until the 1960s and was not truly
appreciated until the 1990s. Cockroach
is now recognized as the dominant
indoor allergen in many urban areas, with
cockroach sensitivity occurring in 30%
to 50% of children with asthma in the
inner city. It has even been shown in the
National Collaborative Inner-City Asthma
Study that the best predictor of asthma
morbidity was a combination of cockroach
exposure and sensitivity (as pictured on the
next slide).
-------
Relationship of Cockroach Allergy to
Asthma Morbidity
Negative
Skin-Test
Result
Positive
Skin-Test
Result
Number
Hos totalizations
Unscheduled Visits
Days when care giver
changed plans
Low Ag
160
0.14
1,40
9,11
High Ag*
141
0.08
1.44
11.07
Low Ag
77
0.10
1.50
7.22
High Ag*
98
0.37
2.56
15.52
P
.001
<-001
.006
"High Ag = 8U/gofdust.
Rosenstreteh DL, Eggteston f, Kattw M, et a). H BtgJ Med. 1997; 336:1356-1363
Copyright © 2003 American Academy of Pediatrics
In this study of children with asthma
in the inner city, patients were
categorized by their allergic sensitivities
and exposure to indoor allergens. Here
those data are displayed for cockroach
allergen, demonstrating that those in the
column with both high exposure and a
positive skin-test result had significantly
greater asthma morbidity as indicated by
hospitalizations, unscheduled doctor visits
for asthma, and the number of days that
the caretaker had to change plans because
of the child's asthma. Similar patterns were
not seen for any other indoor allergen. It
is also important to note that more than
half of the children in the study were
categorized as having high exposure. High
exposure was defined as greater than or
equal to 8 units/g of dust.
Ag = antigens
-------
Cockroach Allergen Control Measures
* Behavioral changes in food sources
(eg, dirty dishes, open food containers,
uncovered trash cans)
* Roach traps and baits
* If above steps do not work, exterminate
thoroughly (ensure asthmatic is not in area
during extermination)
* Thorough cleaning after extermination
* If necessary, extermination of neighboring
dwellings
Copyright © 2003 American Academy of Pediatrics
Cockroach control is an exceedingly
difficult task and possibly one that
will meet with failure. The following
are recommended: Integrated pest-
management techniques are preferable
to excessive use of pesticides. Behavioral
changes to reduce food sources and
roach traps and baits should be tried first.
If those measures don't work, thorough
extermination should be tried. Make
sure any asthmatics are out of the area
during extermination and for several
hours thereafter. Where dwellings are
joined, such as in apartment buildings and
townhouses, extermination of neighboring
dwellings may be necessary. These
methods can reduce cockroach antigen
levels considerably. However, it is still not
clear that even large reductions will have
a clinical benefit beacuse of the degree
of infestation in many homes. Even with
large reductions, many homes are still well
above the threshold of 8 units/g of dust
noted on the previous slide.
-------
Mold Allergens
* Significant indoor and outdoor allergens.
• Aspergillus and PeniciHium most numerous
indoor molds.
« Altemaria and Cladosporium most numerous
outdoor molds.
* Perennial with seasonal variation.
* Growth greatly influenced by temperature and
humidity.
* Particle sizes range from small to very large.
Copyright ® 2003 American Academy of Pediatrics
Molds grow indoors and outdoors.
While a huge number of mold
species exist that may have
the potential to cause allergy, 4 molds
are the most common causes of allergy.
Aspergillus and PeniciHium are the most
numerous indoor molds and Altemaria
and Cladosporium are most numerous
outdoors. Molds are perennial with
significant seasonal variation due to their
dependence on temperature and humidity
for growth.
Most significant indoor mold growth occurs
where there are moisture problems, such
as excessive humidity, leaking roofs, or
previous water damage from flooding.
Molds cannot grow without water; get rid
of the water and you get rid of the mold.
Particle sizes of mold allergens range from
very small to very large (eg, <1 to >60 urn).
-------
Mold Allergen Control Measures
• Identify sites/sources of mold growth.
* Water control is key.
• Clean moldy areas with detergent and water.
* If cleaning not possible, discard/replace moldy
items (eg, carpets, furniture, wallboard).
• Dehumidify.
• Run exhaust vent in bathroom and kitchen.
* Clean refrigerator, dehumidifier, and humidifier
with detergent and water.
Copyright © 2003 American Academy of Pediatrics
Mold control will need to begin with
some detective work to identify
sites of mold growth. Molds can
be removed on most hard surfaces using
detergent and water. It may not be possible
to remove molds from certain fabrics,
such as a carpet that has sustained water
damage, and these items may need to be
discarded. Dehumidification, especially in
basements, can limit mold growth, as can
using a vent in the bathroom and kitchen.
Most significant indoor mold growth
occurs as a result of water problems such
as leaks in the roof, previous flooding
from appliances or natural disasters, and
excessive indoor humidity. Molds cannot
grow without water; if you get rid of the
water, you also get rid of the mold. Leaks
and areas of poor drainage should be
repaired or corrected and other areas of
potential mold contamination should be
cleaned regularly.
The Environmental Protection Agency
(EPA) recommends cleaning mold with
detergent and water rather than with a
fungicide such as bleach solutions. Dead
molds can still be allergenic and need to
be removed. Fumes from fungicides can
trigger asthma symptoms.
-------
Tips for Dealing With Outdoor Allergens
* Wash hands, face, and hair after being outside.
• Keep windows closed.
* Use an air conditioner.
• Some activities may need to be avoided.
• Masks, glasses, and goggles may help reduce
exposure.
Copyright © 2003 American Academy of Pediatrics
While there is much less that can
be done to reduce exposure
to outdoor allergens, there
are a few simple measures that may be
helpful. Patients should be advised to
wash their hands and faces after playing
outdoors and to wash their hair before
going to bed at night. Windows should
be kept closed during pollen seasons and
an air conditioner should be used. Some
activities, such as lawn mowing, may need
to be avoided altogether during certain
times of year; the use of masks, glasses,
and goggles may help to reduce symptoms
if these activities cannot be avoided.
-------
Control of Environmental Irritants
* All families should be asked and counseled
about tobacco smoke exposure.
* Wood smoke, nitrogen dioxide, and other indoor
pollutants can be potent respiratory irritants.
* Outdoor pollutants, especially ozone and
particulate materials, also can increase asthma
symptoms and morbidity.
Copyright © 2003 American Academy of Pediatrics
Nonspecific irritants also can have
significant effects on asthma.
Environmental tobacco smoke is
by far the most common irritant and all
patients and families should be asked and
counseled about ETS exposure. In addition,
other indoor and outdoor pollutants can
increase asthma morbidity through their
irritant effects on the airways. Indoor levels
of outdoor pollutants can be significant,
especially particulates from neighborhood
wood smoke.
-------
Compliance With Environmental Controls
• Difficult because of cost, labor, "nonbelief," family
pets, etc
• Most likely to succeed with
- Education
- Written materials
- Skin testing
- Regular review at follow-up
- Home visits if possible
Copyright © 2003 American Academy of Pediatrics
-------
Clinical Efficacy of Allergen Avoidance
* Dust mite avoidance trials have demonstrated
significant improvements in
- Symptoms
-AHR
- Medication requirements
- Mite-specific IgE levels
* Similar data are not available for animals, cockroach,
or molds (primarily because of lack of study}.
Copyright © 2003 American Academy of Pediatrics
Is it really worth spending so much time
and energy on allergen avoidance? The
answer is absolutely yes! Dust mite
avoidance has been best studied and these
studies have shown that mite avoidance
can significantly reduce symptoms, AHR,
medication requirements, and mite-specific
IgE levels. Other indoor allergens have
not been studied to the same degree,
the same data for animals, cockroach, or
molds are not available. Avoidance of these
allergens is still a logical approach that
would likely reduce disease activity as well.
-------
Considerations for Initiating immunotherapy
Presence of documented IgE-mediated disease
Evidence that specific sensitivity is causing
symptoms
Symptoms sufficiently severe or prolonged to
warrant the time, risk, and cost of immunotherapy
Allergen avoidance and pharmacotherapy not
adequately controlling symptoms
Availability of high-quality vaccines
Copyright © 2003 American Academy of Pediatrics
Immunotherapy is the third major non-
pharmacologic approach to asthma
treatment. Considerations for the use
of immunotherapy are reviewed on this and
the next slide. They are somewhat obvious
but very important to recognize and review
for all patients in whom immunotherapy is
being considered.
• First, the patient must have documented
IgE-mediated disease as well as clinical
evidence that the allergic sensitivities are
causing symptoms.
• Second, the symptoms should be
sufficiently severe or prolonged to
warrant the time, risk, and cost of
immunotherapy.
• Third, immunotherapy should only be
used after appropriate medications and
environmental control measures have
been instituted.
• Fourth, good-quality extracts need to
be available.
-------
Considerations for Initiating Immunotherapy
• Review cost/benefit issues
• Contraindications
- Poor compliance
- Poorly controlled asthma
- Treatment with p-blockers
- Other immunologic disease
- Significant cardiovascular disease
- Children younger than 5 years (relative)
Copyright ® 2003 American Academy of Pediatrics
In addition, cost/benefit issues need
to be considered, as do several
important contraindications to the use
of immunotherapy. These include poor
compliance, poorly controlled asthma,
treatment with beta-blockers, the
presence of other immunologic disease
(eg, immunodeficiency), and significant
cardiovascular disease. The use of
immunotherapy in children younger than
5 years is usually discouraged, although
this is not an absolute contraindication.
There are studies indicating that dust
mite immunotherapy decreases additional
allergen sensitization in young children.
-------
Immunotherapy—WHO Position Paper
• Indications in allergic asthma
- Patients whose symptoms are not controlled with
allergen avoidance and pharmacotherapy
- Patients who do not wish to be on long-term
pharmacotherapy
- Undesirable side effects from treatment
- Patients with both nasal and bronchial symptoms
* Not indicated in severe/unstable asthma
Copyright © 2003 American Academy of Pediatrics
A recent position paper published
by the World Health Organization
(WHO) provides the following
guidelines for the use of immunotherapy
in allergic asthma:
• Patients whose symptoms are not
controlled with allergen avoidance and
pharmacotherapy
• Patients who do not wish to be on long-
term pharmacotherapy
• Undesirable side effects from treatment
• Patients with both nasal and bronchial
symptoms
• A/of indicated in severe disease
Patients with severe asthma are at
high risk of systemic reactions with
immunotherapy. Patients with fixed airway
obstruction are less likely to benefit.
Generally, immunotherapy should be
avoided in patients with forced expiratory
volume in 1 second (FEVi)/forced vital
capacity (FVC) ratio less than 70%.
-------
Immunotherapy—Efficacy
Meta-analysis of 20 studies
* Combined OR for symptom improvement for any
allergen was 3.2.
* Combined OR for reduction in AHR was 6.8.
• Or was 4.2 for i treatment requirement with mite
immunotherapy.
* Mean effect for immunotherapy on all continuous
outcomes was 0.71, corresponding to a mean 7.1%
predicted improvement in FEV.,.
Copyright 3 2003 American Academy of Pediatrics
A recent meta-analysis evaluated
20 studies on the efficacy of
immunotherapy in asthma. This
analysis found that the overall odds for
improvement in symptoms were 3.2,
and the odds for a reduction in AHR were
6.8. In studies of mite immunotherapy, the
odds for reduced medication requirements
were 4.2. When all continuous outcomes
were evaluated together the analysis
determined that immunotherapy provides
a mean 7.1 % improvement in FEW This
improvement is similar to those seen
with the use of leukotriene antagonists
and slightly lower than with inhaled
corticosteroids.
AHR = airway hyperreactivity
FEV!= forced expiratory volume in
one second
OR = odds ratio
-------
Immunotherapy—Efficacy
Long-term efficacy
* Most patients will experience long-term relief with
at least 3 y of immunotherapy for dust mite or
pollens.
* 3Q%-50% appear to relapse, usually within 1 y of
discontinuation.
• Patients who relapse appear to respond well to
reinstitution of immunotherapy.
Copyright © 2003 American Academy of Pediatrics
Immunotherapy should typically be
given for a 3- to 5-year period. After
this length of treatment, a majority
of patients will experience long-term
remission in their symptoms. In those
patients who do relapse, symptoms are
often well controlled with medications;
immunotherapy can be reinstituted (if still
clinically indicated) with a high likelihood
of a good response.
-------
Can Early Use of Immunotherapy Prevent
the Development of Future Allergies?
• 44 children 3-6 y of age monosensitized to dust mite
•Treated with either mite immunotherapy or standard
medical therapy for 3 y
* New allergic sensitivities developed in
- 12/22 of immunotherapy group
- 22/22 of control group (P=0.001)
- New allergies: cat, 53%; dog, 35%; Alternaria, 24%;
pollens, 20%
Copyright @ 2003 American Academy of Pediatrics
In addition to the relief of symptoms,
other possible benefits of
immunotherapy include a reduction
in the development of additional allergies
and a reduced chance of the development
of asthma in children with allergic rhinitis.
In this study, children 3 to 6 years of age
with dust mite sensitivity were treated
with either mite immunotherapy or
standard medical therapy for 3 years.
In that 3-year period, all children who
received medical therapy developed
additional allergic sensitivities compared
to 12 of 22 children in the immunotherapy
group, suggesting that the early use of
immunotherapy may decrease the chance
of acquiring additional allergies over time.
-------
Can Early Use of Immunotherapy
Prevent the Development of Asthma?
• 203 children 7-13 y of age with seasonal allergic
rhinitis.
• Randomized to immunotherapy group and control
group (no placebo group).
• Methacholine reactivity found in 33.6% at baseline.
• Over the first 2 years, "Significantly more children in
the control group developed asthma (P=.04)."
Copyright © 2003 American Academy of Pediatrics
This study, which is still ongoing at
this time (and has thus far only been
published in abstract form), studied
children with allergic rhinitis to determine
if the use of immunotherapy might
decrease the odds of developing asthma
over time. After the first 2 years of study
the results suggest that this may indeed
be the case. Although the study is limited
by the fact that there was no placebo
group and by a high rate of methacholine
reactivity at baseline, the final results
will certainly be of interest when they
are available.
-------
Immunotherapy—Safety
• Local reactions are common and expected.
• Systemic reactions
- 0.1%-1.7% of injections.
- 2.1% of patients/y in one large series.
- Asthma symptoms most common in patients with
asthma.
- Urticaria most common in patients without asthma.
- Most, but not all, occur in first 20-30 min.
Copyright © 2003 American Academy of Pediatrics
Although immunotherapy, overall, is
safe, local and systemic reactions
do occur. Systemic reactions occur
in between 0.1 % and 1.7% of injections
and in one large study were found to occur
in 2.1 % of patients per year. Reactions
can include asthma symptoms, which
are especially common in patients with
asthma. Most, but not all, reactions occur
in the first 30 minutes after the injection
is given.
-------
Immunotherapy—Safety
• Risk factors for systemic reactions
- Asthma
- Low FEV, or PEF (<80% predicted or FEV^FVC ratio <70%)
- "Build-up" phase
- New extract vial
- ? pollen season
• Immunotherapy should only be given in a facility
equipped to treat anaphylaxis.
Copyright © 2003 American Academy of Pediatrics
There are several well-described risk
factors for systemic reactions that
are listed on this slide. It is important
to note, however, that any patient can
have a systemic reaction after any injection
and precautions must therefore be taken
for all patients. The 2 most important
precautions are to require a 30-minute
waiting period after each shot is given
and to only administer allergy shots
in a facility equipped to deal with an
anaphylactic reaction.
FEVi = forced expiratory volume in one
second
PEF = peak expiratory flow
FVC = forced vital capacity
-------
Other Strategies
»Exercise
»Breathing exercises
* Chiropractic
* Acupuncture
• Herbal remedies
Copyright © 2003 Ameri can Academy of Pediatrics
Exercise is good for children, including
those with asthma. But exercise will
not improve asthma, only conditioning
and endurance. Breathing exercises can
help to relax a patient with asthma during
an acute attack, but there are limited data
indicating a long-term benefit in asthma.
Chiropractic manipulation and acupuncture
have not been shown to be superior to
placebo in controlled studies, although the
data are limited. There are no scientific
studies documenting effectiveness of any
herbal remedies. One has to be cautious
about the possible presence of ephedra in
many herbal remedies for asthma.
-------
Non-pharmacologic Asthma Management—Summary
« Allergen avoidance is the most logical and
effective means of controlling allergic disease.
• All children with persistent asthma should be
evaluated for allergic/irritant triggers by history
and appropriate testing.
* Asthma management will almost certainly fail
without appropriate patient education.
* Allergen immunotherapy can provide significant
benefits to select patients with allergic asthma,
especially for unavoidable allergic triggers.
Copyright @ 2003 American Academy of Pediatrics
T
his slide summarizes the important
"take-home" messages for anyone
caring for patients with asthma.
-------
Non-pharmacological Approaches to Asthma Management
Asthma Triggers
Certain things cause asthma "attacks" or make asthma worse. These are called triggers.
Some common asthma triggers are
• Things your child might be allergic to. These are called allergens. (Most children with asthma
have allergies, and allergies are a major cause of asthma symptoms.)
- House dust mites
- Animal dander
- Cockroaches
- Mold
- Pollens
• Infections of the airways
- Viral infections of the nose and throat
- Other infections, such as pneumonia or sinus infections
• Irritants in the environment (outside or indoor air you breathe)
- Cigarette and other smoke
- Air pollution
- Cold air, dry air
- Odors, fragrances, volatile organic compounds in sprays, and cleaning products
• Exercise (About 80% of people with asthma develop wheezing, coughing, and a tight feeling in
the chest when they exercise.)
• Stress
Be sure to check all of your child's "environments," such as school, child care, and relatives'
homes, for exposure to these same things.
Help Your Child Avoid Triggers
While it is impossible to make the place you live in completely allergen- or irritant-free, there are
things you can do to reduce your child's exposure to triggers. The following tips may help.
• Do not smoke or let anyone else smoke in your home or car.
• Reduce exposure to dust mites. The most necessary and effective things to do are to cover your
child's mattress and pillows with special allergy-proof encasings, wash their bedding in hot water
every 1 to 2 weeks, remove stuffed toys from the bedroom, and vacuum and dust regularly.
Other avoidance measures, which are more difficult or expensive, include reducing the humidity
in the house with a dehumidifier or removing carpeting in the bedroom. Bedrooms in basements
should not be carpeted.
-------
If allergic to furry pets, the only truly effective means of reducing exposure to pet allergens is
to remove them from the home. If this is not possible, keep them out of your child's bedroom
and consider putting a high-efficiency particulate air (HEPA) filter in their bedroom, removing
carpeting, covering mattress and pillows with mite-proof encasings, and washing the animals
regularly.
Reduce cockroach infestation by regularly exterminating, setting roach traps, repairing holes in
walls or other entry points, and avoiding leaving exposed food or garbage.
Mold in homes is often due to excessive moisture indoors, which can result from water damage
due to flooding, leaky roofs, leaking pipes, or excessive humidity. Repair any sources of water
leakage. Control indoor humidity by using exhaust fans in the bathrooms and kitchen, and adding
a dehumidifier in areas with naturally high humidity. Clean existing mold contamination with
detergent and water. Sometimes porous materials such as wallboards with mold contamination
have to be replaced.
Pollen exposure can be reduced by using an air conditioner in your child's bedroom, with the
vent closed, and leaving doors and windows closed during high pollen times. (Times vary with
allergens, ask your allergist.)
Reduce indoor irritants by using unscented cleaning products and avoiding mothballs, room
deodorizers, or scented candles.
Check air quality reports in weather forecasts or on the Internet. When the air quality is poor,
keep your child indoors and be sure he takes his asthma control medications.
Decreasing your child's exposure to triggers will help decrease symptoms as well as the need
for asthma medications.
American Academy of Pediatrics IP
DEDICATED TO THE HEALTH OF ALL CHILDREN
Copyright © 2003
-------
Non-pharmacologic Approaches to Asthma Management
Key Points to Cover With Patients
• Most children with asthma have allergies. Allergies become more common with age such that
by age 10 years, 80% to 90% of children with asthma have allergies.
• Allergies are a major cause of airway inflammation in asthma and contribute significantly to acute
and chronic asthma symptoms.
• The most common and important allergens in childhood asthma include dust mites, animals
(especially cats), cockroaches, molds, and pollens.
• Indoor air pollution, especially tobacco smoke, also contributes to airway inflammation and
bronchial hyperresponsiveness.
• Reducing exposure to these allergens and irritants can decrease airway inflammation and
thereby reduce symptoms and medication requirements. Failure to control these exposures will
make the asthma more difficult to manage.
• Immunotherapy (allergy shots) may also significantly improve allergic asthma.
• Exposures to allergens in other environments, particularly school, can also contribute to
increased asthma symptoms.
• Environmental controls should be based on the child's environment and his specific allergic
sensitivities. These controls include the following:
Dust Mites
• First Line (necessary and cost-effective)
- Use mattress and pillow encasings
- Wash bed linens every 1 to 2 weeks, preferably in hot water.
- Remove stuffed toys.
- Regularly vacuum carpeted surfaces and dust hard surfaces.
- Reduce indoor relative humidity (dehumidify and do not add humidity).
• Second Line (helpful but more costly)
- Remove carpets, especially in the bedroom.
- Remove upholstered furniture.
- Avoid living in basements.
American Academy of Pediatrics
DEDICATED TO THE HEALTH OF ALL CHILDREN"
Copyright © 2003
-------
Animals
• Remove source (eg, find a new home for the pet)
• If the pet is not removed
- Use air cleaners, especially in the bedroom.
- Remove carpeting, especially in the bedroom.
- Use mattress and pillow covers.
- Wash animals (not likely to be helpful unless done at least 2 times per week).
Cockroaches
• Change behaviors to reduce food sources.
• Set roach traps and baits.
• Repair holes in walls and other entry points.
• If the above measurements don't work, exterminate [when asthmatic is out of area].
• Thoroughly clean after extermination.
Molds
• Identify sources of mold growth.
• Clean moldy areas with detergent and water.
• If cleaning is not possible, discard moldy items (eg, carpets, furniture).
• Dehumidify.
• Repair leaks and maximize drainage.
• Clean the refrigerator, dehumidifier, and humidifier with detergent and water.
-------
Pharmacologic Management
of Asthma
Copyright © 2003 American Academy of Pediatrics
-------
Goals of Therapy for the
Child With Asthma
* Prevent chronic and troublesome symptoms. Ideally NO
symptoms day or night.
* Prevent exacerbations of symptoms.
Minimal (ideally NO) asthma episodes.
• Maintain normal activity levels.
Minimal (ideally NO) interference with usual or
strenuous activity.
• Maintain normal or near-normal lung functions.
Maintain at least z8Q% of predicted FEV1 or personal-
best PEFR.
Copyright © 2003 American Academy of Pediatrics
Overall goals of therapy are listed
here. Simply, goals are the control
of symptoms and airflow limitation
to the point of allowing the child to function
normally or as close to normal as possible,
and to prevent or at least minimize
the number and intensity of asthma
exacerbations. Pharmacotherapy is only
one, albeit important, aspect of therapy.
FEVi = forced expiratory volume in 1
second
PEFR = peak expiratory flow rate
-------
Goal of Pharmacotherapy
Optimize asthma control with minimal
(ideally NO) side effects.
Copyright © 2003 American Academy of Pediatrics
The key goal of pharmacotherapy
for the child with asthma is to
optimize asthma control chronically
and acutely without incurring any
undesirable effects of the medications
themselves. Although "asthma" is used
in the singular, there are many forms of
asthma. There are general starting rules
for the pharmacotherapy of asthma,
but the pharmacotherapeutic needs
and sensitivity to the potential adverse
effects of pharmacotherapeutic agents
are extremely diverse and individualization
of therapy is an essential component to
pharmacotherapy. Put another way, not
only the needs but the benefit-risk ratio in
pharmacotherapy may vary significantly
from individual to individual.
-------
Key Components of Therapy for
the Child With Asthma
Control factors that contribute to asthma
Pharmacotherapy
Patient and parent education
Assessment and monitoring
Copyright © 2003 American Academy of Pediatrics
Pharmacotherapy is one part of
the overall therapeutic strategy
for childhood asthma. Each part
has implications for the need for and
success of pharmacotherapy. Control
of environmental factors that contribute
to asthma in the first place can reduce
pharmacotherapeutic needs. As
important as the appropriate selection
of pharmacotherapeutic agents for an
individual child may be, their effectiveness
is very much related to the willingness
of patients and caregivers to use these
medications. Their ability and desire to
obtain these medications indicate the
understanding of the importance of their
use and understanding of how and when to
use them. Whatever pharmacotherapeutic
regimens may be considered most
appropriate for the child with asthma,
the ability to predict needs and response
to therapy is highly imperfect, and an
integral part of successful therapy includes
regular assessment and monitoring of
symptoms and, to the extent possible,
objective measures of lung function as
well as adherence and ability to use
the medications appropriately. This can
include the repeated assessment and
reinforcement of the appropriate technique
for inhaling medication from delivery
devices described herein. Repeated
assessment, the frequency of which may
be determined by asthma severity and
other factors, is as important as initial
recognition of asthma as a problem and
initiation of therapy. The stepwise approach
recommended is intended to assist,
not replace, the clinical decision-making
required to meet individual patient needs.
-------
Overall Principles
• Agent selection dictated by chronicity and severity
of asthma and the age of the child
• Chronic symptoms: control airway inflammation
and relieve and prevent bronchoconstriction
* Acute symptoms: relief of bronchoconstriction;
acute therapy of inflammation
* Stepwise approach
- Aggressive therapy to achieve control
- Step down when control achieved
Copyright © 2003 American Academy of Pediatrics
Selection of pharmacotherapeutic
agents and how they are used
are dictated by the chronicity and
severity of asthma and to some extent
the age of the child. The availability of
medications and devices for administration
that are user-friendly for children and
caregivers, as well as safety considerations,
have particular importance in the younger
age groups. For chronic symptoms
including frequent recurrent symptoms,
especially with objective evidence of
chronic airflow limitation (if measurable),
inflammation is considered to be the
chronic underlying problem and therapy
is directed at control of airway inflammation
as well as concomitant relief and
prevention of bronchoconstriction.
For acute symptoms, therapy is directed
first at the relief of bronchoconstriction
but, depending on the degree of
exacerbation of symptoms, may also
include control of inflammation (eg, a
burst of oral corticosteroids).
There are 2 approaches to gaining control
of asthma. The first approach is generally
preferred because it achieves rapid control.
Start with aggressive therapy to achieve
rapid control and then step down to the
minimum therapy needed to maintain
control. Aggressive therapy is therapy at
a higher level than that which corresponds
to the initial evaluation of the child's
asthma severity. It may be accomplished
by adding a 3- to 10-day course of oral
corticosteroids to inhaled corticosteroids,
cromolyn, or nedocromil, or by using a
higher dose of inhaled corticosteroids.
Or start with therapy that corresponds to
the initial evaluation of the child's asthma
severity and step up therapy until control
is achieved and maintained.
Step down therapy gradually when control
is achieved.
Consider consulting an asthma specialist
for infants and young children who require
daily (long-term control) medications
and for children who received more than
2 bursts of oral corticosteroids in the prior
12 months.
-------
Pharmacotherapy of Childhood Asthma
Overall Considerations Relative to
Ch ron icity of Asth ma Severe
Moderate
MiJtK
Intermittent
X*
Long-term controller (anti-inflammatory
therapy)
Inhaled corticosteroids in increasing
dose and/or adding other classes of
drugs for therapy
Quick relief medicine—short-acting 62 -agonist prn * short-term use of oral corticosteroids
Copyright © 2003 American Academy of Pediatrics
Pharmacotherapy in asthma can be divided
into considerations of using agents to
relieve bronchoconstriction on an acute
or short-term basis (acute relief medication)
and the long-term use of maintenance
medications for clinically persistent asthma.
Long-term control (maintenance) therapy
is directed at controlling underlying chronic
inflammation and minimizing ongoing airflow
limitation and bronchial hyperreactivity, which
can lead to bothersome or even life-threatening
airflow limitation.
In mild intermittent asthma, in which symptoms
and the use of short-acting betaa-agonist
bronchodilators occur or are required no
more than 2 days a week, in which nocturnal
symptoms occur no more than twice a month,
and in which lung functions are at least 80%
of predicted or the patient's norm, short-acting
beta2-agonists by inhalation are used to relieve
symptoms. With infrequent exacerbations that
are moderate or severe, the short-term use of
a 3- to 10-day course of oral steroids also may
be added. As a general rule, the frequent need
for steroid bursts (eg, more often than every
6 weeks) indicates persistent asthma and the
need for daily maintenance therapy.
For patients who have symptoms more
frequently than indicated above, maintenance
or long-term controller medication is in order.
Such individuals who are designated as
having persistent asthma have been divided
into mild, moderate, and severe categories,
and guideline recommendations are based
on this categorization. However, asthma is
an undulating disease for many, if not most,
patients with asthma, and individuals may
fluctuate between these categories from time
to time. In addition, many patients considered to
have intermittent asthma in fact underestimate
the degree of symptoms and disease that can
be improved significantly with maintenance
medication. As with intermittent asthma,
short-acting beta-adrenergic agonists by
inhalation are used as quick-relief medications
for bronchodilation with short-term increases
in symptoms.
Long-term control or maintenance medications
include a variety of agents that can be used
alone or together, particularly with increasing
severity of asthma. Inhaled corticosteroids are
the single broadest and most effective class
of anti-inflammatory agents with the greatest
ability to control symptoms of patients with
asthma who have varying degrees of severity,
and are the preferred agents for long-term
control. However, there is significant variation
in needs and responsiveness to inhaled
corticosteroids and to other maintenance
medications and alternatives to inhaled
corticosteroids can be tried, particularly in
the milder forms of persistent asthma.
-------
Quick-relief Medications
* Used prn for ALL asthma severity levels
• Include
- Inhaled short-acting B2-agonists
- Oral corticosteroids (short courses)
- Inhaled anticholinergic (ipratropium bromide)
Copyright © 2003 American Academy of Pediatrics
Quick-relief medications include
short-acting beta2-agonists used
by inhalation, short courses
of systemic corticosteroids generally
by mouth on an outpatient basis, and
ipratropium bromide by inhalation. All
3 may be appropriate to use together
depending on the circumstances and
severity of the asthmatic exacerbation.
Although available orally in liquid and tablet
form, short-acting betaz-agonists generally
are most effective and better tolerated
when used by inhalation, and this route
of administration is preferred. Inhaled
beta-adrenergic agonists are available in
various forms and through various devices
including nebulizers with mouthpieces or
masks, metered-dose inhalers that can
be used alone or with spacers/holding
chambers with or without masks, and
dry powder inhaler devices.
-------
Quick-relief Medications
Short-acting B2-agonist inhalants
• Rapid bronchodilators by inhalation.
• First choice for acute symptoms and exercise-
induced asthma.
* Frequent use suggests lack of control and need
to reevaluate.
Anticholinergic inhalants (ipratropium
bromide)
• Possible additive benefit in acute severe asthma
Copyright © 2003 American Academy of Pediatrics
Short-acting beta2-agonists by
inhalation have the most rapid
bronchodilating activity of any class
of medications and are the preferred quick-
relief medication. They are used for quick
relief for all stages of asthma. They also
are useful in preventing exercise-induced
bronchospasm in most patients, when
used 10 to 15 minutes prior to exercise.
The frequent need for quick relief should
prompt a reevaluation of asthma severity
with consideration of the appropriateness
of placing a patient on maintenance therapy
or increasing already baseline maintenance
therapy. Ipratropium, when employed
ordinarily, is used in addition to short-
acting beta-agonists and can potentiate the
bronchodilator effectiveness of short-acting
beta2-agonists in some patients.
-------
Quick-relief Medications
Oral corticosteroids
• 1-2mg/kg.
• Use a short course (3-10 days) to gain control
of asthma and speed resolution of severe
exacerbations.
• Tapering dose is not necessary.
* Frequent need suggests inadequate control of
chronic disease.
Copyright © 2003 American Academy of Pediatrics
Short courses of oral corticosteroids
are recommended in doses of 1 to
2 mg/kg of prednisone or equivalent
per day divided into 2 doses per day
until symptoms are controlled adequately,
then discontinued. This can be in courses
from 3 to 10 days and can be stopped
without tapering.
-------
Long-term Control
Considerations for Choice of Medicine
* Class of agent
- Efficacy (greatest likelihood of controlling symptoms
and disease)
- Safety
- Therapeutic index—ie, risk-benefit, actual and perceived
* Severity of disease
* Adherence to therapeutic regimen
- Parental/child acceptance
- Ease of use—frequency, palatability
- Lifestyles, cultural
- Economic
Copyright © 2003 American Academy of Pediatrics
Considerations for the choice of
medication for long-term control of
persistent asthma include the class
of agent that has the greatest likelihood of
controlling symptoms and disease and the
medication's safety profile. The severity of
disease influences consideration of risk-
benefit ratios. In addition, the likelihood
or ability of the child and caregiver to
adhere to a therapeutic recommendation
is of strategic importance. The form
and palatability of medication, simplicity
of therapeutic regimen, fears of using
medication, specific medications, and
economic factors all influence the choice
of the most likely beneficial therapy.
-------
Long-term Control Medications
Inhaled corticosteroids
Cromolyn sodium/nedocromil sodium
LTRAs
Long-acting (^-agonist inhalants
Sustained-release theophylline
Oral corticosteroids
Copyright @ 2D03 American Academy of Pediatrics
Medications available for long-term
control of asthma in children
are listed here. These can be
used alone as a single class or combined
to enhance control or diminish side
effects of medications while maintaining
control. Because each class of medication
influences pathogenic mechanisms in
a somewhat unique way, it is easy to
understand that combination therapy may
have advantages over increasing doses
of monotherapy for many patients with
uncontrolled asthma.
LTR = leukotriene receptor antagonist
-------
Inhaled Corticosteroids
• Preferred therapy for all severities
• Broadest action
• Greatest ability to control asthma long-term
• Vary dose for control and safety
* May be combined with other medications
* Safer, even at high doses, than oral
corticosteroids
* Variety of dosages and delivery forms
Copyright © 2003 American Academy of Pediatrics
Corticosteroids have the broadest
action of any class of therapeutic
agents on the inflammatory
processes, and inhaled corticosteroids
have the greatest ability to control asthma
on a long-term basis at all levels of asthma
severity. They improve lung function,
decrease exacerbations, and improve
symptom control. There is evidence of
their ability to decrease mortality rates
as well. Dosages may be increased or
decreased to improve control or minimize
safety concerns. In addition, they may be
combined with other classes of drugs to
enhance control or decrease dosages with-
out a decrease in long-term control. This
has been demonstrated with the addition
of long-acting beta-adrenergic agents or
leukotriene pathway inhibitors in adults
and, to some extent, older children. There
is minimal information available for younger
children, especially those younger than
5 years. The degree of their effectiveness
varies and not all patients respond
adequately to even high doses of inhaled
corticosteroids alone. They are ordinarily
effective on a twice-daily dosage regimen
regardless of dose, and in many patients
with milder spectrum of disease, asthma
control may be maintained on once-daily
dosage. It is important to emphasize that
even at high doses for long periods, there
are less systemic side effects than with
use of oral corticosteroids that otherwise
would be required for long-term control.
There are various inhaled corticosteroids
available with differing intrinsic potencies
used with various kinds of devices and
differing degrees of ease of use and lower
respiratory tract drug deposition.
Fluticasone propionate is considered to be
more potent than other inhaled steroids
on a dosage basis by a factor of 2 or more,
but excessive use of all inhaled steroids
can potentially induce important adverse
effects. It is important to employ the
minimal dosage of any inhaled steroids
that can maintain adequate control of
asthma for that child. It also is important to
emphasize that because asthma tends to
be an undulating disease with periods of
increased and decreased symptomatology,
long-term requirements of inhaled
corticosteroids for asthma control may
vary in a given individual.
-------
inhaled Corticosteroids—Effectiveness
• Most short- and long-term outcome data (30+ y)
• i Exacerbations
* t Quality of life
* Effective for most patients at low dosage
• Cost-effective
* May alter airway remodeling
Copyright © 2003 American Academy of Pediatrics
Cost-effectiveness of the use of
inhaled Corticosteroids compared
to alternative maintenance therapy
has been demonstrated in patients with
persistent asthma. There is suggestive
but not compelling evidence that inhaled
Corticosteroids can alter the ultimate airway
remodeling that leads to fixed airway
obstruction in some patients. Clinically,
in most patients who are controlled with
even lower dose Corticosteroids, cessation
of corticosteroid therapy is followed by
resumption of symptomatology.
-------
Inhaled Corticosteroids—
Safety Concerns
• Systemic absorption—potential side effects
- Growth—dose and specific inhaled
corticosteroid dependent
* Transient 4 growth velocity, no effect on adult height
-Adrenal suppression
• Inhaled corticosteroids—less long-term absorption
(side effects) than oral steroids; can decrease need
for steroid bursts
Copyright © 2003 American Academy of Pediatrics
Although there is less systemic absorption
and therefore less potential systemic
effect with inhaled corticosteroids
than with systemic (oral) corticosteroids long-
term, systemic absorption probably occurs
to some degree even with the lowest doses
of corticosteroids. An effect on morning
cortisol levels can be seen with conventional
doses of inhaled corticosteroids. Except at
higher doses used for prolonged periods,
there is little evidence for clinically significant
effects on the hypothalamic-pituitary-adrenal
axis. Nevertheless, a transient effect on
growth velocity has been demonstrated with
beclomethasone dipropionate and budesonide
in particular. In addition to systemic absorption
that can occur through lung deposition with
all inhaled corticosteroids, beclomethasone
dipropionate is absorbed to a greater degree
from the intestinal tract than other steroids
and is converted on first-pass metabolism
in the liver to the monopropionate, which is
even more active than the dipropionate until
subsequently degraded. There is little evidence
that even with this particular corticosteroid,
low dosage (less than 200 ug/day and possibly
400 MS/day) is associated with such effects.
There is no evidence that the effect on growth
velocity, which seems to be an especially
sensitive indicator of systemic effect (whether
clinically significant) of inhaled corticosteroids,
results in any alteration of final adult height.
Also, beclomethasone and other inhaled
corticosteroids are effective for most patients
at low dosage. It also is important to emphasize
that for patients who have moderate to severe
asthma that requires higher doses of inhaled
corticosteroids and other medications for
adequate symptomatic control, there is much
less systemic absorption and effect than for oral
corticosteroids used either chronically or in the
form of frequent steroid bursts. Subcapsular
cataracts, increased intraocular pressure, and
glaucoma have been associated in adults
with high-dose inhaled corticosteroids and
especially with prolonged or frequent use of oral
corticosteroids. Although this is rare in children,
this potential from prolonged systemic exposure
to corticosteroids needs to be kept in mind and
the lowest dose of inhaled steroids necessary
for therapeutic maintenance should be sought
and reevaluated periodically. At ordinary doses
of inhaled corticosteroids for mild to moderate
asthma, bone density does not appear to be
diminished in studies up to 5 years. It is useful
to point out that corticosteroids used for anti-
inflammatory effects in asthma and other
diseases are not androgens and do not have
the side effects associated with their use.
-------
Gromolyn Sodium/
Nedocromii Sodium
Alternative therapy to inhaled corticosteroids
(less effective)
Can be used to prevent symptoms to
anticipated exposures (exercise, allergens,
irritants) on a prn basis
Used by inhalation (metered-dose inhaler;
cromolyn nebulizer solution available)
Copyright © 2003 American Academy of Pediatrics
Cromolyn sodium and nedocromil
sodium are recommended as
possible alternative therapies to
low-dose inhaled corticosteroids in young
children because of lack of safety concerns
for their use. They are anti-inflammatory
in that they can inhibit early and late
responses to allergen. Risk with use of
these agents is virtually nonexistent, but
general effectiveness does not compare
with low-dose inhaled corticosteroids.
Recent meta-analysis of studies on the
use of cromolyn for the maintenance of
therapy of asthma conclude that "there
is insufficient evidence that disodium
cromoglycate has a beneficial effect as
maintenance treatment in children with
asthma." If insufficiently effective (up
to 3-month trial?), it is recommended to
be replaced by inhaled corticosteroid.
Nedocromil is available only in a metered-
dose inhaler. Cromolyn is recommended
4 times a day whereas nedocromil is
prescribed as a twice-daily dose, but if
apparently effective, less frequent use of
cromolyn can be tried. These agents also
have some effectiveness in preventing
symptoms to anticipated exposures to
allergens or irritants if used 10 to 15
minutes before exposure and can be
at least partially protective alone or in
combination with beta-agonist inhalers
for exercise-induced asthma.
-------
LTRAs
* Montelukast sodium, zafirlukast
* Alternatives to low-dose inhaled corticosteroids
in mild persistent asthma
» Added control when combined with inhaled
corticosteroids
* Convenient (oral) dosing forms
- Chewable tablets (montelukast sodium)
• Safe
• Approved down to age 2 (montelukast sodium)
Copyright © 2003 American Academy of Pediatrics
Leukotriene receptor antagonists
(LTRAs) may be considered alternative
monotherapy to low-dose inhaled
corticosteroids in milder persistent
asthma, but data concerning the
effectiveness compared with low-dose
inhaled corticosteroids long-term are
lacking. Their inhibitory activity on the
inflammatory cascade is significantly
limited compared to corticosteroids.
Nevertheless, some patients do appear
to respond extremely well to these agents,
whereas others seem not to obtain any
significant effect from their use. There
is some controversy as to whether
corticosteroids, and in particular inhaled
corticosteroids, can alter the synthesis
of leukotrienes, but if so, the activity
does not appear to be profound in usual
therapeutic dosages. This is of significance
because the leukotriene pathway appears
to contribute bronchoconstrictive and
some inflammatory effects in many
patients with asthma.
The main advantages of LTRAs, especially
in young children, is that they are available
in various oral forms (for montelukast
sodium), are recommended once a
day, and are not corticosteroids (which
concern many parents and interfere with
compliance). Their good safety record to
date enhances the benefit-risk ratio.
-------
Methylxanthines (theophylline)
• Mild to moderate bronchodilation
• Add-on therapy
* Narrow therapeutic index
- Monitoring required
• Mild anti-inflammatory effect
- Low dose
Copyright © 2003 American Academy of Pediatrics
Methylxanthines, mainly
theophylline and aminophylline,
produce bronchodilatation
to a moderate degree and have some
anti-inflammatory activity. Their relatively
narrow therapeutic index, requiring
periodic monitoring of blood levels, is
accentuated by the fact that various
drug interactions as well as certain viral
infections may raise theophylline levels
to toxicity. The optimal therapeutic range
of serum concentration of theophylline
is now considered to be between 5
and 10 M9/mL, approximately half that
previously recommended. Their virtue
is their relative inexpensiveness, making
them a first-line therapy in parts of the
world in which expense is critical to
availability. Their effectiveness as first-
line maintenance therapy, however, is
less than that of inhaled corticosteroids
and their major role is probably as
add-on maintenance therapy with
other medications used at acceptable
dosages. Theophylline (aminophylline)
is a phosphodiesterase inhibitor;
more selective inhibitors of isoforms
of phosphodiesterase, believed to
be important in asthma, are being
investigated.
-------
Dual Controllers
Preferred for moderate persistent asthma in
children older than 5 years
- Data lacking in younger children
Low/medium-dose inhaled corticosterotds plus
- Inhaled long-acting B2-agonists (preferred)
- LTRAs, theophylline
Copyright © 2003 American Academy of Pediatrics
The 2002 updates to the National
Heart, Lung, and Blood Institute
Expert Panel Report 2 guidelines note
that extensive literature has demonstrated
that dual-controller therapy is more
effective than increasing the dose of
inhaled corticosteroids in patients with
moderate persistent asthma. The data on
the combination of inhaled corticosteroids
and inhaled long-acting beta2-agonists are
the strongest. These data apply mainly to
older children and adults. Data on adults
suggest that LTRAs may have steroid-
sparing effects on clinical control of
asthma and may enhance clinical control
if combined with inhaled corticosteroids.
In studies comparing adding long-
acting beta2-agonists with a given dose
of inhaled steroid with the addition of
LTRAs, long-acting beta2-agonists were
more efficacious in the population overall.
Accordingly, the National Asthma Education
and Prevention Program (NAEPP) 2002
Expert Panel Report 2 updates to the
guidelines now recommend low/medium
dose inhaled corticosteroids plus long-
acting beta2-agonists as the preferred
therapy for children older than 5 years and
adults with moderate persistent asthma.
Combinations of inhaled corticosteroids
with LTRAs are listed as alternatives. For
children younger than 5 years, data are not
available. For this age group, the NAEPP
Expert Panel recommends either inhaled
corticosteroids plus long-acting beta2-
agonists or increasing the dose of inhaled
corticosteroids.
LTRA = leukotriene receptor antagonist
-------
Oral Corticosteroids
Broad anti-inflammatory effects
Long-term use
- Systemic effects
- Reserved for severe asthma
Dosage increases prn for exacerbations
Copyright © 2003 American Academy of Pediatrics
Maintenance or long-term therapy
with oral corticosteroids is
reserved for patients with
severe asthma not controllable with other
maintenance medications, including high-
dose inhaled corticosteroids. The lowest
dosages of these steroids, preferably with
a short half-life (eg, prednisone), used
on an alternative-day basis is sought,
recognizing that short bursts of increased
doses of steroids used to obtain control
of acute exacerbations of asthma may
be needed.
-------
Stepwise Approach to Therapy
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X'X LTRA, theophylline (>5 y)
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ICS medium dose or
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or + LTRA, theophylllne
y=Short-acting B2-agonist pm ± short-term use of oral cortioosteroids
Copyright © 2003 American Academy of Pediatrics
Whether a patient is on
monotherapy or combination
therapy for asthma, alterations
in pharmacotherapy are often necessary
and should always be considered
to either increase asthma control or
decrease potential side effects from the
pharmacotherapy used. As indicated
previously, short-acting inhalant beta2-
agonists are used for quick relief in all
degrees of asthma requiring long-term
controller medication. Choice of controller
therapy is dictated by the degree of
severity of asthmatic symptoms and
airflow limitation as well as other factors,
including the child's age. In young children
with milder disease, cromolyn, nedocromil,
or LTRAs may be considered first, but an
inhaled corticosteroid in low to high dose
is the preferred pharmacotherapeutic
agent, either alone or in conjunction with
other maintenance therapy, at all ages.
Leukotriene receptor antagonists can
be considered as alternatives to low-
dose inhaled corticosteroids in milder
patients. With increasing degrees of
severity, in addition to consideration of
progressively higher doses of steroids
to enhance control, adding other
maintenance medication including long-
acting beta2-agents (LABA) (preferred),
LTRAs, theophylline, or any combination
thereof can be considered. It is usual to
add a single agent at a time and assess
the effects of doing so before either
withdrawing the agent if apparently
ineffective or adding another class of agent
to the therapy. This is so-called step-up
therapy, which may have to occur from
time to time even for patients who are
generally well controlled on a monotherapy
or combination therapy regimen.
LTRA = leukotriene receptor antagonist
-------
Sample Asthma Management Plan
Pedtatrtc Asthma: Promoting Best Practice. A Cwrfe tor Managing Asllima in Children. Milwaukee, Wl:
American Academy of Allergy, Asthma, and Immunology. 1999. @ 2002 Ail rights reserved
Copyright © 2003 American Academy of Pediatrics
This slide shows a representative
sample of a written asthma
management plan. Note that zones
are based on symptoms or peak flow.
-------
Infants and Young Children—
When to Start Controllers
* >3 episodes of wheezing in the last year and
• Parental history of asthma or physician diagnosis
of eczema
Or 2 of the following
• Physician diagnosis of allergic rhinitis, wheezing
apart from colds, peripheral eosinophilia
• Courses of oral steroids more often than every 6 wk
• Symptoms >2x/wk, nocturnal symptoms >2x/mo
Copyright © 2003 American Academy of Pediatrics
Based on observational studies, it is
the opinion of the Expert Panel 2
that the initiation of long-term
control therapy should be considered
in infants and young children who have
had more than 3 episodes of wheezing
in the past year that have lasted more
than 1 day and affected sleep, and who
have risk factors for the development
of asthma (parental history of asthma
or physician-diagnosed atopic dermatitis
or 2 of the following: physician-diagnosed
allergic rhinitis, wheezing apart from
cold, peripheral blood eosinophilia).
This is in addition to previously
recommended indications for starting
long-term control therapy—ie, in infants
and young children requiring symptomatic
treatment more than 2 times per week
or experiencing severe exacerbations
less than 6 weeks apart.
-------
Principles of Maintenance Therapy
• Start high.
* Step down once control is achieved.
* Maintain at lowest dose of medication that
controls asthma.
• Step up and down as indicated.
Copyright © 2003 American Academy of Pediatrics
Most experts prefer to obtain rapid
control of asthma by starting
control medications at higher
doses than would be expected to be
necessary for the degree of severity at
the time of presentation. For example,
a patient with previously intermittent
asthma presents with a history of almost
daily use of rescue medications for the
past several weeks, frequent nocturnal
awakening, and interference with exercise.
This patient would be started at therapy
for moderate persistent severity instead of
mild persistent. Once control is reached,
therapy can be stepped down with the
goal to maintain control of asthma with
the lowest dose of medication possible.
Asthma is a dynamic condition that often
fluctuates in severity. There may be
periods in which maintenance therapy
needs to be stepped up for a while, then
stepped down as control is achieved.
-------
Step-down Therapy
Step down once control Is achieved.
• After 2-3 mo.
• 25% reduction over 2-3 mo.
Follow-up monitoring
• Every 1-6 mo.
• Assess symptoms.
* Review medication use.
• Objective monitoring (PEFR or spirometery).
* Review medication.
Copyright © 2003 American Academy of Pediatrics
Once asthma is brought under control,
consideration should be given to
stepping down therapy by either
decreasing dosage (eg, of an inhaled
corticosteroid) or eliminating part of the
combination therapy. An adequate period
should be given for the maintenance of
asthma control before considering stepping
down, however. This is somewhat arbitrary,
but it is generally recommended that
symptomatic control for at least (in milder
asthma) 2 to 3 months after initial therapy
should be maintained prior to consideration
of stepping down. Stepping down may
include the possibility of decreasing the
frequency of medication as a way to
enhance adherence and decrease dosage
at the same time.
Asthma is a dynamic and often fluctuating
disorder that may require step-up and
step-down therapy periodically. The entire
step-up and step-down process implies
the need for regular monitoring of patients,
the frequency of which is dictated by the
stability of asthma and degree of asthma
control possible. Reassessment includes
carefully eliciting evidence of symptomatic
control and measuring airflow objectively.
Although symptoms can reflect lung
functions, it is important to emphasize the
imperfect relationship between airflow
limitation and symptoms, with a wide
range among the patient population of
perceived degree of airflow limitation.
Review of adherence, the ability to use
medication properly, and other aspects of
therapy are also important on a repeated
basis.
PEFR = peak expiratory flow rate
-------
Step-up Therapy
Indications: symptoms, need for quick-relief
medication, exercise intolerance, decreased
lung function.
- May need short course of oral steroids.
Continue to monitor.
- Follow and reassess every 1-6 mo.
- Step down when appropriate.
Copyright © 2003 American Academy of Pediatrics
Consider stepping up therapy when
goals of therapy are not being
achieved. This may require short-
term aggressive therapy to obtain or regain
control, after which it may be possible to
step down therapy to the previous or a
new maintenance level.
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Acute Exacerbations
Principle: Gain control as quickly as possible.
Treat all asthma exacerbations promptly
and aggressively.
* Inhaled fi2-agonist inhalants for quick relief
* Access to quick relief medication
• Written action plan
- Indications
- Medications
- When to contact physician or emergency medical services
• Short course of oral corticosteroids
Copyright © 2003 American Academy of Pediatrics
All asthma exacerbations need to be
treated promptly and aggressively.
The aggressiveness depends on
the degree of exacerbation as well as the
child's history of severity of exacerbations
and response to treatment. Short-acting
inhaled beta2-agonists such as albuterol are
preferred over other agents, including oral
beta2-agonists, for quick relief. Depending
on the age of the child, the child and
caregivers should have appropriate access
to quick-relief medications regardless
of where the child is. This includes at
the babysitter's, school, overnight at a
friend's house, and, of course, home. An
action plan, as simple as possible, should
be available for the caregiver and child,
if old enough. Children with a history of
severe, rapid onset disease should have
epinephrine available for initial therapy.
Depending on the origin and severity, the
effectiveness of bronchodilators alone may
be limited (eg, with infections involving
the lower respiratory tract due to viruses)
and a short burst of corticosteroids may
be needed. Bursts have been shown to
be effective in decreasing the likelihood of
hospital admission and length of hospital
stay in some studies. There is not good
evidence that systemic steroids alter
the course of acute asthma in infants
(3-18-month-olds). Beta-adrenergic
agents can decrease the degree of
symptomatology in bronchiolitis, but
there is not convincing evidence that
they alter hospitalization admission rates
in children with the more severe end of
the spectrum of disease. The addition of
ipratropium to beta2-agonist inhalants has
resulted in marginal improvement in acute
exacerbations overall. There is conflicting
evidence concerning the effectiveness of
theophylline in acute asthma. In children
on inhaled corticosteroids, at least doubling
the daily dose of inhaled steroid may
obviate the need for oral corticosteroids.
Some physicians use bursts of inhaled
corticosteroids during acute exacerbations
in children who are not on maintenance
therapy.
Peak flow assessments at home are
useful in helping to determine the severity
of exacerbation and course of action in
children able to perform this maneuver and
for whom baseline normal or optimal levels
have been established.
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Acute Exacerbations
Office Management
Assess severity.
• Symptoms, signs, lung function, pulse oximetry (if available)
I
• Oxygen recommended
• Short acting R2-agonist inhalant every 20-30 min
* ± Ipratropium—metered-dose inhaler, inhalation solution
• * Corticosteroid—orally, intravenous if vomiting
* Intravenous favored if dehydrated
• Follow-up—hours (phone) to 1-7 d
Copyright © 2003 American Academy of Pediatrics
Office management is similar in overall
principal to management at home.
However, it is important that an airflow
measuring device such as a peak flow meter
or, in the case of offices that see patients with
asthma and asthmatic exacerbations with some
frequency, pulmonary function equipment
is used. The availability of pulse oximetry is
desirable but even in the absence of oximetry,
with moderate to severe exacerbations, oxygen
should be available and given. In extreme cases
in which it is impossible to obtain cooperation
with inhalational agents or in which the child has
extremely poor inspiratory effort (with severe
exacerbations), epinephrine may be given.
It is emphasized, however, that in almost all
instances inhalation of selective beta2-agonists
is at least as effective as parenteral epinephrine
and can be administered for sufficient effect.
Steroid action is relatively slow, taking hours in
most instances, and is not necessarily faster by
the parenteral route. If the child can tolerate oral
medication it is preferred, except in the more
extreme cases. Because some children with
asthma, particularly with a moderate to severe
exacerbation, are dehydrated, intravenous fluids
may be indicated and may serve as a conduit
for systemic steroids. Care should be taken not
to overhydrate the child, however, as increased
negative intrapleural pressure may predispose
to pulmonary edema.
As a general rule, with an acute exacerbation,
decisions concerning whether the child can
be treated further at home (or in the office) or
requires longer term treatment in an emergency
department or hospital admission, can be made
based on the response to therapy within a 2-
hour period. On the other hand, some children
will respond with continued therapy over a
period of 6 to 8 hours in the office, to the point
that they then can be further managed at home.
It is important under circumstances of moderate
to severe exacerbations to employ objective
assessment (eg, oxygen saturation, lung
function) in addition to changes in signs and
symptoms. It also is important to recognize that
peak flows and pulmonary functions in general
are effort-dependent and poor effort, even in
the absence of a great deal of airflow limitation,
may result in falsely low values. On the other
hand, peak flows tend to underestimate the
degree of airflow limitation compared to FEVi
and other parameters of pulmonary function.
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Risk Factors for Death From Asthma
• Patient history of sudden, severe exacerbations
• Prior intubation
* Prior intensive care unit admission
* ss2 hospitalizations
• >3 emergency department visits in past 12 mo
* Hospitalization or emergency department visit
in last mo
Copyright ® 2003 American Academy of Pediatrics
Several factors have been identified
that put a patient with asthma
at risk of a fatal or near-fatal
exacerbation. This slide lists those factors
in the patient's history that should make
the clinician very cautious in treating
an exacerbation. These factors include
previous emergency department visits and
previous hospitalizations and intensive care
unit admissions for asthma.
-------
Risk Factors for Death From Asthma
• >1 canister/mo of albuterol
« Current chronic use of oral corticosteroids
• Difficulty perceiving airflow obstruction
* Low socioeconomic status and urban residence
• Illicit drug use
* Serious psychiatric disease or psychosocial
problems
Copyright © 2003 American Academy of Pediatrics
In addition to historical clues mentioned
in the previous slide, evidence for poor
control of asthma or severe asthma also
places the child at increased risk. Children
who have trouble perceiving the severity
of airflow obstruction will often present
late in the course of an exacerbation, when
bronchodilator therapy may be ineffective.
Finally, several socioeconomic and
psychosocial factors have been identified
as well, which probably are associated
with decreased adherence to asthma
management plans or lack of access to
adequate medical care.
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Special Considerations
Infants and Children <3 y
Recurrent wheezers—? Long-term control therapy
Considerations
• Frequency and severity of exacerbations
* Symptoms, signs between visits?
* Chronic persistent symptoms
• Seasonal? (Viral)
• Family history asthma, atopy
• Presence of other atopic disease
Copyright © 2093 American Academy of Pediatrics
A dilemma may arise in determining
whether recurrent wheezers in this age
group (and even in older children) have
persistent underlying disease that requires
maintenance therapy even when completely
asymptomatic. This is particularly difficult
in the youngest children in which objective
measures of airflow are difficult or ordinarily
impossible in practice. Evidence of any
degree of symptomalogy should be sought,
including any exercise-intolerance or exercise-
related symptoms, even in the absence of
overt wheezing between exacerbations. This
may require educating not only parents but
other caregivers. Some children have virtually
persistent asthma during the respiratory viral
season but are symptom free during other parts
of the year and may benefit from maintenance
during the former season.
Based on observational studies, it is the opinion
of the Expert Panel that the initiation of long-
term control therapy should be considered
in infants and young children who have had
more than 3 episodes of wheezing in the past
year that have lasted more than 1 day and
affected sleep and who have risk factors for
the development of asthma (parental history of
asthma or physician-diagnosed atopic dermatitis
or 2 of the following: physician diagnosed
allergic rhinitis, wheezing apart from colds,
peripheral blood eosinophilia). This is in addition
to previously recommended indications for
starting long-term control therapy—ie, in infants
and young children requiring symptomatic
treatment more than 2 times per week or
experiencing severe exacerbations less than
6 weeks apart.
Recurrent wheezing when the patient is
younger than 3 years is relatively common and
not necessarily associated with persistence
of asthma beyond this age. In other words,
these are children who do not appear to have
asthma in the sense that it is the chronic
disorder that is a common characteristic of
the disease. Associated factors that increase
the likelihood that recurrent wheezing is, in
fact, a manifestation of asthma in this age
group include the family and particularly
parental history of asthma and/or a history of
other atopic diseases in closely related family
members. A particularly high association occurs
between the development of asthma and the
presence of eczema in young children.
(NOTE: At this point, lecturers may wish to use
further information about the significance of
wheezing in younger age groups, [eg, data from
the Tucson group].)
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Special Considerations
Acute Exacerbations—Infants and Children <3 y
* (i2-agonist (by nebulizer or mete red-dose inhaler with
spacer and mask)
- May decrease symptoms, but may not alter hospital admission rates
- Conflicting evidence for effectiveness in bronchiolitis
* Ipratropium (by nebulizer or metered-dose inhaler with
spacer and mask)
- Conflicting evidence; marginal improvement
• Oral or intravenous steroids
- Conflicting evidence
- May decrease symptoms and length of hospital stay
- Evidence poor for altering likelihood of admission over course of
bronchiolitis or acute asthma
Copyright © 2003 American Academy of Pediatrics
Evidence for effectiveness for infants
and children younger than 3 years
of various agents shown to be
effective in older children is somewhat
conflicting. This is probably related to
the heterogeneity of origin of wheezing
in this age group as well as the nature
of inciting agents and the particular
role of viral agents that affect the lower
respiratory tract. Nevertheless, in some
children inhaled beta-agonists are helpful in
significantly relieving symptoms, although
in children with severe obstruction, they
may not improve airflow limitation to the
point that hospitalization is avoidable. The
effectiveness of beta-adrenergic agents
in bronchiolitis is conflicting, but some
reports indicate that at least some patients
appear to respond. However, nebulized
epinephrine may be superior to selective
beta2-agonists.
The use of ipratropium for acute
exacerbations in this age group has been
somewhat successful in some instances,
but improvement in general appears to
be marginal. Its effectiveness is more
impressive in severe exacerbations. It
is not considered of value for bronchiolitis.
The ability of oral or parenteral
corticosteroids to markedly alter the course
of disease in this age group is not as
impressive as in the older age group, but
in some studies children treated with a
burst of steroids have fared better as a
group than those not so treated.
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Special Considerations
Inhaled Medications
Preferred over oral agents at all ages
Present special problems in younger children
Nebulizers with masks and mouthpieces
Metered-dose inhaler with holding chamber and
mask, spacer without mask
Dry powder inhalers
Copyright © 2003 American Academy of Pediatrics
Inhaled beta2-agonists are preferred
over oral agents in children at all
ages, but in the youngest age group
they may present particular problems.
Various devices are available and can
be tailored to the needs and abilities of
individual children. Numerous studies
have documented that a metered-dose
inhaler with spacer is equally effective
as a nebulizer for delivering albuterol
during an acute exacerbation of asthma.
-------
Monitoring—At Home
Usefulness of Peak Flow Meters
Response to maintenance therapy.
May improve adherence.
Underestimates severity of obstruction.
No substitute for spirometry for diagnosis.
Long-term monitoring requires periodic spirometry.
Assist in decisions about acute intervention.
Copyright © 2003 American Academy of Pediatrics
It is recommended that a peak flow
meter be available for monitoring
airflow at home for children who have
moderate to severe asthma or recurrent
exacerbations of more than mild severity.
In addition to helping to assess the severity
of an acute exacerbation, peak flow meters
can be used periodically for limited periods
to help evaluate the response to therapy
by the caregiver and physician.
It also is important to recognize that
peak flows and pulmonary functions in
general are effort dependent, and poor
effort even in the absence of a great
deal of airflow limitation may result in
falsely low values. Also, peak flows may
seriously underestimate airflow limitation
in severe exacerbations. Assessment of
airflow by peak flow meters, whether at
home or in office, are not a substitute
for spirometry, which is much more
definitive in determining the degree of
overall airway patency.
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Comorbld Conditions
Allergic rhinitis
Sinusitis
GERD
Copyright © 2003 American Academy of Pediatrics
Comorbid conditions can complicate
asthma therapy. These conditions
can all act as triggers for asthma
and, if unrecognized and untreated, make
the control of a patient's asthma more
difficult. Clinicians need to be aware of
these potential comorbidities and treat
them as well as the asthma.
GERD = gastroesophageal reflux disease
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Exercise-induced Asthma
Considerations
80% or more of children with asthma
Interference with the psychosocial development
Can be controlled
Isolated exercise-induced asthma rare
Subtle signs
- Cough, chest or throat tightness, poor stamina,
fatigue, inactivity
Copyright © 2003 American Academy of Pediatrics
Exercise-induced asthma can often
present with subtle symptoms such
as chest pain, abdominal pain, throat
tightening, and frequent cough, in the
absence of obvious wheeze or shortness
of breath. Shortness of breath can be
misleading. Children with poor physical
conditioning will be short of breath with
exercise that may be out of proportion
to their peers. Typically, such shortness
of breath resolves rapidly with rest (2-3
minutes), whereas children with exercise-
induced asthma have symptoms that last
several minutes to even hours.
Children younger than 6 years with
exercise-induced asthma may require
treatment for persistent asthma because
they are always spontaneously exercising.
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Exercise-induced Asthma
Therapy—General Principles
Exercise-induced asthma may reflect suboptimally
controlled asthma, which may require adjustment of
overall therapy of asthma.
Goal: facilitate normal activity levels, including
competitive sports.
Individualize therapy.
Child needs to understand and be partner in therapy.
Copyright ® 2003 American Academy of Pediatrics
It is important to recognize that exercise-
induced asthma is a physiologic test
for bronchial hyperresponsiveness
and may reflect suboptimally controlled
asthma that requires adjustment of overall
therapy. The goal of therapy is to facilitate
normal activity levels, including competitive
sports, at least to the point that there is no
interference with normal physical activity
and what the child wishes to be able to
do. At the same time it is important to
recognize that many children with exercise-
induced asthma will decrease their activity
levels and choose not to be more active
because of the discomfort they personally
experienced from these activities.
There are general rules of therapy but
much individualization of therapy is
needed, as in asthma overall. The child
needs to understand and be a partner
in therapy to accomplish the goals of
therapy. This, of course, is true also of the
caregivers. Appropriately therapy should
be immediately available for preventing or
treating exercise-induced asthma.
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Treatment for
Exercise-induced Asthma
(l2-agonist
Cromolyn
LTRAs
Treat underlying inflammation
Warm-up
Consider another diagnosis
Copyright © 2003 American Academy of Pediatrics
Medications possibly useful for exercise-
induced asthma are listed here. The single
most effective class for pretreating or
preventing asthma are beta-agonists aerosols. Rapid
short-acting betaj-agonists such as albuterol are
the drugs of choice, given ideally 10 to 15 minutes
prior to exercise, but their duration of protection is
relatively short. Long-acting beta2-agonists, specifically
salmeterol xinafoate and formoterol fumarate, also
are effective in preventing exercise-induced asthma
and tend to be effective for many hours. However,
continued (eg, daily) use of the agents may diminish
the duration over which effective protection occurs.
Also, these physiologic antagonists decrease but do
not eliminate a potential for exercise-induced asthma,
so with an increase in the intensity of exercise, the
protective effect is relatively decreased. (NOTE:
Salmeterol, if used as a preventative, should be taken
20-30 minutes before exercise; formoterol acts as
rapidly as albuterol).
Cromolyn sodium and nedocromil sodium also have
been shown to be effective in preventing exercise-
induced asthma, although somewhat less so
compared to beta-adrenergic agonists aerosols alone.
In individuals who receive definite but incomplete
benefit from the use of either of these classes of
agents, the combination of these agents (eg, albuterol
plus cromolyn sodium as a preventative) can be more
effective than either alone.
The more recent availability of leukotriene pathway
inhibitors has been accompanied by evidence of
effective inhibition of exercise-induced asthma for
even greater periods of time than the long-acting
beta-adrenergic agents and no appearance of any
loss of protection with chronic use. They are used
as maintenance medication and are not officially
approved for prn use for exercise-induced asthma
prevention. Several studies in children and adults do
indicate excellent prevention after single doses, some
tested only 2 to 4 hours after being taken.
Antihistamines may have some, albeit relatively weak
effect in inhibiting exercise-induced asthma, but in
any event are not contraindicated for use in asthma
or exercise-induced asthma.
Although anticholinergic aerosols and methylxanthines
have been shown to be of some help in studies, their
effectiveness is neither as profound or consistent
as with the previously indicated agents and they
generally are not recommended.
Inhaled corticosteroids are effective mainly with
long-term use in controlling underlying asthma
pathology, decreasing the bronchial hyperreactivity
associated with ongoing asthma and therefore
bronchial hyperresponsiveness to exercise.
General recommendations for treatment of exercise-
induced asthma include pretreatment either with a
betas-agonist inhalant, cromolyn, or nedocromil, or the
combination of the 2 classes of drugs. Leukotriene
pathway inhibitors are a potential alternative but are
recommended mainly as maintenance therapy at this
time. Other agents listed are generally much less
effective in preventing exercise-induced asthma and
are not recommended.
Optimizing overall control of asthma can be a
very effective way to minimize exercise-induced
asthma. Inhaled corticosteroids or other long-
term control medications, in particular leukotriene
pathway inhibitors alone or in conjunction with other
maintenance therapy, are useful.
If exercise-induced symptoms are not significantly
diminished by any of the major preventers indicated
here or by optimizing long-term asthma control, the
diagnosis of exercise-induced asthma should be
reconsidered and the patient referred to an asthma
specialist for further evaluation. One masquerader
of exercise-induced asthma, at least in older children
(and adults), is vocal cord dysfunction.
LTRAs = leukotriene receptor antagonists
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Adherence to Therapy
General Considerations
• Make therapeutic schedule as simple and
convenient as possible.
• Make therapeutic plan as clear as possible (include
written instructions).
* Use as user-friendly devices/mode of delivery as
possible.
* Involve child as important participant.
• Address patient and family fears and expectations.
Copyright © 2003 American Academy of Pediatrics
The effectiveness of therapy for
disorders depends on appropriate
diagnosis, appropriate therapeutic
recommendations, and adherence by
the patient to therapy. It is important
to make any therapeutic schedule as
simple and convenient as possible
to foster ease of adherence and to
make the therapeutic plan as clear as
possible, as well. This may and often
does include clear written instruction. An
understanding by the child, if old enough,
and caregivers of the rationale for the
therapeutic recommendations, as well
as the acceptance of the caregivers and
child, if old enough, of the plan, are also
critical. The schedules for administration
of medication need to be as user-friendly
as possible. Because inhalational therapy
in particular may require a greater or lesser
degree of coordination depending on the
device, education, including repetitive
education, of appropriate use is important.
This should be considered during each
of the periodic visits to determine clinical
status and adherence to therapy. Alteration
of medical plans to optimize therapy,
including acceptance of therapy, is of
continued importance.
The more the pediatric patient can be
involved as an active participant in therapy,
along with the caregiver, the greater the
likelihood of adherence and success
of therapy. There are many fears and
expectations that families and children
have about the disease and its treatment,
and it is important to address these to
determine what patients and families are
likely to accept and expect. Reasonable
expectations including time frame and
approach to therapy are important aspects
of this discussion.
-------
Consider Referral to an
Asthma Specialist
History of life-threatening exacerbation
Goals of therapy not met after 3-6 mo
Atypical signs and symptoms
Comorbid conditions complicating therapy or
diagnosis
Additional diagnostic testing indicated
Copyright © 2003 American Academy of Pediatrics
Consideration should be given to
referral to an asthma specialist,
particularly an allergist, in these
particular situations. Any child who has
had a life-threatening asthma exacerbation
is at increased risk of having another and
will often need intensive management.
Children who continue to experience
asthma morbidity after 3 to 6 months
of therapy, such as interference with
exercise, nighttime awakenings more
often than twice monthly, and emergency
department visits, may need more
intensive therapy or evaluation. If the
child is unresponsive to therapy, referral
should be considered even sooner. Some
asthma symptoms and signs may be
atypical, and if the response to therapy
is questionable, further evaluation and
testing, such as bronchoprovocation,
may be needed. The response to therapy
may be suboptimal if there are other
conditions present that complicate the
diagnosis such as allergic rhinitis or
sinusitis. Children with persistent asthma
often need additional testing, such as
pulmonary function testing or allergy skin
testing, to optimize their therapy.
-------
Consider Referral to
an Asthma Specialist
• Additional education and guidance needed
• Consideration for immunotherapy
• Severe persistent asthma
• Moderate or severe persistent asthma in child <3 y
* Long-term oral corticosteroids, high-dose inhaled
cortrcosteroid therapy, or >2 y burst of oral
corticosteroids in 2 mo
Copyright © 2003 American Academy of Pediatrics
Some children and their families
may need additional education
and guidance on complications
of therapy, problems with adherence,
or avoidance of triggers. Children with
asthma triggered primarily by allergic
triggers, confirmed by skin testing,
may experience improved control of
asthma with immunotherapy. Asthma
specialists, particularly allergists, can
identify these children and supervise their
immunotherapy. Finally, children with
more severe disease, as exemplified by
higher levels of therapy, may benefit from
specialized care.
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Pharmacologic Management of Asthma
Asthma Medications
The goals of treatment for asthma are to minimize symptoms and allow children to participate
in normal physical activities with minimum side effects. It is also important to prevent
emergency department visits and hospitalizations due to asthma attacks. Ideally, this means
your child should not experience asthma symptoms more than once or twice per week, asthma
symptoms should not wake your child at night more than twice per month, and your child should
be able to participate in all play, sports, and physical education activities.
Asthma medications come in a variety of forms, including the following:
• Metered-dose inhalers
• Dry powder inhalers
• Liquids that can be used in nebulizers
• Pills
Inhaled forms are preferred because they deliver the medication directly to the air passages with
minimal side effects.
Medications Used to Treat Asthma
Asthma is different in every patient, and symptoms can change over time. Your health care
provider will determine which asthma medication is best for your child based on the severity
and frequency of symptoms and your child's age. Children with asthma symptoms that occur
only once in a while are given medications only for short periods. Children with asthma whose
symptoms occur more often need to take controller medications every day.
Sometimes it is necessary to take several medications at the same time to control and prevent
symptoms. Your health care provider may give your child several medications at first, to get the
asthma symptoms under control, and then decrease the medications as needed. Your health care
provider may also recommend a peak flow meter for your child to use at home to monitor lung
function. This can help you make decisions about changing therapy or following the effects of
changes made by your health care provider.
Asthma medications are divided into 2 groups: quick-relief medications and controller medications.
Quick-Relief Medications
Quick-relief medications are for short-term use to open up narrowed airways and help relieve the
feeling of tightness in the chest, wheezing, and breathlessness. They can also be used to prevent
exercise-induced asthma. These medications are taken only on an as-needed basis. The most
common quick-relief medication is albuterol.
Controller Medications
Controller medications are used on a daily basis to control asthma and reduce the number of
days or nights that your child has symptoms. Controller medications are not used for relief of
symptoms. Children with symptoms more than twice per week or who wake up more than twice
per month should be on controller medications.
-------
Controller medications include the following:
• Inhaled steroids
• Long-acting bronchodilators
• Combination products that contain inhaled steroids and long-acting bronchodilators
• Leukotriene receptor antagonists (only available in pill form)
• Inhaled nonsteroids (such as cromolyn or nedocromil)
• Methylxanthines (for example, theophylline)
Inhaled corticosteroids are the preferred controller medication for all ages. When used in the
recommended doses, they are safe for most children. In your child's particular case, however,
your health care provider may recommend another type of controller medication.
Asthma Management Plan
It is usually helpful to have an asthma management plan written down so you can refer to it from
time to time. Such a plan should contain information on daily medications your child takes as well
as instructions on what to do for symptoms. A plan should also be provided to your child's school.
Exercise-Induced Asthma
Exercise can often trigger symptoms in children with asthma. It can almost always be prevented
with use of quick-relief medications taken 10 to 15 minutes before exercise. If it occurs frequently,
however, it may mean your child's asthma is not under control. Proper asthma control can make a
great difference in the ability for a child to exercise normally. It is important for parents to speak to
their child's physical education teachers and coaches about their child's asthma management.
American Academy of Pediatrics
DEDICATED TO THE HEALTH OF ALL CHILDREN™
Copyright © 2003
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Pharmacologic Management of Asthma
Key Points to Cover With Patients
• Goals of therapy are to (1) minimize symptoms, ideally no symptoms day or night; (2) minimize
asthma exacerbations, ideally no exacerbations requiring emergency department visits
or prednisone; (3) maintain normal activity levels and school attendance; (4) maintain normal
or near normal pulmonary function; and (5) minimize adverse effects from medications.
• Key components of therapy are to control those factors that contribute to asthma (environmental
control), pharmacotherapy, parent and patient education, assessment, and monitoring.
• Agents used for asthma include quick-relief medications, such as albuterol, and controller
medications, such as inhaled corticosteroids, leukotriene receptor antagonists (LTRAs),
cromolyn, or theophylline. Quick-relief medications are used for the relief of symptoms of
asthma. Controller medications are used daily to control asthma. These medications can be
delivered to the patient in a variety of forms, including nebulizers, metered-dose or dry powder
inhalers, or pills. Inhaled forms are preferred, with the exception of LTRAs.
• Pharmacologic agent selection is based on the chronicity and severity of asthma, the age of
the child, and in cooperation/partnership with the patient and/or parents. Every patient is an
individual, and treatment approaches need to be individualized. Children with symptoms more
than twice weekly, or nocturnal awakening with symptoms more than twice monthly, require
controller medications. Children who have severe exacerbations requiring oral corticosteroids
more often than every 6 weeks also should be on controller therapy.
• A stepwise approach to therapy is used, with aggressive therapy initially to maintain rapid
control, with a step-down process once control is maintained.
• Inhaled corticosteroids are the preferred anti-inflammatory therapy for patients of all ages with
persistent asthma. Side effects at recommended doses are not persistent or clinically significant.
In some situations, however, other controller therapies might be considered.
• Exercise is a trigger for asthma in most children and can usually be prevented if they use their
quick-relief medication shortly before exercise.
• A written management plan, including instructions on management of exacerbations, should be
provided to all patients and/or parents. A similar plan should be provided for school, if applicable.
• Peak flow monitoring should be considered in children with moderate or severe persistent
asthma or in those who have difficulty recognizing symptoms.
American Academy of Pediatrics
DEDICATED TO THE HEALTH OF ALL CHILDREN
Copyright © 2003
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Management Aids
Inhalers, Spacers, Peak Flow Meters, Nebulizers
Photos courtesy of Andrew Silk.
Copyright © 2003 American Academy of Pediatrics
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Introduction
• Multiple inhaler systems and devices available
as management adjuncts for asthma (inhalers,
dry powders, spacers, PFMs, nebulizers).
* Useful in carrying out asthma control plan.
* Knowledge of proper use key to their success.
* Repeated education about these devices must
occur in physician's office, emergency room,
hospital, school.
Copyright © 2003 American Academy of Pediatrics
Multiple respiratory inhaler systems
and devices are now available for
the treatment and management
of asthma in children. New devices and
gadgets are being introduced regularly.
These management adjuncts can be useful
in carrying out a child's asthma control plan.
However, good technique is necessary
with these devices for good results. Failure
of a medication plan or asthma control
plan is often caused by poor technique.
Education and reeducation about these
management adjuncts needs to occur in
the physician's office.
PFM = peak flow meter
-------
Challenges in Pediatric
Asthma Therapy
Large age span with
- Different developmental stages
- Variable inhaler/device technique
- Changing lung capacity
Repeated education of patient and parent
is required.
Information about lung delivery is limited.
Device changes with age.
Copyright © 2003 American Academy of Pediatrics
Photo courtesy of Andrew SEIk.
Pediatrics spans a large age range
with different developmental stages,
variable inhaler/device technique
and ability, and changing lung capacity.
In addition, a child's asthma severity can
vary over time. As a result, the caregiver
must tailor the inhaler device to specifically
fit the child, including maturity level
and severity of asthma. Education and
reeducation of the parent and child needs
to take place over time. The technique or
device the child uses today may not be the
right one tomorrow as the child matures
and asthma severity varies. An additional
challenging aspect of pediatric asthma
therapy is that very little information is
available about the effect on inhaled dose,
lung deposition, etc, when a spacer is
used or when medications are given by
nebulization. Similarly, less is known about
the beneficial effects of the use of peak
flow monitoring in children with asthma
than adults.
-------
Inhaler Delivery Systems
MDI
-CFC
-HFA
- Autohaler
DPI
- Single dose
- Multidose
Nebulizer
Copyright © 2003 American Academy of Pediatrics
There are 3 major ways inhaled drugs
for asthma are delivered to patients.
The most common and with the
longest history is the pressurized metered-
dose inhaler (pMDI or MDI). Most currently
available MDIs contain a chlorofluorocarbon
(CFC) propellant, although with time,
as per the Montreal Protocol, MDIs
with a CFC propellant are to be phased
off the market. Some MDIs that have
appeared on the market contain the new,
environmentally friendlier propellant
hydrofluoroalkane (HFA). All MDIs,
except one, require a press-and-breathe
technique in which the patient is required
to coordinate actuation of the inhaler with
inhalation of the drug. In one inhaler (the
Maxair Autohaler), this coordination is not
necessary—the unit automatically fires
upon inhalation by the patient. Dry powder
inhalers (DPIs) are becoming increasingly
common. Dry powder inhalers do not
require a press-and-breathe technique—
the powder is directly inhaled in to the
lungs with a rapid and forceful inspirator/
maneuver. A limited number of different
DPI devices are available—some are
multidose units (ie, do not require reloading
the device with a dose [eg, Turbuhaler,
Discushaler]) and others are single dose
(ie, require loading the device with a dose
each time, like a capsule [eg, Ventolin
Rotocaps, Foradil Aerolizer]). Children
mature enough to be able to take a deep
and rapid inspiration on command (usually
not younger than 4 years) generally can
use a DPI. Finally, asthma medications can
be delivered by a nebulizer, a device that
aerosolizes liquids.
-------
Ways to Use an MDI
* Closed mouth
* Open mouth
• Spacer
Copyright © 2003 American Academy of Pediatrics
A child with asthma can use an MDI
by closed-mouth technique, by
open-mouth technique, or with the
aid of a spacer. In closed-mouth technique,
the MDI is placed in the mouth through the
teeth and with the tongue out of the way
of the orifice. In open-mouth technique,
the MDI is held about 2 to 3 fingerbreadths
d"-2") in front of an open mouth. The open-
mouth method allows for spacing to occur
between the MDI and throat, allowing
aerosol particles to slow up before having
to turn in the oropharynx and enter into
the lungs. This spacing can enhance lung
delivery, if done properly, but open-mouth
technique has its own pitfalls. Use of an
MDI with a spacer is necessary in all young
children (ie, younger than 5 or 6 years) and
others unable to master an MDI without
one, and with certain medications (eg,
inhaled corticosteroids).
-------
Closed-mouth Technique
• Prime (if necessary); shake vigorously Plw">""""""'•"*"<*ws"k
• Child relaxed, shoulders down, chin in neutral position
* Thumb on bottom of plastic holder, index finger on top
of canister ("pinch")
• Mouthpiece through teeth, tongue underneath/out of
way of orifice
• Breathe out, then canister depressed as child begins
to inhale slowly
* Slow/deep maximal inspiration
• Breath held for 10 s
Copyright © 2003 American Academy of Pediatrics
Newly purchased inhalers or those
not used for awhile (ie, more than
a few days) should be primed (ie,
fired once). Chlorofluorocarbon (CFC)
propellent-containing MDIs are gaseous-
powder suspensions and therefore need
to be shaken vigorously before use. Certain
HFA-propellant-containing MDIs (eg, HFA
beclomethasone dipropionate or, Q-Var)
are solutions, not suspensions, and do not
need to be shaken. The child should be
fully relaxed, with shoulders down and chin
in a neutral position. To allow the child to
easily depress and fire the MDI, have the
child put his or her thumb on the bottom
of the plastic holder and index finger
on top of the canister (ie, "pinch" the
inhaler). Put the mouthpiece well into the
mouth, through the teeth with the tongue
positioned underneath and away from the
orifice. Just as the child begins to inhale,
he or she is to depress/fire the canister and
continue to inhale slowly and deeply to a
maximal inspiration, followed by holding his
or her breath for 10 seconds.
-------
Open-mouth Technique
Same technique as closed except
- Open mouth fully,
- Position inhaler 2-3 fingerbreadths
(1"-2") in front of open mouth,
aimed directly into mouth.
Breathe out, fire canister at very beginning of inhaling
slowly and deeply.
Potential problems leading to decreased lung delivery
- Mouth not fully open (bounces off lips, teeth).
- Canister not aimed correctly (misses mouth
opening).
Photo cauti*iy of ftndrttwsilk.
Copyright © 2003 American Academy of Pediatrics
Open-mouth technique is
recommended, as it takes advantage
of the fact that positioning the MDI
a short distance away from the mouth
allows for the aerosol to slow up before
arriving at the throat. This reduces the
amount of medication impacting on the
back wall of the oropharynx, thereby
resulting in more aerosol particles reaching
the lungs. The only difference between
open- and-closed mouth techniques is
the initial positioning of the MDI relative
to the mouth. The child opens his or her
mouth fully and positions the inhaler 2
to 3 fingerbreadths (1"-2") in front of the
open mouth. He or she then fires the MDI
aerosol into the mouth just as initiating a
slow and deep inhalation, followed by a
10-second holding of the breath. Common
problems with open-mouth technique are
that the child aims the inhaler in the wrong
direction and misses the mouth or fails
to open the mouth fully and the mist hits
the lips and teeth and does not enter the
mouth. A spacer can provide the spacing
that occurs with open-mouth technique,
circumventing the problems of the open-
mouth approach and serving other useful
functions at the same time (see future
slides on spacers).
-------
Errors Made When Using an MDI
Forget to prime; shake; use of a "dead" inhaler
Miss mouth or mouth not fully open (open-
mouth technique)
Tongue or teeth obstructing
Poor coordination of actuation with inhalation
Two actuations at a time
Copyright © 2003 American Academy of Pediatrics
An MDI is not always used correctly;
many mistakes can be made.
Patients and parents sometimes
are not aware that an inhaler is empty
and, therefore, are using a "dead" inhaler.
Another common mistake is forgetting
to shake the canister before use, which
results in variable dosing of the medication.
Common errors inherent in open-
mouth technique are missing the mouth
altogether with the aerosol medication and
not fully opening the mouth. With closed-
mouth technique, patients sometimes
forget to keep the tongue or teeth away
from the mouthpiece orifice, resulting in
a blockage of aerosol medication coming
out of the inhaler. Proper coordination
or timing of actuation of the medication
with inhalation is very important. Firing
the MDI either too early or too late leads
to diminished amounts of medication
to the lungs. If this coordination cannot
be done properly, a spacer is needed.
One inhalation should accompany one
actuation—make sure the child is not doing
2 hits of the inhaler with one inhalation.
-------
Errors Made When Using an MDI
Improper inspiratory flow rate (too slow/fast)
Head/shoulder action but not chest action
Nasal breathing
Incomplete inspiration
Inadequate breath hold
Using an empty MDI
Copyright © 2003 American Academy of Pediatrics
The proper inhalation rate is about 30
to 45 L per minute, which turns out
to be "not too fast, but not too slow."
Children need to be reminded to avoid
inhaling too rapidly. The child should show
good chest excursion with their inhalation
and not just head movement. Make sure
the child is inhaling completely through
the mouth, and not via the nose. A nose
plug or holding the nose is sometimes
necessary to accomplish this. Often
children do not inhale maximally, robbing
themselves of optimal lung delivery—
always encourage a full deep breath. Most
children capable of using an MDI without
spacer can hold their breath for 10 seconds
after actuation and should be encouraged
to do so. Because of all of these potential
mistakes, initial proper training is key
and checking and rechecking of inhaler
technique at follow-up visits is essential.
One of the disadvantages of an MDI is
the lack of reliable ways to know when it
is empty. Floating the canister in a bowl
of water is not reliable. Most controller
medication inhalers contain enough doses
for 1 month's use (or 2 months at lower
doses). Parents should get in the habit of
refilling these medications regularly every
1 or 2 months. The issue is somewhat
more complicated with rescue inhalers,
and having a spare inhaler available is
always a good idea.
-------
Proper Use of a DPI
* Open DPI device (ie, slide open,
remove cap cover) and load powder.
* Put mouth tightly around mouthpiece;
hold device horizontally.
• Relax, shoulders down, chin in neutral
position.
• Breathe out, then inhale forcefully and
rapidly.
• Hold breath for short time.
• Close device (slide or replace cover).
* Take notice of counter.
Copyright © 2003 American Academy of Pediatrics
Photo eoutteay of Andrew Silk.
More and more DPI devices are
becoming available for use for
asthma. Proper technique is
essential to getting their full benefit. The
technique used with a DPI is somewhat
different from an MDI. Different delivery
systems exist (eg, Turbuhaler, Discushaler,
Aerolizer) with different advantages to
each. The DPI device first needs to be
opened and the powder loaded in front of
the mouthpiece. Each system has its own
way of doing this. The device should then
be put in the child's mouth, with the lips
tightly around the mouthpiece, and the
device held horizontally. The child should
be relaxed, with shoulders down and chin
in the neutral position. The child is asked
to inhale forcefully and rapidly, preferably
at a rate greater than 60 L/minute. A long
breath-holding period after inhalation is
not needed with use of a DPI. The device
should then be closed by sliding it to
the closed position or putting its cover
on. Closing of the device is important to
avoid moisture getting in and ruining the
dry powder properties of the medication
inside. A counter system is built into 2 of
the systems (Turbuhaler, Discushaler)—it is
important to check this counter after each
use to know when the DPI device is empty
and needs to be replaced.
-------
Advantages of a DPI
• No need for coordination of actuation with inhalation
* Less inhalations per dosing (certain DPIs)
• No spacer needed
* Counter system built in
* No taste (certain DPIs)
• Combination drugs
Copyright © 2003 American Academy of Pediatrics
There are certain advantages of a DPI
over an MDI. The biggest one is
eliminating the need for the patient
to coordinate actuation of the inhaler
with inhalation. This coordination can be
difficult for children; DPIs get around this
aspect of MDI use. In some cases, the
DPI version of a medication needs less
puffs or inhalations by the patient than
the MDI version (eg, salmeterol xinafoate
[Serevent]), making the DPI quicker to use.
The need for a spacer, often used with an
MDI, is eliminated, saving the family the
cost of buying one. The counter systems
built into DPIs allow the patient to know
exactly when to obtain another one, unlike
with an MDI. Some DPIs (eg, budesonide
[Pulmicort Turbuhaler]) use pure drug in
their device; because the quantity is small,
the drug is barely perceived by the patient,
increasing patient acceptance. Finally,
DPIs easily allow for a combination of
medications to be delivered at one time
(eg, fluticasone propionate/salmeterol
xinafoate [Advair/Discus], making it simpler
for patients needing to use more than one
inhaler medication.
-------
Reasons for Spacers
Overcome coordination problems with MDI
Enhance drug delivery to lungs
Reduce adverse taste
Minimize local drug deposition in oropharynx
Decrease amount of drug swallowed
Copyright ® 2003 American Academy of Pediatrics
Children are often asked to use
spacers with their MDIs. A major
reason is that it can help overcome
the coordination problems associated with
the press-and-breath technique required
with an MDI. A spacer allows a child not
to have to inhale exactly when the MDI
is actuated. Another reason is that drug
delivery to the lungs, even when inhaler
technique is good, is enhanced by use
of a spacer. This is because the aerosol
particles lose velocity while traversing and
being held in the spacer, thereby increasing
the likelihood of particles leaving the spacer
and making it to the lungs and decreasing
the amount impacting on the back wall of
the throat. An additional benefit of a spacer
is its ability to trap out drug that would
have otherwise deposited in the mouth
and throat, which helps in reducing the
adverse taste of certain MDI medications
(eg, AeroBid, Tilade). In the case of inhaled
corticosteroids, this trapping effect also
helps minimize local adverse effects such
as oral candidiasis. Finally, a spacer's
ability to decrease the amount of drug
in the oropharynx reduces the amount
swallowed, which in turn reduces the
amount of drug systemically absorbed
via the gastrointestinal tract, an effect
particularly important with certain inhaled
corticosteroids (eg, beclomethasone
dipropionate).
-------
Types of Spacers
• Tube spacers
- With/without mask
- With/without one-way valve
- Small/large volume
» Bag spacers
• Other
Photos courtesy of Andrew Silfc
Copyright © 2003 American Academy of Pediatrics
Two types of spacers are available:
tube type and bag type. Many brands
of tube spacers exist. The shape of a
tube spacer is often cylindrical or close to
cylindrical. The MDI is placed into one side
of the spacer, and the child inhales the drug
from the other end. The spacer volume can
vary, which can be important when using a
spacer for a young child or infant. A large-
volume spacer for an infant (ie, greater
than 150 ml) would create excessive dead
space and not be as effective as a smaller
volume spacer. Some tube spacers have
a one-way valve and, because of this,
also are referred to as holding chambers.
The one-way valve allows the child to re-
breathe a number of inspiratory/expiratory
cycles without the spacer/chamber being
diluted with expired air. This feature is
particularly important for young children
(ie, infants, toddlers) who are treated with
an MDI with the aid of certain tube-valved
spacers fitted with a mask.
A bag spacer uses a collapsing bag to
receive the aerosol medication from the
MDI. Soon after the actuation of the
MDI into the bag, the child is instructed
to inhale deeply. In doing so, the bag
collapses and visually demonstrates to the
parent and child that an inhalation of drug
occurred. The simple visual feedback of the
bag collapsing helps the child learn how
to use the spacer and, therefore, to take
advantage of an MDI. Children between
the ages of 3 to 7 years often can be
taught how to use an MDI using this kind
of spacer.
-------
Available Spacers—Tube Type
With one-way valve (holding chamber)
-AeroChamber Plus
-Pocket Chamber
-OptiChamber
-EasiVent
-Space Chamber
-Vortex (not shown)
(Alt of the above come
with mask for children.)
Copyright © 2003 American Academy of Pediatrics
Without one-way
valve
-Pocket Spacer
-OptiHaler
-ACE
-Ellipse
-MicroChamber
A number of brands of tube spacers
are available in the United States.
Additional spacers are used in
Europe and other countries that are not
used here (eg, Babyhaler, Nebuchamber).
The AeroChamber (150-mL volume) is
widely used in this country and has been
most studied. It is an example of a spacer
that is also considered a holding chamber,
as it has a one-way valve that permits the
child to re-breathe into it. The latest version
is called the AeroChamber Plus; instead
of having a star-shaped flap valve like the
original AeroChamber, it has an O-ring
valve. The Pocket Chamber, OptiChamber,
EasiVent, and Space Chamber are
other holding chambers similar to the
AeroChamber, but with different volumes
(Pocket Chamber: 105 ml, OptiChamber:
220 ml; EasiVent: 135 ml; Space
Chamber: 250 ml). All of these valved
spacers (ie, holding chambers) are available
with a mask that allows infants and
toddlers to use the device. The first and
only metal spacer available in the United
States is the Vortex, made of aluminum
and using a duck-type one-way valve.
Various tube spacers exist without a one-
way valve (eg, Pocket Spacer, OptiHaler,
ACE, Ellipse, MicroChamber), each with
certain minor advantageous features. One
of the original spacers (Volumatic) is a
large-volume (750 ml), pear-shaped device
used in adults, but it is not very practical
or convenient for children because of its
large size and volume, which can create
unwanted dead space.
-------
Other Available
Spacers
• Bag spacers
- InspirEase
- EZ Spacer
* Homemade spacers
- Paper cup
- Plastic cola bottle
- Plastic tubing
- Toilet tissue tube
Copyright © 2003 American Academy of Pediatrics
Two bag spacer brands are available:
InspirEase and EZ Spacer. The
InspirEase is horizontally oriented
and a closed system (ie, once the bag
collapses, it is difficult to draw air through
it). The EZ Spacer is vertically oriented
and, in contrast to the InspirEase, is an
open system. Bag spacers allow for visual
feedback to the parent and child that
helps encourage and verify that the child
is indeed inhaling deeply and, therefore,
getting the inhaled dose.
Crude spacers can be made from common
household items like a paper cup, toilet
tissue tube, or plastic cola bottle. Plastic
tubing used by respiratory therapists also
can be used. Although these homemade
spacers are somewhat rudimentary, they
do accomplish one important function of
a spacer—namely, the slowing up of
aerosol particles before they arrive at the
mouth. The cola bottle does even more
in that it traps out both the fast-moving
and large-sized particles that were never
destined to make it to the lungs. The
major advantage of homemade spacers
is their cost, as regular spacers can be
expensive and often not covered by third-
party insurers.
The use of homemade spacers should
be discouraged, particularly for inhaled
steroids, because the volume of the
spacer and mechanical characteristics
of the device may have adverse effects
on the amount of medication delivered
to the lungs.
-------
Suggested Ages for Spacer Types
* Tube spacer with mask: infants,
toddlers (0-4 y)
* Bag spacer: preschool, kindergarten
(3-7 y)
• Tube spacer without mask:
age 6-7 y and older
Copyright © 2003 American Academy of Pediatrics
It is important that the type of spacer
selected for a patient is appropriate for
the patient's age. Infants and toddlers
require a tube spacer with mask, preferably
one with a one-way valve so it serves as a
holding chamber (eg, AeroChamber with
mask, OptiChamber with mask, Pocket
Chamber with mask). It is important to be
sure that the size of the mask is proper
for the child's face. A tube spacer with
mask has considerable medication loss
because of various factors (eg, the mask
not tightly sealed, deposition of drug inside
the spacer, loss of drug inside the nose),
so young children, when possible (usually
age 3-4 years), should graduate to the use
of a bag spacer (eg, InspirEase). At around
age 7 years, children should be changed
to a tube spacer without mask, or at least
be using an open bag spacer (eg, EZ
Spacer). The reason is that older children
have inspirator/ lung volumes that exceed
the volume of a bag spacer, and if the bag
spacer system is closed (eg, InspirEase),
the child is unable to inhale fully, as
inspiratory efforts are limited by the bag.
-------
Problems With Spacers
Dose unknown
Incorrect type/size
Cost (not covered by third-party payers)
Proper maintenance important
Need for replacement periodically
Electrostatic charge can reduce dose
Copyright © 2003 American Academy of Pediatrics
There are pitfalls with spacers a
treating physician needs to be aware
of. First, the dose of medication
delivered by an MDI has usually been
studied and characterized without a
spacer being used. Therefore, when a
spacer is introduced into the system for
delivery, the actual dose being delivered
becomes unknown. There is little to no
information about how spacers alter the
dose delivered to the patient, especially
in children. Another common problem
is when an incorrect size and/or type of
spacer is given to the child. For example,
spacers with masks for young children
come in 2 mask sizes (infant and child,
or small and medium). A child-size mask
erroneously given to an infant results in
excessive dead space and inefficient lung
delivery. An infant-size mask incorrectly
given to a toddler will not completely fit
over the nose and mouth and, therefore,
result in a suboptimal dose being delivered.
Furthermore, as the child grows older
(older than 4-5 years), the child should
graduate from a tube spacer with mask,
which is an inherently inefficient delivery
system, to a more efficient system such as
a bag spacer, a tube spacer without mask,
or no spacer at all.
Physicians should be aware that the cost
of a spacer is usually not covered by third-
party payers, which can be a barrier to
the spacer being purchased by the family.
Once purchased and used, spacers often
are not properly maintained, resulting
in poor spacer function. Spacers with
valves need to be cleaned regularly to
ensure that the valve does not become
hard, noncompliant, and/or bent. Finally,
all spacers made out of plastic are known
to have electrostatic charge on their
walls, and this charge is known to absorb
medication, thereby reducing the amount
deliverable to the patient. For this reason,
spacers made of plastic, when washed,
should have a final rinse with mild soapy
water to allow a film of detergent to be
left on the walls; this serves to reduce
the charge.
-------
Mistakes Made With Spacers
Excessive wait time
Multiple actuations
Abnormally slow/fast flow rate
Perception that crying is good
Copyright © 2003 American Academy of Pediatrics
Although spacers can help reduce
errors made by children using an
MDI (eg, poor timing of actuation
and inhalation), mistakes also can be
made with spacers. Parents should be
taught that once the aerosol is put into
the spacer, there is a limited amount of
time allowed before the child inhales. The
amount of drug available to the patient
begins to markedly decrease over a matter
of seconds after actuation. One actuation
of medication should be followed by one
inhalation—multiple inhalations into the
spacer at one time should not occur. Drug
delivery to the lungs is more efficient
by performing one actuation, then one
inhalation. The inspirator/ flow rate used
by the child should not be too fast or too
slow. The more common problem is the
child inhales too rapidly. Some of the
spacers have a built-in device that creates
a whistle when the child inhales too fast,
giving feedback to the child and parent
to slow up the inspirator/ rate. There is a
common misconception that crying by the
young child helps increase lung delivery
of medication. It has been discovered that
quiet tidal volume breathing with use of a
spacer and mask is a more efficient way
of delivering aerosol than the breathing
associated with crying.
-------
Tube Spacer With Mask:
Proper Use
• Parent training
• Proper mask size
• Tight seal around nose and mouth
• Tidal volume breathing (or deep inhalation,
if child able to)
• Cooperative child best; avoid crying
• 4-6 breaths or 10-15 s with spacer in place
per actuation
Copyright © 2003 American Academy of Pediatrics
The successful use of a tube spacer
with mask in an infant or toddler
requires parent training. This should
be done in the office by the physician or
staff. The proper mask size needs to be
obtained for the tube spacer to ensure a
proper fit on the child. Children younger
than 12 to 15 months require the small
(infant) size, while children older than this
age require the medium (child) size. The
parent needs to be instructed to put the
mask on the face of the child so that there
is a tight seal around the nose and mouth.
Application of the spacer and mask against
the face should occur before actuation
of the aerosol. The parent actuates the
aerosol medication into the spacer, while
the child does quiet tidal volume breathing
(note: crying is not effective in delivering
medication to the lungs). If the child can
be taught to do deep inhalation breaths,
this is even better. The spacer is to be
left applied to the face for 4 to 6 breaths
or 10 to 15 seconds. The next dose
of medication is then administered by
repeating the whole procedure.
-------
Proper Maintenance of Spacer
Regular washing is suggested (eg, 1x/wk).
Dry device out well before use.
Do final rinse with mild soapy water (plastic
spacers} to reduce electrostatic charge.
Replace periodically (eg, once/y).
Copyright © 2003 American Academy of Pediatrics
A spacer needs regular washing and
cleaning to continue to function
properly. This is particularly true
for holding-chamber-type spacers that
have one-way valves. Washing in warm
detergent water about once a week is
advised on a regular basis. A final rinse
with mild soapy water, not regular water,
is recommended to help reduce any
electrostatic charge on the plastic walls.
This final rinse with soapy water is not
necessary with a metal spacer (eg, Vortex
[aluminum]). The spacer needs to dry
out well before use. Although not much
information is available about the life
span of spacers, it is generally suggested
that they be replaced periodically (eg,
every year).
-------
PFMs
• Helpful in monitoring asthma
• Allow for objective assessment of airway caliber
« Should be considered for moderate or severe
persistent asthma (1997, 2002 NAEPP
guidelines; 1999 Guide for Managing Asthma
in Children)
* Daily monitoring recommended for moderate or
severe persistent asthma
Copyright © 2003 American Academy of Pediatrics
Apeak flow meter (PFM) can be
helpful in monitoring asthma in
children. Peak flow measurements
allow for objective assessments of
airway caliber and can be particularly
useful in children who tend not to report
or recognize signs and symptoms of
worsening asthma. The 1999 Guide for
Managing Asthma in Children states,
"Children with moderate or severe
persistent asthma should have a PFM at
home and at school, if feasible." The 1997
National Heart, Lung, and Blood institute
(NHLBI) National Asthma Education and
Prevention Program (NAEPP) guidelines
state, "It is the opinion of the Expert Panel
that peak flow monitoring for patients with
moderate or severe persistent asthma
should be considered because it may
enhance clinician-patient communication
and may increase patient and caregiver
awareness of the disease status and
control." The 2002 update to the guidelines
notes that the available literature is
extremely limited on the value of peak
flow monitoring in asthma management
plans, especially in children.
-------
PFMs in Children
* Children >5 y usually able to perform adequate maneuver
• Proper training of child/family required
* Important to use device with low range for young children
(5-7 y)
• Warn parents: often not covered as benefit by third-party
payers
Copyright © 2003 American Academy of Pediatrics
Children 5 years and older usually are
able to perform an adequate peak
flow maneuver. However, proper
training and explanation are required on
how to do the maneuver and what a
reading means. It is essential that the child/
parent be able to read the actual value off
the PFM. Some PFMs are available with
a low-range, expanded scale for young
children (ages 5-7 years) who normally
have lower readings. It is important to warn
the parent that as with spacers, the cost
of purchasing a PFM is often not a benefit
covered by most third-party payers.
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Uses/Value of Peak Flow Monitoring
• Detect exacerbations early
• Make decisions about acute interventions and
athletic participation
* Confirm control
* Monitor medication adjustments
Copyright © 2003 American Academy of Pediatrics
Use of a PFM can help in detecting
an asthma exacerbation early.
Children, in particular, often will
not report symptoms or complain as
they develop problems with asthma.
Measuring peak flow can decrease the
need to completely rely on the subjective
reporting of children. Another important
value of a peak flow measurement is
the way it can help in making decisions
about acute intervention. A decision about
initiating new or higher dose medications
(eg, beta-agonists, oral corticosteroids)
or recommending a patient seek acute
medical help in the physician's office or
emergency room can be tied to a peak flow
determination. This is particularly helpful in
the settings of in-office phone triage and
phone consultation with the patient after
office hours. Similarly, the family or school
can be taught how to make decisions
about the child's participation in certain
activities on a given day using the child's
peak flow value. A peak flow reading less
than a certain number, for example, would
suggest to the family that the child should
not go to school that day or participate
in sports or physical education. Finally,
peak flow monitoring can help in making
decisions about whether a patient's asthma
control medication program is appropriate
or needs to be adjusted. Regular reduced
peak flow values indicate that a patient's
medication program likely needs to
be stepped up. Similarly, if peak flow
monitoring consistently shows normal
values, a tapering down of medication
can be started. If medication reduction is
recommended, peak flow monitoring can
help decide if the patient's asthma remains
under control as the medication dose is
being reduced.
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Peak Flow and Asthma Action Plans
• Asthma action plans can be peak flow-based
in children older than 5 y.
• Personal-best peak flow rate must be known.
* Color system used
Green: 80%-100%; continue same
: 50%-80%; caution, extra therapy
needed
- Red: <50%; danger, immediate action
(call physician; emergency room; office visit;
start oral steroids)
Copyright © 2003 American Academy of Pediatrics
Patients with asthma, particularly
those with persistent asthma,
should have an asthma action plan
for home and school. Such a plan gives
the patient and family clear directions on
how to control the child's asthma using a
medication program, including controller
agents, and additional medications
necessary to treat exacerbations. For
children old enough to be able to use a
PFM, an asthma action plan can be based
on peak flow readings. A personal-best
peak flow rate needs to be known to
create a plan tied to peak flow.
The personal-best (or 100%) value is
determined by checking the peak flow of
the patient when he or she is doing well in
terms of asthma. A predicted normal peak
flow rate (based on height and sex) can be
used initially until a personal-best number
is obtained from home monitoring. A zone
system using peak flow readings can be
generated, with different measures to be
taken by the child/parent, depending on
what zone the patient's peak flow reading
is in. The system recommended by the
1997 NHLBI NAEPP asthma guidelines has
3 zones: green (80%-100% of personal
best)—continue same medications; yellow
(50%-80%)—caution—extra therapy
needed such as albuterol by an MDI or
nebulization and/or a temporary increase
of inhaled anti-inflammatory therapy; red
(below 50%)—danger—immediate action
needed to get out of the red zone such as
initiation of high-dose albuterol, taking of
oral corticosteroids, calling the physician,
and/or proceeding to the physician's office
or emergency room.
-------
Photo courtesy of ftnttriw Silk.
Proper PFWI Use
* Keep peak flow device horizontal.
• Inhale deeply away from device.
• Put mouth around mouthpiece tightly.
• Blow out hard and fast ("punch").
» No coughing, spitting, or jerking of
PFM.
• Repeat until peak flow value
consistent; take highest reading of at
least 3 blows.
Copyright © 2003 American Academy of Pediatrics
To obtain a peak flow value that is
meaningful, it is important that the
peak flow measurement (PFM)
is done properly by the child. The peak
flow device should be kept horizontal
throughout the whole maneuver. The
patient should inhale deeply away from
the device, put the mouth around the
mouthpiece tightly, and then blow out hard
and fast (not long). No coughing or spitting
into the device or jerking downward of the
meter should occur. A tight seal around
the mouthpiece is important. The child
should reset the needle to zero and repeat
the maneuver until the peak flow value
is consistent. Once consistent, the
highest value of at least 3 blows is taken
as the measurement.
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Problems With Peak Flow Readings
• Technique not optimal
- Coughing
- Leakage around lips
- Not resetting to zero
* Effort dependent
* Different readings from different devices
(eg, school vs home)
* Can be normal in face of airway obstruction
Copyright © 2003 American Academy of Pediatrics
There are limitations and problems
with peak flow monitoring that need
to be appreciated. The technique of
doing the peak flow maneuver needs to
be correct (see previous slide), otherwise
the value is not meaningful. A peak flow
measurement is effort dependent, so
the child must be coached to do a hard,
vigorous blow. Purposeful false low or
high readings can be a result of intentional
manipulation and deceit by the child.
Different peak flow readings can occur
using different devices, so it is hard to
compare readings. The reading used with
the peak flow meter at school may be
different from the one obtained at home or
in the physician's office. Peak flow readings
are best interpreted when the same
device is being used. Finally, peak flow
measurements can sometimes be normal
or close to normal even in the setting
of airway obstruction. For this reason,
clinical symptoms (eg, cough, chest
tightness) need to be looked at when
assessing a child with asthma, not just
peak flow reading.
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Peak Flow in Physician's Office
• Peak flow reading in office: objective
assessment of asthma.
• Not as useful as spirometry date.
* Best used to monitor asthma; less useful in
establishing a diagnosis of asthma.
• Normal predicted values need to be available.
• Office staff need to be trained in proper
technique.
Copyright © 2003 American Academy of Pediatrics
Peak flow measurements can be
used as an objective assessment
of asthma in children when they
are seen in the office. However, a peak
flow value is not as useful and reliable
as spirometry data (eg, forced expiratory
volume in 1 second [FEVi]). A peak flow
determination is best used in the office
to estimate a response to an intervention
over a short period (eg, acute albuterol
therapy) or long period (eg, adjustment
of a child's controller medication therapy).
It is less useful in establishing a diagnosis
of asthma—spirometry is preferred. It is
helpful to have normal predicted values for
children in the office as a rough reference
guide to determine if the child is in or near
the normal range for his or her height and
sex. Office staff need to be trained and
knowledgeable in peak flow measurement
technique so that measurements done in
the office are valid and meaningful and to
ensure patients are correctly taught by the
staff how to properly use a PFM at home.
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Photo courtesy oTAndriw Silk
Nebulizer Therapy
General
Available for acute and chronic therapy.
Helpful in children unable to use an MDI
or a DPI.
Efficacy with MDI may be same,
assuming good cooperation/technique
with MDI.
Advantages and disadvantages clearly
exist.
Copyright © 2003 American Academy of Pediatrics
Nebulizers are widely used
therapeutically for various
respiratory disorders to administer
solutions or suspensions of beta-agonists,
anticholinergics, corticosteroids, cromones,
mucolytics, and antibiotics. Nebulizer
therapy is available for acute and chronic
treatment of asthma. Because nebulizers
require neither hand-lung coordination
or a controlled inhalation maneuver,
they can be helpful for children unable
to use an MDI or a DPI. However, the
role of the nebulizer in asthma therapy
is a debated one, as it has been shown
that efficacy with the MDI, even in young
children (assuming good cooperation
and technique), may be the same as
with the nebulizer. Nevertheless, certain
advantages as well as disadvantages
exist with nebulization therapy that need
to be appreciated.
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Nebulizer Therapy
Advantages
* Little to no coordination required.
* Can be done by children unable to use MDI or DPI.
• Delivers high dose of medication slowly.
• Administers medication over prolonged period in
semi-passive way.
• Wet therapy may have some benefit over dry
aerosol or powder.
Copyright © 2003 American Academy of Pediatrics
The major advantage of nebulization
therapy is that little to no coordination
is required to carry out inhaled
treatment. Nebulized therapy can therefore
be done by children unable to use inhaler
devices like an MDI or a DPI or who will
not cooperate with a spacer. Another
advantage is that medication delivered by
a nebulizer can be administered slowly and
gradually and at a high dose. Treatment
with a nebulizer is done in a semi-passive
way, a feature felt to be favorable by certain
patients, particularly during the time of an
acute episode of asthma. Finally, the wet
therapy given by nebulization may have
some benefit over a dry aerosol or powder.
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Nebulizer Therapy
Disadvantages
* Time-consuming
• Bulky, not very portable
• Cost
• Not all medications available for nebulizer
* Delivery of drug inefficient
• Assembly/cleaning required
• Variability in output between nebulizers
* Mask for young child not always available
Copyright © 2003 American Academy of Pediatrics
Nebulizer treatments are often time-
consuming, and active toddlers
often will not sit still for the entire
treatment. Parents must be educated on
ways to make nebulizer treatments an
enjoyable experience for the child when
there are no other options. The typical
air compressor used with a jet nebulizer,
the most common type of nebulizer, is
bulky, heavy, and not very portable. The
cost of a nebulizer is not insignificant,
although most third-party payers will
cover the nebulizer as a benefit. Not all
medications are available for the nebulizer,
although this situation has improved
overall, especially with the availability of
the nebulized corticosteroid-budesonide
inhalation suspension. Delivery of the
drug is inefficient—a range for the optimal
amount of drug delivered to the lungs by
nebulization technique is 1 % to 10%, with
children typically being at the lower end
of the range. This compares with a range
of 8% to 20% with an MDI, depending
on the specific aerosolized drug, patient
technique, and use of a spacer. Certain
dry powder devices can deliver as high
as 35% to the lungs (eg, Pulmicort
Turbuhaler) if proper technique is done.
Nebulizers require assembly and some
technical know-how to use them correctly,
as well as maintenance and cleaning.
There can be a large variation in total drug
output and percentage of aerosol particles
in the respirable range between different
nebulizers, making it important that a good-
quality nebulizer and compressor with good
specifications be selected for the patient.
Certain nebulizers can be fitted with a
mask but not all, an important feature
to consider when obtaining a nebulizer
system for a young child.
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Types of Nebulizers
Jet
- Most common; least expensive
- Made up of nebulizer, air compressor
- Typical treatment time: 7-15 min
- Proper cleaning, maintenance important
Ultrasonic
- Portable, quiet
- More expensive
Copyright © 2003 American Academy of Pediatrics
There are 2 major categories or types
of nebulizers: jet and ultrasonic. Jet
nebulizers are most commonly used.
They consist of an air compressor and
nebulizer bowl with a mouthpiece or face
mask. Compressed air (or oxygen) passes
through a narrow orifice, and liquid droplets
are produced as a result of a Venturi effect.
A typical treatment time for a jet nebulizer
is 7 to 15 minutes, depending on the
specific nebulizer and compressor, patient
technique, and volume initially put into the
nebulizer. Cleaning and maintenance of
the nebulizer components are important
to ensure it continues to function properly.
An ultrasonic nebulizer relies on ultrasound
energy to generate droplets with the help
of a piezoelectric crystal that vibrates at a
high frequency. The quality of the aerosol
(ie, particle size distribution) generated
with an ultrasonic unit is similar to that of
jet nebulizers. Advantages of an ultrasonic
nebulizer are that it is quiet and, because it
tends to be smaller in size, it can be quite
portable. Nebulizer time also can be faster
with an ultrasonic nebulizer, especially
if undiluted drug is used (eg, albuterol).
Disadvantages of an ultrasonic unit are that
it costs more than a jet nebulizer and is
less durable overall.
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General Features of Jet Nebulizers
Nebulizer output varies based on
* Intrinsic design characteristics
• Flow rate
* Initial volume
* Patient's breathing pattern
Copyright © 3003 American Academy of Pediatrics
The drug output of jet nebulizers (ie,
the amount of drug converted to
aerosol that leaves the nebulizer) is
affected by a number of variables. Many
of these factors are nebulizer dependent,
but not all. There can be great variability in
nebulizer output simply based on the brand
of nebulizer and compressor. One study
with budesonide inhalation suspension
found a ninefold difference in nebulizer
output between certain nebulizers.
A well-known and good-quality/tested
brand needs to be selected for a patient
who is going on a nebulization program.
Make sure patients do not use disposable
nebulizers obtained from hospitalization
for repeated use at home—they were not
intended for this. Certain nebulizers require
either high or low flow rate of air coming
from the compressor to create the aerosol.
Be certain the air compressor and nebulizer
bowl are compatible in this regard. As the
amount of volume of drug initially placed
into the nebulizer increases (referred to as
the charge), the amount of drug released
from the nebulizer increases because the
residual volume (ie, volume of solution left
in the nebulizer bowl after nebulization)
remains constant. Therefore, the larger the
starter volume, the higher the percentage
of medication will be delivered to the
patient. However, nebulization time
increases as drug volume increases,
which can wear out the patience of
the child. The efficacy of nebulizer drug
delivery also depends on the breathing
pattern of the child (eg, breathing
frequency, tidal volume). Steady normal
tidal volume breathing interspersed with
occasional deep breaths is optimal. Fast
inspiration leads to impaction of drug-
containing aerosols into the upper airways,
not where it is desired. Crying during
nebulization significantly reduces the
amount of drug delivered to the airways,
contrary to popular belief.
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Types of Jet Nebulizers
3 major types
• Constant output (eg, Nebumist)
• Breath-enhanced (eg, Part LC Jet Plus)
• Breath-actuated (eg, AeroEclipse)
Copyright © 2003 American Academy of Pediatrics
Photo courtesy of Andrew SiDf.
There are 3 major types of jet
nebulizers. The first and most
common delivers a constant output.
Because the patient is not always inspiring
during nebulization, constant output
nebulizers have a significant degree of
wastage of aerosol. The Hudson Nebumist
is an example of this kind of nebulizer.
A breath-enhanced nebulizer is a second
type in which drawing additional air into
the nebulizer during regular use increases
output and decreases medication waste.
The Pari LC Jet Plus is a breath-enhanced
nebulizer. Nebulizer dose delivery can be
further increased and waste decreased
with a breath-actuated nebulizer, a third
type in which drug delivery occurs only
during inspiration. The AeroEclipse
functions in this manner.
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Nebulizers and Amount of Drug
Delivered to Patient
* Inhaled mass = total quantity of drug delivered
to patient mouthpiece
Respirable mass - particles less than 6 urn
• Large inter-nebulizer variability in inhaled mass;
range: 2%-18% of original dose
• Respirable mass about 25% of inhaled mass
• Actual amount delivered to lower airways small
(1%-5% of original dose put in nebulizer)
Copyright © 2003 American Academy of Pediatrics
The inhaled mass is the total quantity
of drug delivered to the patient
mouthpiece. There is a large
variability in the inhaled mass depending
on nebulizer brand, type of nebulizer,
breathing technique, and other patient
and non-patient variables. In general,
the inhaled mass in children receiving
nebulizer therapy is anywhere from 2%
to 18% of the original amount. However,
this does not represent what is actually
delivered intrapulmonary, as not all of the
inhaled mass contains aerosol particles
of the appropriate size that actually can
be inhaled into the lungs. Only particles
of 6 urn in diameter or less make it past
the oropharynx and trachea and constitute
what is called the respirable fraction. The
respirable fraction is usually about 25% of
the inhaled mass. In doing the math, one
sees that the actual amount of medication
making it to the lower airways where it
is needed is quite small (1 %-5% of the
original amount of drug placed in the
nebulizer). This is why a larger amount of
medication needs to be used in a nebulizer
as compared to what is used by an MDI
(eg, 0.5 cm3 of concentrated albuterol
inhalation solution represents 2,500 ug;
2 puffs of albuterol MDI is 180 (jg).
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Medications Available
for Nebulization
• Albuterol (0.5% concentrated inhaled solution;
premixed 0.63-, 1.25-, and 2.50- mg/
3ml_ saline)
• Levalbuterol (0.31,0.63 mg; 1.25 mg/ampule)
• Ipratropium (0.5 mg/ampuie)
• Cromolyn (20 mg/ampule)
• Budesonide (0.25 or 0.5 mg/Respule) (jet only)
Copyright © 2003 American Academy of Pediatrics
An increasing number of medications
have become available for
nebulization therapy. Albuterol is
available as an inexpensive concentrated
inhalation solution and needs to be mixed
with normal saline (usually 2-3 ml). The
saline can be purchased through the
pharmacist or bought over-the-counter.
Albuterol also comes premixed with saline
but is more expensive in this form. All of
the other medications come diluted in their
appropriate diluent and further dilution is
not necessary or recommended. Mixing
of the nebulized medications (eg, albuterol
and cromolyn, albuterol and ipratropium)
is commonly done and does not appear
to alter potency, although not much is
published on this. Budesonide inhalation
suspension, an inhaled corticosteroid, is
the newest medication to become available
for the nebulizer. Although not stated in the
package insert, budesonide and albuterol
appear to be compatible and can be
mixed. All of the listed medications can be
delivered by a jet or an ultrasonic nebulizer
except for budesonide, which should not
be used in an ultrasonic nebulizer.
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Nebulizer Therapy
How to deliver mist to patient
Mouthpiece (older child)
Mask (infants, toddlers)
Photos courttay of Andrew Silh.
Blowby (infants)
(avoid, if possible)
Copyright © 2003 American Academy of Pediatrics
Mouth inhalation using a
mouthpiece is preferred for adults
and children, although this is not
always feasible with children. When using
a mouthpiece, it is sometimes necessary
and useful to use a nose plug in children
to ensure breathing via the oral route rather
than nasal. Delivery of inhaled drug by use
of a face mask involves nasal breathing
along with mouth breathing, which may
decrease delivery to the lungs and,
therefore, be less efficient than delivery
by a mouthpiece. However, enough drug
usually can be delivered so that it is still
clinically effective. Blowby technique is
very inefficient and should be discouraged
and used only if absolutely necessary.
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Tips for Proper Nebulizer Therapy
Encourage mouth breathing (may need nose clip).
Tight fit if mask used.
Avoid biowby technique.
Proper coaching is essential (eg, deep, not rapid
breaths).
Make nebutization a positive experience.
Copyright © 2003 American Academy of Pediatrics
Encourage mouth breathing as much
as possible. If a mask is used, make
sure the fit on the face is tight.
Biowby technique is convenient but
inefficient and should be avoided. Proper
coaching of the child is important; make
sure the child performs deep breaths,
not rapid ones. Make the nebulization
experience a positive one by associating
it with favorable activities like reading a
book to the child or engaging in pretend
play, like make-believing the child is an
airplane pilot as the child does his or her
nebulization. Maintain the compressor and
nebulizer properly; in particular, make sure
the filter is replaced when needed, clean
the nebulizer bowl routinely, and replace
the bowl on a periodic basis.
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Management Aids
Devices to Help Deliver Asthma Medications
Medications for asthma can be given to your child using a variety of devices including the
following:
Photo courtesy of Andrew Silk.
• Nebulizer—This is often used with younger
children. This device uses an air compressor
and cup to change liquid medication
into a mist that can be inhaled through
a mouthpiece or mask. Inhaled steroids
and quick-relief medications can be given
this way.
• Metered-dose inhaler (MDI)—This is the
most commonly used device for asthma
medications. However, your child will need
to learn how to use it properly, which means
pressing (or actuating) the device while taking a deep breath at the same time. The technique
is reviewed on the following pages. Some MDIs are "breath actuated," that is, they give out
a puff of medication when you start to take a breath. These types of MDIs are much easier to
use, but are only available for one type of quick-relief medication. Spacers can be used to help
relieve some of the coordination problems in using MDIs and should always be used when using
inhaled steroids.
• Dry powder inhaler (DPI)—This device is available for some medications. It is easier to use
because you do not need to coordinate breathing with actuation. It also has less taste, and often
has a built-in counter to help keep track of doses taken and doses left.
Some asthma medications only come in
pill form. However, inhaling the medication
."•/"" ; using one of the devices listed above is
'.'•;- * usually better because the medication passes
;• :.'.,;• straight into the airways. As a result, side
effects are reduced or avoided altogether.
Because there are several different inhalers
on the market, your health care provider will
suggest the one that is best for your child.
There are important differences in the way
they are used and in the amounts of medications they deliver to the airways. Your child will be
taught how to use the inhaler, but her technique should be checked regularly to make sure she is
getting the right dose of medication.
Peak Flow Meter
To help control asthma, your child may need to use a peak flow meter. This is a handheld device
that measures how fast a person can blow air out of the lungs. Asthma treatment plans using
peak flow meters use 3 zones—green, yellow, and red, like traffic lights—to help you determine
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if your child's asthma is getting better or worse. Peak flow
rates decrease (the numbers on the scale go down) when
your child's asthma is getting worse or is out of control.
Peak flow rates increase (the numbers on the scale go up)
when the asthma treatment is working and the airways
are opening up.
When to Use the Peak Flow Meter (if your health care
provider has recommended one)
Check your child's asthma using the peak flow meter at
the following times:
• Every morning, before he takes any medications.
• If your child's symptoms worsen or if he has an asthma
attack. Check the peak flow rate before and after using
medications for the attack. This will help you to see if
the medications are working.
• Other times during the day, if your health care provider
suggests.
Keep in mind, there are differences in peak flow rate measurements at different times of the day.
These differences are minimal when asthma is well controlled. Increasing differences may be an
early sign of worsening asthma. Also, children of different sizes and ages have different peak flow
rate measurements.
Keep a record of your child's peak flow numbers each day.
This will help you and your health care provider see how
your child's asthma is doing. Bring this record with you
when you visit the pediatrician.
Photo courtesy of Andrew Silk.
Photo courtesy of Andrew Silk.
American Academy of Pediatrics
DEDICATED TO THE HEALTH OF ALL CHILDREN"
Copyright © 2003
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Management Aids
Key Points to Cover With Patients
• Different inhaler delivery systems are available for asthma medications: nebulizers, metered-
dose inhalers (MDIs) (chlorofluorcarbon propellant, hydrofluoroalkane propellant, Autohaler), dry
powder inhalers (DPIs) (single- or multi-dose). Nebulizers are probably no better than a properly
used MDI with spacer, but in individual cases may be preferred for the delivery of inhaled quick-
relief medications, cromolyn, or steroids. Self-actuating inhalers, such as the Autohaler, may be
easier to use for some children. Dry powder inhalers are also easier to use for children because
they do not require coordination of actuation with inspiration.
• Proper technique for the use of inhalers should be taught at the initial visit and reviewed at
subsequent visits. Closed mouth or open mouth technique should be discussed, with the open
mouth preferred if the child is able. Dry powder inhaler technique should be reviewed for those
using such devices.
• Spacers/holding chambers can be helpful to overcome coordination problems with the use
of MDIs, reduce adverse taste, decrease the oral deposition of the drug, and increase the
deposition of drugs in the lungs. Spacers should always be used with inhaled corticosteroids
and should be considered for all MDI use in younger children. Holding chambers are spacers
with larger volumes and one-way valves that keep expired air from re-entering the "holding
chamber." Holding chambers are usually used in younger children. In addition, holding chambers
can be fitted with masks and used with children as young as infants. The type of spacer
prescribed will depend on the age, development, and "attitude" of the child.
• Peak flow meters are useful for the monitoring of asthma and determining the severity
of an exacerbation. They can serve to improve the communication between provider and
patient/parent. They can also be used for following the effects of addition or deletion of
medications. Peak flow technique should be taught at the initial visit and its use reinforced
at subsequent visits.
American Academy of Pediatrics
DEDICATED TO THE HEALTH OF ALL CHILDREN
Copyright © 2003
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Asthma and Schools
Copyright © 2003 American Academy of Pediatrics
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Asthma and Schools
Epidemiology
16%-26% of students may have wheezing.
The average student with asthma misses 10 or
more schools days per y, compared with 2-3 d for
students without asthma.
Copyright © 2003 American Academy of Pediatrics
A
Isthma is the most common
chronic disorder in children
and adolescents.
Students with severe asthma may
miss about 30 days of school per
year. The good news is that despite
its morbidity and frequent school
absences, school grades are not
usually affected by asthma, except
in some students with more poorly
controlled asthma.
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National School Asthma Strategies
National Asthma Education and Prevention
Program (NAEPP)
American Lung Association (ALA)/Kaiser
Permanente
US Centers for Disease Control and Prevention
(CDC) Division of Adolescent and School Health
(DASH)
Copyright © 2003 American Academy of Pediatrics
There are several national programs and
educational forums that have focused
on students with asthma in the last
few years. These programs can be helpful
to the primary care physician because they
provide many different resources on school
issues related to asthma management.
The Asthma and Schools subcommittee
of the National Asthma Education and
Prevention Program (NAEPP) has developed
several documents and program over the
years to assist schools, clinicians, and
parents in dealing with their child's asthma
in the school. These include School Asthma
Education Slide Set Asthma Awareness
Curriculum for the Elementary Classroom,
How Asthma-Friendly Is Your School, Asthma
and Physical Activity in the School, and
NAEPP Resolution on Asthma Management
at School. These documents are all available
free of charge and can be downloaded from
the National Heart, Lung, and Blood Institute
(NHLBI) Web site (www.nhlbi.nih.gov/
health/prof/lung/index.htm). How Asthma-
Friendly Is Your School is a simple checklist
that can be very helpful to clinicians,
parents, and school personnel to evaluate
an individual school's asthma policies.
In November 2000, the American Lung
Association (ALA) and Kaiser Permanente
Health Plans convened a national
conference on asthma. Out of this
conference, key elements of school-based
education and intervention were developed
by an expert panel. These key elements are
shown on the next 2 slides. The entire list of
recommendations can be downloaded from
the ALA Web site at www.lungusa.org/
asthma/reportOI.
In September 2002, the Centers for Disease
Control & Prevention (CDC) Division of
Adolescent and School Health (DASH)
combined the NAEPP tools, the ALA/Kaiser
Permanente strategies, and a model of
a coordinated school health program to
develop Strategies for Addressing Asthma
Within a Coordinated School Health
Program. This document has concepts that
are helpful to any person concerned about
students with asthma, within the schools
and health care community, and forms
the framework for this discussion. More
information is available at www.cdc.gov/
nccdphp/dash/asthma.htm.
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ALA/Kaiser Strategies
Have a full-time school nurse for each school.
Identify and track all students with asthma.
Create an asthma action plan for each student with
asthma.
Provide an individualized health plan for each
student with asthma.
Provide immediate access to medications.
Copyright © 2003 American Academy of Pediatrics
The ALA/Kaiser recommendations
for students with asthma are listed
on this and the next slide. It should
be noted that these are the ultimate
objectives and may not be immediately
achievable for some schools.
Clinicians caring for students with asthma
play an important role in many of these
recommendations. They are responsible
for generating the asthma action plan,
which forms the basis for the asthma
individualized health plan for the student
and will be covered in more detail later
in this module. The clinician also should
be an advocate for patients obtaining
immediate and unrestricted access to
their medications. While not directly
involved, clinicians should consider the
value of a school nurse in every school.
Identification and tracking of students
with chronic health problems is obviously
a key to providing an appropriate and
healthy environment for those children.
This identification often allows school
personnel to work in partnership with
clinicians to ensure that each child with
asthma has proper treatment at school.
-------
ALA/Kaiser Strategies
Standard emergency protocols
Consulting health care professional/physician
for each school
Case management for students with more
severe asthma
Mechanisms for referral to health care provider
Copyright © 2003 American Academy of Pediatrics
This slide shows the remainder of
the ALA/Kaiser strategies. These
strategies apply to school officials,
but a student's primary care physician
should make sure that the school has
standard emergency policies to deal with
acute asthma exacerbations if a student
does not have his or her own plan available.
In addition, mechanisms for referral to a
health care provider can be helpful when
school staff note problems with asthma
symptoms in students who may not have
a diagnosis of asthma or whose asthma
might not be well controlled.
-------
CDC DASH Strategies
Management and support systems
Health and mental health services
Asthma education
Healthy school environment
Physical education and activity
Coordination of school, family, and community efforts
Copyright © 2003 American Academy of Pediatrics
The Division of Adolescent and School
Health (DASH) of the Centers for
Disease Control and Prevention
has developed strategies for asthma
management in schools based on
the concept of a coordinated school
health program.
The determination of management and
support systems is up to the school, but
these other factors need to be in place for
a school to do an adequate job of asthma
management. A community physician can
and should be involved in most of the other
strategies to a variable extent, depending
on interest. All of these strategies are
similar to the same approach a physician
would take in managing patients' asthma
at home.
-------
CDC DASH Strategies
Health and Mental Health Services
Written asthma action plan
Immediate access to medications
Standard emergency protocols
Copyright © 2003 American Academy of Pediatrics
Every student with asthma should
have an asthma action plan as part
of his or her individual health file.
This plan should be established by the
child's asthma care provider in concert
with parents and provided to the school
by the parents. Share the plan with
appropriate faculty and staff in accordance
with the Family Educational Rights and
Privacy Act (FERPA).
Students with asthma need immediate
access to rescue medications at all times.
Ideally this would be accomplished by
allowing students to self-carry and self-
administer rescue medications. However,
not all children are mature enough to do
so and, regrettably, not all schools allow
it even when the child is competent to
do so. Decisions about who should be
allowed to self-carry and self-administer
medications should be made on a case-by-
case basis with input from the physician,
school nurse, and parents and should
not be determined by blanket policy.
Often, keeping medications locked in the
office serves as a deterrent to use. If the
medications are kept in the office, policies
need to be established as to who has the
keys and how to reach those people any
time during the school day. In addition,
policies need to be in place for after-school
and off-school-property activities, including
field trips and athletic participation.
Children who self-carry their rescue
inhaler also need to have a spare inhaler
kept in the office in case they forget their
own or run out.
The school needs to establish a standard
emergency protocol for the treatment
of respiratory distress for those students
with asthma who do not have an asthma
action plan.
-------
Asthma Action Plan
* Address triggers.
* Indicate routine and emergency medicines.
• Specify treatment guidelines for acute
exacerbations based on PFM and/or symptom-
based zones.
• Indicate emergency contacts.
* Place plan in student's health record.
Copyright © 2003 American Academy of Pediatrics
T
I his slide outlines the contents of
an asthma action plan.
Every effort should be made to have a
written asthma plan for every student with
persistent asthma. The plan needs to be
reviewed and updated periodically, based
on stability of symptoms. All medicines
should be checked for expiration dates.
NOTE: See sample asthma action plan in
this kit (Pharmacologic Management of
Asthma, slide 21, and the Student Asthma
Action Card in this section).
PFM = peak flow meter
-------
Holding Chambers (Spacers)
Advantages
* Help improve inhaler technique.
* Should be part of the asthma action plan for
younger students.
* School staff needs training in the use of holding
chambers.
Copyright © 2003 American Academy of Pediatrics
Iany school-aged children have
trouble with the proper use of
metered-dose inhalers (MDIs).
Spacers/holding chambers can be very
helpful for acute exacerbations for such
children. Proper use of an MDI with a
spacer can be an equivalent substitute
for a nebulizer in younger children. School
nurses should train responsible staff
members in proper use of such spacers.
Better technique makes it easier for
non-nurse personnel to assist in managing
acute exacerbations.
-------
Peak Flow Meters
* Can be helpful for all children
* Kept in nurse's office
• Know child's personal best
* Correct technique essential
• Helpful in determining degree and type of response
needed
• Can be used alone or in combination with symptom
zones as part of written action plan
• Can be used before PE
Copyright © 2003 American Academy of Pediatrics
Peak flow meters can be helpful for
students with asthma for a variety
of reasons. Often, non-nurse
personnel are the only staff available to
assist a student with an acute asthma
exacerbation. Because these personnel
are not skilled in the assessment of the
severity of an attack, other means of
monitoring can be helpful, especially if the
student uses a peak flow meter at home
and is aware of his or her own personal-
best value. It is also useful in gauging the
response to therapy. Measurement of
peak flow before physical education (PE)
also can be helpful to the PE teacher when
deciding whether participation on any given
day is appropriate.
Proper training of staff in the technique
of using peak flow meters is essential.
Documentation of personal best also
should be a part of any asthma action plan.
-------
CDC DASH Strategies
Standard Emergency Protocol
Establish a plan for acute asthma episodes.
• Assist student in proper administration of prescribed
medication (eg, albuterol pressurized MDI).
* Assess and record student's response including
auscultation, pulse, respiration, and PEFR.
• Call EMS/911 for deteriorating respiratory status/level
of consciousness or lack of response to treatment.
• Students with ineffective response or frequent asthma
episodes should be referred for medical consultation.
Copyright © 2003 American Academy of Pediatrics
The school should have plans and
procedures in place for dealing with
acute episodes. The policies should
include treatment protocols for respiratory
distress and treating someone without an
individualized care plan.
EMS = emergency medical services
PEFR = peak expiratory flow rate
-------
CDC DASH Strategies
Health and Mental Health Services
Full-time school nurse
-Assessment
- Tracking
-Training
- Link with community
Referral mechanisms
Copyright © 2003 American Academy of Pediatrics
Full-time school nurses are a insurers in their community and provider
controversial subject, primarily panels for each insurer.
due to budget constraints of school
districts. In the final analysis, however,
school nurses in every school may
actually save money. Schools often are
paid based on full-time attendance, and
keeping students with asthma in school
increases revenue. A registered school
nurse is the only person with the training
and background to perform the necessary
tasks to ensure a successful asthma
management program. The school nurse
can assess the student for skills in use of
MDIs and peak flow meters, train the staff
in assessing acute exacerbations, serve as
the link between community care providers
and the school, and educate faculty, staff,
and parents about asthma.
Mechanisms also should be in place
to refer students without health care
providers to a primary care provider or
asthma specialist, if indicated. Also,
mechanisms, primarily parental consent,
are helpful to communicate concerns about
asthma control to the student's health care
provider. Nurses should be familiar with
-------
CDC DASH Strategies
Asthma Education
Students with asthma
Faculty and staff
Students without asthma
Smoking cessation and prevention for students,
parents, and staff
Copyright © 2003 American Academy of Pediatrics
Students with asthma should have
the opportunity to participate in
asthma education programs that
teach asthma basics and self-management.
Parents also should have an opportunity to
participate. Examples of available education
programs are listed on the next slide.
Provide school staff with education on
asthma basics, asthma management,
and emergency response as part of their
professional development activities. Staff
should include classroom teachers, PE
teachers, coaches, secretaries, administra-
tive personnel, cafeteria and playground
workers, maintenance and facility workers,
and bus drivers. Helpful resources include
Asthma and Physical Activity in the School
from the NHLBI and Indoor Air Quality
(IAQ) Tools for Schools kit from the
Environmental Protection Agency (EPA).
Students without asthma also benefit from
asthma education. Educated students
without asthma can serve as support for
students with asthma in recognition of
acute symptoms and following an asthma
action plan. A good resource is the Asthma
Awareness Curriculum for the Elementary
Classroom from the NHLBI, designed to be
part of a general health education program
for students from kindergarten through
sixth grade.
Provide and/or support smoking prevention
and cessation programs for staff, teachers,
students, and parents.
-------
Asthma Education Programs for Students
• Open Airways (ALA)
- For children 8-11 y.
-Can be taught by professionals or volunteers.
• Power Breathing (AAFA)
- Empowers and motivates teenagers to take
control of their asthma.
- Can be taught by professionals or volunteers.
Copyright © 2003 American Academy of Pediatrics
0
pen Airways (ALA)
This program consists of 6 lessons
that are taught during the school day. Each
lesson is 40 minutes long and designed
to be easy for trained volunteers or school
staff to present. Best results are obtained
when the school nurse or other health
professional teaches the program.
A detailed curriculum, an instructor's guide,
plus posters and handouts make teaching
and learning fun for everyone involved. This
program can provide an excellent source of
asthma education for patients with asthma
of busy clinicians who may not have the
time or resources to provide educational
programs themselves.
Power Breathing Program (Asthma and
Allergy Foundation of America [AAFA])
This 3-session program assists teenagers
in learning about asthma, developing
decision-making skills needed to
make appropriate choices in managing
their asthma, and integrating asthma
management into their day-to-day lives.
Specific fears and concerns teenagers
experience in their unique social
situations are addressed in a peer-friendly
environment, and alternative strategies
are explored to achieve effective asthma
management. Elements include hands-
on instruction, problem-based learning,
discussion and strategic thinking, video
animation, and Class Dismissed!, a
board game to test asthma knowledge.
Adolescents with asthma often deny
symptoms and may be non-adherent with
medication programs. Such educational
programs can serve as very useful adjuncts
to regular asthma care.
-------
CDC DASH Strategies
Healthy School Environment
Prohibit tobacco use at all times.
Reduce exposure to asthma triggers.
Keep temperature and humidity at appropriate
settings.
Replace carpeting with hard surface flooring.
Schedule maintenance during off-school hours.
Use integrated pest management.
Copyright © 2003 American Academy of Pediatrics
Environmental control is important in
managing asthma at home; providing
a healthy indoor environment at
school is just as important.
Prohibit tobacco use at all times on all
school property, on school buses, and
at school-sponsored events off school
grounds.
Reduce exposure to irritants and allergens
and improve IAQ by eliminating tobacco
smoke, reducing dust and debris from
construction or remodeling, reducing dust
mites by removing carpeting and frequent
damp dusting, reducing animal dander by
prohibiting furry animals in the classroom,
and keeping coats outside the classroom.
Such instructions should be part of the
asthma action plan.
Maintaining humidity below 50% will
reduce dust mites and molds. Regular
scheduled maintenance of heating,
ventilation, and air conditioning (HVAC)
systems can improve air quality. Schools
should repair any water leaks or damage
to prevent mold infestation. It would be
a good idea for schools to develop an
IAQ team using the EPA IAQ Tools for
Schools kit. This kit contains many helpful
suggestions for dealing with IAQ. If you
have a patient/student who is having
asthma problems at school, mentioning
this approach to school administration
could be helpful.
Try to schedule major maintenance
projects, such as resurfacing gym floors
and painting, at times when school is
not in session, such as summer and
spring break. Maintenance tasks such as
lawn mowing should be performed after
school hours. The use of integrated pest
management techniques can reduce the
need for pesticides, which can be irritating
to airways and trigger asthma symptoms.
-------
Asthma Triggers in School
Allergens—dust mites, animal dander, mold, pollen
Irritants—cold air, paint, cleaning solution, chalk
dust, cigarette smoke, auto and bus exhaust
Exercise—especially in cold weather
Copyright © 2003 American Academy of Pediatrics
Asthma triggers do not stop at home.
The school environment cannot be
ignored and must be monitored,
especially for students with persistent
asthma.
-------
Indirect Dander Exposure
Cat allergen is carried on clothing of cat owner's
students.
Indirect exposure is risk factor for sensitization in
non-cat-owner's students.
Worsening of asthma occurred in cat-allergic
students who attended classes with >18% students
who were cat owners.
Copyright © 2003 American Academy of Pediatrics
Cat allergen is carried on the clothing
of the school children of cat owners.
The studies by Almqvist strongly
suggest that indirect exposure to animal
dander at schools can sensitize a non-cat
owner to develop cat allergy, and students
already allergic to cats can have worsening
of asthma symptoms in the school setting.
Thus, asthma medication in children with
cat allergy may be affected by indirect cat
exposure at school.
-------
Indoor Air Quality (IAQ)
When to suspect IAQ problems
• Stained ceiling tiles
• Air intake grills
* Fresh varnish on the gym floor during school
session
• Stagnant water
» Inadequate ventilation, crowding
Copyright © 2003 American Academy of Pediatrics
Pollutants exist in indoor as well as
outdoor air. The most common
pollutants found in buildings are
(1) gases and particles from tobacco
smoke and heating and cooking appliances;
(2) building-related substances such as
asbestos, formaldehyde, pesticides, paint
fumes, and radon gas; and (3) biologic
pollutants including bacteria, viruses,
insects (eg, dust mites, cockroaches),
and dander from pets and humans.
These pollutants can aggravate allergies
and asthma.
The EPA IAQ Tools for Schools kit helps
schools plan improvements in IAQ.
-------
IAQ Tools for Schools
Action kit developed by the EPA
Help school personnel deal with IAQ problems
Management plan, checklists for school personnel,
problem-solving wheel
Fax: 703/438-4318
www.epa.gov/iaq/schools
I-BEAM software
Copyright © 2003 American Academy of Pediatrics
Many IAQ problems in schools
can impact the health of children
with asthma. Potential problems
include chemical pollutants from building or
building maintenance materials and science
and art classes, improperly maintained
HVAC systems, and allergens and irritants
covered earlier in this section.
The IAQ Tools for Schools kit helps school
personnel identify, solve, and prevent
IAQ problems in the school environment.
A coordinator's guide is included that
explains the fundamental elements of IAQ
and procedures for improving air quality.
There is also a 19-step management plan
and checklists for virtually everyone on
the school staff. The checklists cover the
HVAC systems, maintenance procedures,
classrooms (animal and mold control), and
food service areas. Also included are a
guide for health professionals and a video
covering the ventilation checklist and ways
to implement the program.
Additional tools available to help schools
implement the IAQ Tools for Schools kit
include a quick-start guide and problem-
solving wheel to help find solutions to
common problems quickly.
Schools, school districts, and nonprofit
groups may receive a copy of the IAQ Tools
for Schools kit at no cost simply by faxing
a request on school or group letterhead
to IAQ Info at 703/356-5386. For more
information, call IAQ Info at 800/438-4318.
The entire kit can be downloaded from the
EPA Web site at www.epa.gov/iaq/schools.
The EPA also has free software available
called I-BEAM that can help schools
estimate the cost of deferred versus
immediate maintenance. This software
also can be downloaded from the Web site.
For the most effective approach, schools
should form an IAQ coordinating committee
using the information in the kit. The
problem-solving wheel is particularly helpful
in getting to the root of IAQ problems.
-------
Special Situations
Exercise-induced Asthma
Albuterol pre-exercise
- Access
Long-acting beta2-agonists
Leukotriene receptor antagonists
Optimize anti-inflammatory therapy
- Avoid triggers
Warm-up
Copyright @ 2003 American Academy of Pediatrics
Managing exercise-induced asthma in
the school setting can present some
challenges. Good communication
with the school, especially the PE teacher
or coach, and parents can help to solve some
of them.
Albuterol pre-exercise is the treatment of
choice. Embarrassment about using an inhaler
in front of peers or problems with access,
such as the requirement to go to the school
office for medications, can interfere with
adherence to this therapy. Regardless of these
pretreatment concerns, however, albuterol
needs to be available for rescue therapy, ideally
at the site where exercise is taking place.
This is important to remember for after-school
activities when the school is locked up.
For those children who have difficulty
with pretreatment, use of long-acting
bronchodilators in the morning before school
may be a suitable alternative. These agents
have a duration of action of up to 12 hours
and should be adequate for most physical
activity during school hours. Studies suggest
that continued use of one of these agents,
salmeterol xinafoate, may be associated with
a decline in the duration of effectiveness,
which may make it less useful for after-school
activities. Whether this occurs with the other
US-licensed agent, formoterol fumarate, is
not clear.
Leukotriene receptor antagonists do have
some effectiveness against exercise-
induced asthma, although less than inhaled
beta-agonists. They can be given 2 hours
before exercise and do not appear to lose
effectiveness with continued use. The duration
of protection should be more than adequate
for the entire day.
Exercise-induced asthma is a manifestation
of increased bronchial hyperresponsiveness,
which is a function of the degree of airway
inflammation. Control of exercise-induced
asthma can be improved by treating this
inflammation by avoidance of allergens and/or
use of regular anti-inflammatory therapy.
About 50% of children with exercise-induced
asthma will develop a refractory period after
exercise, such that episodes of exercise-
induced bronchoconstriction will not occur for
1 to 2 hours after recovering from an initial
episode. By allowing warm-up to the point
of symptoms, then resting until recovered,
the student may be able to participate in
the athletic event without problem. Such an
approach can be helpful for children who do
not respond to the other approaches.
-------
CDC DASH Strategies
Physical Education and Activity
Promote participation in all activities.
• Every effort should be made to keep the child in
physical activities.
* Temporarily curtail activities during flare-ups.
* Specify type and length of limitation.
• Avoid making the child feel different.
Copyright © 2003 American Academy of Pediatrics
Adaptive or full physical education
excuse should be avoided. Work
with parents, coaches, and school
nurses to bring these children's asthma
under good control. Asthma can be
controlled—expect nothing less!
Good asthma control at school means
• Full participation in PE, recess, and
sports
• No coughing, difficulty breathing,
wheezing, or chest tightness
• No acute episodes
• No absences from school
• No side effects from medicines
Children may need to temporarily reduce
or curtail physical activity during times of
asthma exacerbations. Try to continue to
have children participate in class activities
in a role that allows them to reduce their
physical activity but still be a part of the
class. Sending children away to spend
time in the library only makes children feel
different and may result in them trying to
hide their asthma.
-------
Asthma or Not?
Evaluate for psychosoclal issues at home, school.
Monitor peak flow meter during attacks.
Evaluate response to quick-relief inhaler.
Communicate with parents, school staff.
Copyright © 2003 American Academy of Pediatrics
In some cases, a child may present
with asthma-like symptoms that may
or may not respond to typical asthma
medicines. An underlying problem such as
parental divorce or a recent death in the
family could be the main culprit.
-------
CDC DASH Strategies
Goal: Effective Communication
• Form links among school, home, and health
care providers.
* Observe and report symptoms, medication use.
• Review difficulties students may have with daily
school management plan.
* Resolve problems with school performance
related to asthma.
• Encourage active student participation in
school activities.
Copyright © 2003 American Academy of Pediatrics
Obtain written parental permission
for school staff and the asthma care
provider to share student health
information. Parents should sign release
of record forms at school and the health
care provider's office. It is required by The
Family Educational Rights and Privacy Act
(FERPA) that written releases be signed
to exchange this information. Educate,
support, and involve family members
and school staff in efforts to reduce
asthma symptoms and school absences.
Provide an asthma action plan for your
patients to take to school. Inform parents
about education programs such as those
mentioned in this presentation.
Community clinicians or school nurses can
teach school staff symptoms and signs of
uncontrolled asthma and encourage them
to report such signs and symptoms to the
school nurse.
Assist students with aspects of their
asthma management program, including
having the school nurse review inhaler
and peak flow technique and perhaps
providing maintenance medications at
school. Evaluate asthma control and school
performance and make corrections when
necessary to allow for full participation and
minimize absences.
The Family Educational Rights and Privacy
Act (FERPA) regulations apply to any school
information sent to outside agencies or
providers. The Health Insurance Portability
and Accountability Act (HIPPA) regulations
apply to records sent from any outside
agency to schools.
-------
Laws and Regulations
Section 504, Rehabilitation Act, 1973
Americans with Disabilities Act (ADA), 1990.
Pro-Children Act, 1994
Individuals with Disabilities Education Act (IDEA),
1997
FERPA, 2002
Copyright © 2003 American Academy of Pediatrics
Most schools are as concerned
with a child's health as the
child's doctor. With proper
communication and education, most
students with asthma can experience
an equal and complete educational
experience, unfettered by their condition.
In some situations, however, schools
can be reluctant to follow through with
recommendations, either because of
funding limitations or lack of understanding.
In these situations, there are several
federal laws that can be helpful in ensuring
that students with asthma receive proper
asthma management within the school
and have free access to public education
(FARE). Clinicians who care for children
with asthma and parents should be familiar
with these laws, as they can be used
as sanctions when schools are reluctant
to follow through with suggestions
for management.
The most frequently applicable law is
Section 504 of the Rehabilitation Act of
1973. This law prohibits discrimination
of individuals with a disability under
any program receiving federal financial
assistance. This applies to public schools,
but not to most private schools. Children
covered under Section 504 must have a
disability that substantially limits a major
life activity. Asthma qualifies as such a
disability. Depending on the level to which
the disability limits a student's learning, a
school district must determine if a student
is also eligible under the Individuals with
Disabilities Education Act (IDEA).
The Americans with Disabilities Act (ADA)
prohibits discrimination based solely on
the basis of disability in employment,
public services, and accommodations.
It does not directly deal with FARE,
however; it provides additional protection
in combination with actions brought under
Section 504 and IDEA. Protections from
ADA also apply to nonsectarian private
schools, but not to organizations or entities
controlled by religious organizations.
Thus, it expands protection to some
private schools.
The Pro-Children Act of 1994 prohibits
smoking in facilities (in some cases,
portions of facilities) in which certain
federally funded children's services are
-------
Laws and Regulations continued
provided on a regular or routine basis. This
applies to practically all public elementary
and secondary schools and library facilities.
The Individuals with Disabilities Education
Act applies to children who are eligible by
reason of certain disabilities and who need
special education and related services.
Implementation of this law requires
schools to complete an individualized
health plan and individualized education
plan (IEP) for students with disabilities.
The IEP program of IDEA may be used
to meet the Section 504 requirement.
The Family Educational Rights and Privacy
Act (PERPA) is designed to protect the
privacy of a student's education records
and applies to all schools that receive US
Department of Education funds. These
include health inquiry forms, asthma action
plans, and other health records. Generally,
schools must have written permission from
a parent (or student if older than 18 years)
to release such records.
FERPA = Family Educational Rights and
Privacy Act
-------
-------
• •'•&&$%£• Asthma and Allergy
'"'•''fi&fKf'i:'''' Foundation of America
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Homeroom Teacher:
Parent/Guardian Name:
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Physician Treating Student for Asthma:
Other Phvsician:
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ACTION CARD ft
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Prevention
Room:
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Education and
Program
ID Photo
Name Relationship Phone
Name Relationship Phone
Ph:
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M EMERGENCY PLAN ^^^^^^^^^^^^^^^^^^^^^^^^^^1
Emergency action is necessary when the
student has symptoms such as,
or has a peak flow reading of
• Steps to take during an asthma episode:
1. Check peak flow.
2. Give medications as listed below. Student should respond to treatment in 15-20 minutes.
3. Contact parent/guardian if
4. Re-check peak flow.
5. Seek emergency medical care if the student has any of the following:
• Coughs constantly
• No improvement 15-20 minutes after initial treatment
with medication and a relative cannot be reached.
• Peak flow of
• Hard time breathing with:
• Chest and neck pulled in with breathing
• Stooped body posture
• Struggling or gasping
• Trouble walking or talking
• Stops playing and can't start activity again
• Lips or fingernails are grey or blue
Emergency Asthma Medications
Name
IF THIS HAPPENS, GET
EMERGENCY HELP How!
Amount
When to Use
1.
4.
See reverse for more instructions
-------
DAILY ASTHMA MANAGEMENT PLAN
• Identify the things which start an asthma episode (Check each that applies to the student.)
D Exercise D Strong odors or fumes D Other
D Respiratory infections D Chalk dust / dust
D Change in temperature D Carpets in the room
D Animals D Pollens
D Food D Molds
Comments
• Control of School Environment
(List any environmental control measures, pre-medications. and/or dietary restrictions that the student needs to prevent an asthma
episode.)
• Peak Flow Monitoring
Personal Best Peak Flow number:
Monitoring Times:
• Daily Medication Plan
Name Amount When to Use
1.
2.
3.
4.
COMMENTS / SPECIAL INSTRUCTIONS
FOR INHALED MEDICATIONS
D I have instructed in the proper way to use his/her medications. It is my
professional opinion that should be allowed to carry and use that medication by
him/herself.
D It is my professional opinion that should not carry his/her inhaled medication by him/herself.
Physician Signature Date
Parent/Guardian Signature Date
AAFA • 1233 20th Street, N.W., Suite 402 , Washington, DC 20036 • www.aafa.org • 1-800-7-ASTHMA
02/00
-------
Asthma and Schools
Children spend a significant part of their day at school. That is why it is so important that
asthma symptoms are well managed while they are there. It is also important that you
are aware of your child's symptoms and any problems with how your child's asthma is
managed in school.
Effective Communication
Good communication is essential to asthma care and management in school. The school needs
to know about your child's asthma, how severe it is, what medications your child takes, and what
to do in an emergency. This communication can be helped by having your health care provider
complete an asthma action plan for the school (see sample provided), as well as a medication
permission form that includes whether your child should be allowed to carry and use her own
inhaler. You should also sign a release at school and at your health care provider's office to allow
the exchange of medical information between you, the school, and your health care provider.
Your child's school needs to communicate to you its policies on how your child will get access to
her medications and how they deal with emergencies, field trips, and after-school activities. The
school should also inform you about any changes or problems with your child's symptoms while
she is at school.
Peak Flow Meter
Peak flow meters can be helpful for school staff in determining the severity of an asthma attack.
If your child's health care provider has recommended a peak flow meter, determine your child's
best peak flow (your health care provider should tell you how to do this). Then keep a peak flow
meter at school.
School Environment
The environment at school is as important as the environment at home. Use How Asthma-Friendly
Is Your School? checklist to check your child's school and classroom.
-------
Coping With Asthma at School
Students with asthma face a number of problems related to school. Talk to your child about how
well his asthma is being managed in school. Also talk to your child's teachers, school nurse,
coaches, and other school personnel to get their opinions on how well your child is coping with
asthma in school and to see if asthma symptoms are causing any of the following problems:
• Missing school due to asthma symptoms or doctor visits.
• Avoiding school or school activities. Work with your health care provider and school personnel to
encourage your child to participate in school activities.
• Not taking medication before exercise. Your child may avoid going to the school office or nurse's
office to use his inhaler before exercise. Schools that allow children to carry their inhalers with
them can help avoid this problem.
• Side effects from medication. Some asthma medications may alter your child's ability to perform
in school. Teachers need to know if and when your child takes asthma medication so that you
can be notified if there are any problems.
Physical activity is important for your child's physical and mental health. Children with asthma
should be able, and encouraged, to participate completely in physical education, sports, and other
activities in school. All students should have some knowledge of asthma basics and management.
Encourage your school to offer asthma awareness education as part of the health education
curriculum.
Know Your Rights
Learn about the federal laws that can help you with asthma management concerns at school.
These include the following:
• Section 504 of the Civil Rights Act of 1973
• Americans with Disabilities Act (ADA)
• Individuals with Disabilities Education Act (IDEA)
American Academy of Pediatrics
DEDICATED TO THE HEALTH OF ALL CHILDREN
Copyright © 2003
-------
Asthma and Schools
Key Points to Cover With Patients
• Children spend a significant portion of their day at school. Asthma management programs
need to be administered at school as well as at home. This includes environmental control
and medication use.
• Parents need to communicate with the school nurse and teachers about their child's asthma.
Such communication can be helped with the use of a written asthma action plan from the health
care provider that can be kept on file at school. Also, parents should sign a release for records
from the school to your office, and vice versa at the school.
• Students need to have immediate access to medications at school. This should include self-carry
and self-administer protocols for children that are mature enough to do so. Furthermore, children
need to have access to medications for activities off school grounds and after school. Parents
should check with their school about these policies.
• Peak flow meters are often helpful when non-medical personne are involved in asthma
emergencies and medication administration, as is often the case in school.
• Asthma education for students, staff, and parents can be very helpful, and parents should check
and see what is available in their school.
• Parents need to be aware of the school and classroom environments, and whether triggers
for their student's asthma are present. How Asthma-Friendly Is Your School?, provided by the
National Asthma Education and Prevention Program, can be helpful.
• Physical education and activity is important for the physical and psychosocial development of
all children. Children with well-controlled asthma should not have any problems, but every child
with asthma may have times of asthma exacerbations when physical activity may need to be
decreased. It is important to try to continue to include the child in some way in the class activity
during these times.
• There are certain federal laws that can help you or your child establish a management plan
appropriate for them at school. These can be used if you feel that the school is not cooperating
with your wishes.
American Academy of Pediatrics
DEDICATED TO THE HEALTH OF ALL CHILDREN
Copyright © 2003
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Pediatric Asthma—Overview
Copyright © 2003 American Academy of Pediatrics
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Pathogenesis of Allergy and Asthma
Genetics
•TH2
• Lung
factors
Rhinitis
Copyright © 2003 American Academy of Pediatrics
Allergic inflammation
Asthma
Most cases of asthma begin in
childhood. A number of genetic
factors have been identified,
particularly those associated with the
regulation of immune responses. There
are data suggesting that overproduction
of TH2 cytokines may be important in
asthma pathogenesis and that this may
be regulated in part by genetics. It is
also likely that lung-specific factors will
be identified. Environmental factors also
influence the development of allergies
and asthma. These include exposure
to allergens, infections, microbes, and
pollution. Age may be a third critical
factor and several studies have identified
infancy as an important period for lung
development and for environmental
exposures to affect the development of
the immune system. The net result of
these 3 factors can be the development of
allergic inflammation. In some children this
manifests as allergic rhinitis, while others
go on to develop asthma.
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Epidemiology of
Asthma
« f incidence
* Global distribution
• Associations with environmental factors
Copyright © 2003 American Academy of Pediatrics
It has been recognized that for many
years the prevalence of asthma has
increased in children in the United
States and many other western countries.
According to the latest data from the
National Health Interview Survey (2001),
12.6% of children 0 to 17 years of age
(9.2 million) reported that they had a
diagnosis of asthma made by a health
professional at some time in their lives.
Eight-point-seven percent (8.7%) of
children (6.3 million) of the same ages
reported that they still had asthma.
As part of a global study of respiratory
health called the ISAAC study, wheezing in
13-and 14-year-old school children during
the past 12 months was ascertained by a
carefully standardized survey. It showed a
wide range in the prevalence of wheezing
in different countries around the world.
The highest rates of wheezing have been
found in westernized countries. Notably,
in many underdeveloped countries the
frequency is much lower.
Immigrant studies have shown an increase
in asthma prevalence when families
move from Third World countries to more
developed countries.
These findings strongly suggest that
wheezing and asthma in children are
driven by local environmental factors,
and high rates of asthma in westernized
countries may be related to lifestyle, which
can influence the indoor environment in
particular.
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What caused the recent
epidemic of allergic
diseases and asthma?
* Pollution
* f Allergen exposure
• Changes in exposure to childhood
illnesses/pathogens
* Changes in exposure to microbes
- Endotoxin or LPS
Copyright © 2003 American Academy of Pediatrics
This raises questions about what
specific environmental influences
have led to increases in allergic
diseases and asthma. Some of the factors
that have been evaluated include pollution,
allergen exposure, changes in exposure
to childhood illnesses and pathogens, and
changes in exposure to microbes in the
environment.
LPS = lipopolysaccharide
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The Updated Hygiene Hypothesis
Birth
TH2
Child care
Older siblings
Animals
Microbes
Infections
n
Only child
Few infections
Tolerance
Healthy
Still TH2
Allergies
Asthma
Copyright © 2003 American Academy of Pediatrics
One of the theories about the
pathogenesis of asthma is called the
hygiene hypothesis. It relates the
impact of early life exposures to infections
and microbes to the development of
allergy. All children are born with a TH2
immune response. Exposure to certain
infections and microbes or microbial
products (eg, endotoxin) can cause a
shift in the immune response to a more
normal TH1 response, whereas the
absence of such infectious exposure
favors the development of allergy. The
updated version of the hypothesis comes
from recent data suggesting that certain
exposures, particularly animals, can lead to
a modified TH2 response and tolerance to
exposure to those allergens.
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Understanding the Increases In Asthma
Copyright © 2D03 American Academy of Pediatrics
In future studies it will be important to
study the potential interactions between
these factors to determine which
combinations of factors and interactions
between environmental exposures are
key to the development of asthma. It
is likely that there are distinct sets of
environmental factors that are responsible
for the high prevalence of asthma in
different geographic locations (eg, US inner
cities versus New Zealand).
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Diagnostic Approach to Asthma
Clinical suspicion
Clinical history with focus on symptom patterns
Confirm diagnosis with objective measurement
Copyright © 2003 American Academy of Pediatrics
Besides the obvious presentation of
wheezing and respiratory distress,
the clinician should consider the
diagnosis of asthma in children who
present with chronic or recurrent cough
without colds and repeated episodes of
bronchitis or bronchiolitis.
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Medical History
• Symptoms
- Frequency and severity of symptoms
— Exacerbating factors
• Medications—frequency and response
• Allergic diseases
• Family history
Copyright © 2003 American Academy of Pediatrics
I
mportant elements of the medical
history include:
• Presence of symptoms such as cough,
wheeze, shortness of breath, or chest
tightness
- Frequency of symptoms: less than
weekly, more than twice weekly, daily,
or continuous
- Severity of symptoms, including
nighttime awakening, missed school
and other limitations to activities such
as sports, emergency room visits,
and hospitalizations
- Exacerbating factors for symptoms,
such as exercise, upper respiratory
infections (URIs), pets, and smoke
• Need for and response to medications,
especially short-acting bronchodilators
• Personal history of other atopic disease,
such as atopic dermatitis and allergic
rhinitis
• Family history of asthma or other atopic
disease
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Objective Evaluation of Asthma
Physical examination
Pulmonary function
Broncho pro vocation
Copyright © 2003 American Academy of Pediatrics
The objective evaluation for asthma
includes the physical examination,
objective monitoring of pulmonary
function (ideally with spirometry initially),
and, in some cases, evaluating the
response to bronchoconstrictive tests
or agents.
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Allergy Testing
Evidence for allergy common in pediatric
patients with asthma
May help guide environmental control
Skin testing (prick with or without intradermal}
the "gold standard"
In vitro (RAST) testing an alternative in some
situations
Copyright ® 2003 American Academy of Pediatrics
Because evidence for allergy is found
in up to 85% of pediatric patients
with asthma, allergy testing may
be useful as a part of their evaluation.
If sensitization to allergens can be
demonstrated, asthma may be improved
by control of exposure. In the case of dust-
mite-sensitive patients with asthma, for
example, asthma severity improves with
control of dust mite exposure.
Allergy testing may have prognostic value
in younger children. Young children who
wheeze are more likely to have persistent
disease if they are atopic.
Skin testing (prick with or without
intradermal testing) is the "gold standard"
of allergy testing, but radioallergoabsorbent
testing (RAST) may be an alternative
in some situations. For example, RAST
testing may be preferred in patients with
severe dermatitis or who are unable to
tolerate skin testing or refrain from taking
antihistamines. Radioallergoabsorbent
testing is considered less sensitive
than skin testing. Newer forms of RAST
(the so-called CAP RAST) do provide
quantitative value, especially in food
testing. The standardization of RAST
can vary significantly from laboratory
to laboratory.
Positive skin-test results also can be
a significant predictive factor for the
diagnosis of asthma in patients with
chronic lower respiratory symptoms.
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Asthma Phenotypes
• Transient early wheezing
* Non-atopic wheezing
• Allergic wheezing/asthma
Copyright © 2003 American Academy of Pediatrics
The Tucson Children's Respiratory
Study, has provided a great deal of
useful information about childhood
asthma and allergic disease. It was
originally established as a long-term,
longitudinal, prospective study of the risk
factors for acute lower respiratory tract
illnesses in early childhood and chronic
obstructive airways disease in later life.
A total of 1,246 newborns were enrolled
into the study between May 1980 and
January 1984. Subjects from the study
have been extensively evaluated. One
important finding of the study is the
identification of several different asthma
phenotypes in pediatric patients: transient
early wheezing, non-atopic wheezing, and
atopic wheezing/asthma.
This study has demonstrated that not all
children who wheeze in early childhood will
develop asthma. Many of the children who
wheeze in the first 3 years of life do not
have the classic asthma inflammation and
may not respond to the same treatments
as children with persistent asthma. These
children usually are no longer wheezing
by age 6. Such phenotypes are not easy
to identify with certainty clinically, and
there may be some overlap. It is important
to remember that children who go on to
develop persistent asthma also start before
age 3 and the outcome may depend on
early recognition and therapy. Because
there are no single markers to differentiate
children who are transient wheezers from
children who are persistent wheezers,
careful follow-up with attention to historical
features and signs of persistent disease
is crucial.
Clues that indicate which children may
need controller therapy will be covered
later in this module.
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Goals of Therapy for the
Child With Asthma
• Prevent chronic and troublesome symptoms.
Ideally NO symptoms day or night
* Prevent exacerbations of symptoms.
Minimal (ideally NO) asthma episodes,
• Maintain normal activity levels.
Minimal (ideally NO) interference with usual or
strenuous activity.
• Maintain normal or near-normal lung functions.
Maintain at least zSO% of predicted FEV1 or
personal-best PEFR.
Copyright © 2003 American Academy of Pediatrics
Overall goals of therapy are listed
here. Simply, goals are the control
of symptoms and airflow limitation
to the point of allowing the child to function
normally or as close to normal as possible,
and to prevent or at least minimize
the number and intensity of asthma
exacerbations. Pharmacotherapy is only
one, albeit important, aspect of therapy.
FEVi = forced expiratory volume in
1 second
PEFR = peak expiratory flow rate
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Non-pharmacologjc Approaches to
Asthma Management
General strategies
1. Asthma education
2. Environmental control (eg, allergens, irritants)
3. Immunotherapy
4. Other (eg, exercise, chiropractic)
Copyright © 2003 American Academy of Pediatrics
While pharmacologic management
is necessary for all patients
with asthma, it is also important
to consider possible non-pharmacologic
approaches. These may allow for improved
asthma control with lower doses of
medication and are therefore logical and
appealing to patients and their families. The
following 4 strategies will be discussed:
1. Asthma education—important and
necessary for all patients.
2. Avoidance of allergens and nonspecific
irritants—this should be employed
for all patients. Even those without
allergies can have symptoms triggered
or exacerbated by exposure to irritants,
especially environmental tobacco smoke
(ETS).
3. Immunotherapy—appropriate for
selected patients, especially those with
clear allergic triggers.
4. Other (eg, exercise, chiropractic)—
limited data that these are effective.
-------
Asthma Education
* Critical to effective asthma management
• Primary caregivers should provide regular
follow-up and education on
- Asthma signs and symptoms
- Expectations of asthma treatment
- Medications and their administration
- Written action plans, PFMs
- Environmental control measures
Copyright © 2083 American Academy of Pediatrics
As part of ongoing asthma care,
practitioners should take time to
educate their patients about asthma
facts and therapy. Teach what asthma
symptoms and signs are, such as cough
without colds, cough at night, cough
with exercise, chest tightness, and
throat tightness.
The goals of asthma therapy are well
outlined in the National Heart, Lung, and
Blood Institute (NHLBI) Expert Panel
Report 2: Guidelines for the Diagnosis and
Management of Asthma released in 1997.
These goals include
• Minimal symptoms of asthma (rescue
inhaler use less than twice per week)
• Full participation in physical activity
• Minimal school absences
• No emergency department visits or
hospitalizations
• Minimal adverse effects from medications
• Near-normal pulmonary function
The types of medications used and their
purposes need to be reviewed. Patients often
are non-adherent to medication programs
because they do not understand the purpose
of a medication.
Written actions plans may be helpful in
asthma self-management program and should
specify when to use rescue medications,
adjustments to controller medications during
exacerbations, and when to notify the health
care provider. According to the National
Asthma Education and Prevention Program
(NAEPP) Expert Panel Report: Guidelines
for the Diagnosis and Management of
Asthma—Update on Selected Topics—2002,
there are inadequate data to support the use
of peak flow meters (PFMs) over symptom-
based management plans. Nonetheless,
peak-flow-based management plans may be
helpful in patients with moderate or severe
asthma and may improve physician-patient
communication. They are also particularly
helpful for patients who do not recognize
significant degrees of airway obstruction.
Avoidance of triggers of asthma are as, if
not more important than medication use,
and details will be provided throughout this
presentation.
PFM = peak flow meter
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Classification of
Environmental Triggers
Allergens
Indoor
- Mites, animals,
cockroaches, molds
Outdoor
- Pollens (eg, trees,
grass, weeds)
- Molds
Copyright ©2003 American Academy of Pediatrics
Irritants
- Tobacco smoke
- Air pollutants
- Odors, fragrances
-VOCs
Molds can be triggers both indoors
and outdoors. However, molds do
not ordinarily occur indoors to a
significant extent unless there is ongoing
problems with moisture, such as leaking
roofs or previous significant water damage.
Air pollutants come from wood smoke,
automobile exhaust, and volatile organic
compounds (VOCs) in sprays, solvents, and
household cleaners.
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Dust Mite Control Measures
First line (necessary and cost-effective)
* Use mattress and pillow encasements.
• Wash bed linens every 1-2 weeks, preferably in hot
(>130°F) water,
• Remove stuffed toys.
• Regularly vacuum carpeted surfaces.
* Regularly dust hard surfaces.
• Control humidity (dehumidify if possible, but at least do
not add humidity!).
Copyright ® 2003 American Academy of Pediatrics
These are the "first-line" measures of
dust mite control. They are first line
because they are necessary and not
terribly expensive or difficult to implement.
There are no industry standards for vacuum
cleaners, although a few studies have
shown that those with High Efficiency
Paniculate Air (HEPA) filters or filter
bags leak less allergen particles into
the indoor air.
Dusting should be done with a damp or
treated cloth to pick up the dust. Feather
dusters should not be used.
Dehumidification may be difficult and
expensive in humid environments. Indoor
air conditioning is an effective way to
dehumidify the air, but is expensive if
not already available. It is not known
whether local dehumidification is possible
or effective.
Water temperatures >, 130°F are necessary
to kill dustmites.
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Animal Allergen Control Measures
• Remove source (ie, find a new home for the pet!).
- Reduces allergen in settled dust.
- Clinical benefit presumed but never proven.
- Allergen levels fall slowly-benefits not expected for
weeks to months.
- Should be followed by aggressive cleaning to remove
reservoirs of allergen.
- Possible role for tannic acid to augment allergen removal.
Copyright © 2003 American Academy of Pediatrics
The approach to animal allergy should
be simple—find a new home for
the pet and clean aggressively. You
should remember, however, that even
with these measures allergen levels fall
over a period of weeks to months, so a
clinical benefit should not be expected
immediately.
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Animal Allergen Control Measures
* If pet is not removed, the following measures may help
reduce allergen levels:
- Limit access, especially from bedroom.
- Run air cleaners.
- Remove carpeting.
- Use mattress and pillow covers.
-Wash animals (not likely helpful unless done at least
2-3 times a week).
* However, these may not reduce levels enough to help
patients who are highly allergic.
Copyright © 2003 American Academy of Pediatrics
Unfortunately, most families are
unwilling to remove pets from their
homes, even when they are causing
significant disease. A number of measures
have therefore been studied that may help
to reduce exposure even with the pet still
living in the home. These include keeping
the pet out of the bedroom, running air
cleaners, removing carpeting, and using
mattress and pillow covers (because
carpets, mattresses, and pillows are
huge reservoirs of allergen). Washing
cats and dogs has been recommended
but it has now been shown that the
effects of washing are very short-lived—
it would be necessary to wash the animals
2 or more times per week to have any
potential benefit.
It is also very important to note that these
measures are not likely to be effective for
patients who are highly allergic, for whom
the only proper advice is to remove the pet
from the home.
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Cockroach Allergen Control Measures
Behavioral changes in food sources (eg, dirty dishes,
open food containers, uncovered trash cans)
Roach traps and baits
If above steps do not work, exterminate thoroughly
(ensure asthmatic is not in area during extermination)
Thorough cleaning after extermination
If necessary, extermination of neighboring dwellings
Copyright © 2003 American Academy of Pediatrics
Cockroach control is an exceedingly
difficult task and possibly one that
will meet with failure. The following
are recommended: Integrated pest-
management techniques are preferable
to excessive use of pesticides. Behavioral
changes to reduce food sources and
roach traps and baits should be tried first.
If those measures don't work, thorough
extermination should be tried. Make
sure any asthmatics are out of the area
during extermination and for several
hours thereafter. Where dwellings are
joined, such as in apartment buildings and
townhouses, extermination of neighboring
dwellings may be necessary. These
methods can reduce cockroach antigen
levels considerably. However, it is still not
clear that even large reductions will have
a clinical benefit beacuse of the degree
of infestation in many homes. Even with
large reductions, many homes are still well
above the threshold of 8 units/g of dust
noted on the previous slide.
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Mold Allergen Control Measures
• Identify sites/sources of mold growth.
• Water control is key.
• Clean moldy areas with detergent and water.
• If cleaning not possible, discard/replace moldy
items (eg, carpets, furniture, wallboard).
» Dehumidify.
• Run exhaust vent in bathroom and kitchen.
• Clean refrigerator, dehumidifier, and humidifier
with fungicide.
Copyright © 2803 American Academy of Pediatrics
Mold control will need to begin with
some detective work to identify
sites of mold growth. Molds can
be killed on most hard surfaces using a
fungicide. It may not be possible to remove
molds from certain fabrics, such as a
carpet that has sustained water damage,
and these items may need to be discarded.
Dehumidification, especially in basements,
can limit mold growth, as can using a
vent in the bathroom and kitchen. Most
significant indoor mold growth occurs as a
result of water problems such as leaks in
the roof, previous flooding from appliances
or natural disasters, and excessive indoor
humidity. Molds cannot grow without
water; if you get rid of the water, you
also get rid of the mold. Leaks and areas
of poor drainage should be repaired or
corrected and other areas of potential mold
contamination should be cleaned regularly.
The Environmental Protection Agency
(EPA) recommends cleaning mold with
detergent and water rather than with a
fungicide such as bleach solutions. Dead
molds can still be allergenic and need to
be removed. Fumes from fungicides can
trigger asthma symptoms.
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Considerations for Initiating
Immunotherapy
Presence of documented IgE-mediated disease
Evidence that specific sensitivity is causing symptoms
Symptoms sufficiently severe or prolonged to warrant
the time, risk, and cost of immunotherapy
Allergen avoidance and pharmacotherapy not adequately
controlling symptoms
Availability of high-quality vaccines
Copyright © 2003 Ameri can Academy of Pediatrics
Immunotherapy is the third major
non-pharmacologic approach to asthma
treatment. Considerations for the use
of immunotherapy are reviewed on this
slide. They are somewhat obvious but
very important to recognize and review
for all patients in whom immunotherapy
is being considered.
• First, the patient must have documented
IgE-mediated disease as well as clinical
evidence that the allergic sensitivities are
causing symptoms.
• Second, the symptoms should be
sufficiently severe or prolonged to
warrant the time, risk, and cost of
immunotherapy.
• Third, immunotherapy should only be
used after appropriate medications and
environmental control measures have
been instituted.
• Fourth, good-quality extracts need to be
available.
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Overall Principles of
Pharmacologic Therapy
Agent selection dictated by chranicity and severity of
asthma and the age of the child
Chronic symptoms: control airway inflammation and relieve
and prevent bronchoconstriction
Acute symptoms: relief of bronchoconstriction; acute
therapy of inflammation
Stepwise approach
- Aggressive therapy to achieve control
- Step down when control achieved
Copyright © 2003 American Academy of Pediatrics
Selection of pharmacotherapeutic
agents and how they are used
are dictated by the chronicity and
severity of asthma and to some extent
the age of the child. The availability
of medications and devices for
administration that are user-friendly for
children and caregivers, as well as safety
considerations, have particular importance
in the younger age groups. For chronic
symptoms including frequent recurrent
symptoms, especially with objective
evidence of chronic airflow limitation (if
measurable), inflammation is considered
to be the chronic underlying problem and
therapy is directed at control of airway
inflammation as well as concomitant relief
and prevention of bronchoconstriction. For
acute symptoms, therapy is directed first
at the relief of bronchoconstriction but,
depending on the degree of exacerbation
of symptoms, may also include control
of inflammation (eg, a burst of oral
corticosteroids).
There are 2 approaches to gaining control
of asthma. The first approach is generally
preferred because it achieves rapid control.
Start with aggressive therapy to achieve
rapid control and then step down to the
minimum therapy needed to maintain
control. Aggressive therapy is therapy at a
higher level than that which corresponds
to the initial evaluation of the child's
asthma severity. It may be accomplished
by adding a 3- to 10-day course of oral
corticosteroids to inhaled corticosteroids,
cromolyn, or nedocromil, or by using a
higher dose of inhaled corticosteroids.
Or start with therapy that corresponds to
the initial evaluation of the child's asthma
severity and step up therapy until control is
achieved and maintained.
Step down therapy gradually when control
is achieved.
Consider consulting an asthma specialist
for infants and young children who require
daily (long-term control) medications
and for children who received more than
2 bursts of oral corticosteroids in the prior
12 months.
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Quick-relief Medications
Used prn for ALL asthma severity levels
Include
- Inhaled short-acting B2-agonists
- Oral corticosteroids {short courses)
- Inhaled anticholinergic (ipratropium bromide)
Copyright © 2003 American Academy of Pediatrics
Quick-relief medications include
short-acting beta2-agonists used
by inhalation, short courses
of systemic corticosteroids generally
by mouth on an outpatient basis, and
ipratropium bromide by inhalation. All
3 may be appropriate to use together
depending on the circumstances and
severity of the asthmatic exacerbation.
Although available orally in liquid and tablet
form, short-acting beta2-agonists generally
are most effective and better tolerated
when used by inhalation, and this route
of administration is preferred. Inhaled
beta-adrenergic agonists are available in
various forms and through various devices
including nebulizers with mouthpieces or
masks, metered-dose inhalers (MDIs) that
can be used alone or with spacers/holding
chambers with our without masks, and
dry powder inhaler (DPI) devices.
-------
Long-term Control Medications
* Inhaled corticosteroids
* Cromolyn sodium/nedocromii sodium
• LRTAs
* Long-acting &2-agonist inhalants
* Sustained-release theophylline
* Oral corticosteroids
Copyright © 2003 American Academy of Pediatrics
Medications available for long-term
control of asthma in children
are listed here. These can be
used alone as a single class or combined
to enhance control or diminish side
effects of medications while maintaining
control. Because each class of medication
influences pathogenic mechanisms in
a somewhat unique way, it is easy to
understand that combination therapy may
have advantages over increasing doses
of monotherapy for many patients with
uncontrolled asthma.
LIRA = leukotriene receptor antagonist
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Inhaled Corticosteroids—
Safety Concerns
* Systemic absorption—potential side effects
- Growth—dose and specific ICS dependent
* Transient 4 growth velocity, no effect on adult
height
-Adrenal suppression
* ICS—less long-term absorption (side effects)
than oral steroids; can decrease need for
steroid bursts
Copyright © 2093 American Academy of Pediatrics
Although there is less systemic absorption
and therefore less potential systemic effect
with inhaled corticosteroids than with
systemic (oral) corticosteroids long-term, systemic
absorption probably occurs to some degree even
with the lowest doses of corticosteroids. An
effect on morning cortisol levels can be seen
with conventional doses of inhaled corticosteroids
(ICS). Except at higher doses used for prolonged
periods, there is little evidence for clinically
significant effects on the hypothalamic-pituitary-
adrenal axis. Nevertheless, a transient effect on
growth velocity has been demonstrated with
beclomethasone dipropionate and budesonide
in particular. In addition to systemic absorption
that can occur through lung deposition with
all inhaled corticosteroids, beclomethasone
dipropionate is absorbed to a greater degree
from the intestinal tract than other steroids and
is converted on first-pass metabolism in the liver
to the monopropionate, which is even more
active than the dipropionate until subsequently
degraded. There is little evidence that even with
this particular corticosteroid, low dosage (less than
200 pg/day and possibly 400 pg/day) is associated
with such effects. There is no evidence that
the effect on growth velocity, which seems to
be an especially sensitive indicator of systemic
effect (whether clinically significant) of inhaled
corticosteroids, results in any alteration of final
adult height. Also, beclomethasone and other
inhaled corticosteroids are effective for most
patients at low dosage. It also is important to
emphasize that for patients who have moderate
to severe asthma that requires higher doses of
inhaled corticosteroids and other medications for
adequate symptomatic control, there is much
less systemic absorption and effect than for oral
corticosteroids used either chronically or in the
form of frequent steroid bursts. Subcapsular
cataracts, increased intraocular pressure, and
glaucoma have been associated in adults
with high-dose inhaled corticosteroids and
especially with prolonged or frequent use of oral
corticosteroids. Although this is rare in children,
this potential from prolonged systemic exposure
to corticosteroids needs to be kept in mind and
the lowest dose of inhaled steroids necessary
for therapeutic maintenance should be sought
and reevaluated periodically. At ordinary doses
of inhaled corticosteroids for mild to moderate
asthma, bone density does not appear to be
diminished in studies up to 5 years. It is useful
to point out that corticosteroids used for anti-
inflammatory effects in asthma and other diseases
are not androgens and do not have the side effects
associated with their use.
-------
Leukotriene Receptor Antagonists
(LTRAs)
* Montelukast sodium, zafirlukast
• Alternatives to low-dose inhaled corticosteroids
in mild persistent asthma
• Added control when combined with inhaled
corticosteroids (ICS)
• Convenient (oral) dosing forms
- Chewable tablets (montelukast sodium)
* Safe
* Approved down to age 2 (montelukast sodium)
Copyright © 2003 American Academy of Pediatrics
Leukotriene receptor antagonists
(LTRAs) may be considered
alternative monotherapy to low-
dose inhaled corticosteroids in milder
persistent asthma, but data concerning
the effectiveness compared with low-
dose inhaled corticosteroids long-term
are lacking. Their inhibitory activity on
the inflammatory cascade is significantly
limited compared to corticosteroids.
Nevertheless, some patients do appear to
respond extremely well to these agents,
whereas others seem not to obtain any
significant effect from their use. There
is some controversy as to whether
corticosteroids, and in particular inhaled
corticosteroids, can alter the synthesis
of leukotrienes, but if so, the activity
does not appear to be profound in usual
therapeutic dosages. This is of significance
because the leukotriene pathway appears
to contribute bronchoconstrictive and some
inflammatory effects in many patients
with asthma.
The main advantages of LTRAs, especially
in young children, is that they are available
in various oral forms (for montelukast
sodium), are recommended once a
day, and are not corticosteroids (which
concern many parents and interfere with
compliance). Their good safety record to
date enhances the benefit-risk ratio.
-------
Dual Controllers
Preferred for moderate persistent asthma in
children older than 5 years
- Data lacking in younger children
Low/medium-dose ICS plus
- Inhaled long^acting Bj-agonists (preferred)
- LTRAs, theophylline
Copyright @ 2003 American Academy of Pediatrics
The 2002 updates to the NHLBI
Expert Panel Report 2 guidelines
note that extensive literature has
demonstrated that dual-controller therapy
is more effective than increasing the dose
of inhaled corticosteroids in patients with
moderate persistent asthma. The data on
the combination of inhaled corticosteroids
and inhaled long-acting beta2-agonists are
the strongest. These data apply mainly to
older children and adults. Data on adults
suggest that LTRAs may have steroid-
sparing effects on clinical control of
asthma and may enhance clinical control
if combined with inhaled corticosteroids.
In studies comparing adding long-
acting beta2-agonists with a given dose
of inhaled steroid with the addition of
LTRAs, long-acting beta2-agonists were
more efficacious in the population overall.
Accordingly, the NAEPP 2002 Expert Panel
Report 2 updates to the guidelines now
recommend low/medium-dose inhaled
corticosteroids (ICS) plus long-acting
beta2-agonists as the preferred therapy for
children older than 5 years and adults with
moderate persistent asthma. Combinations
of ICS with LTRAs are listed as alternatives.
For children younger than 5 years, data
are not available. For this age group, the
NAEPP Expert Panel recommends either
ICS plus long-acting beta2-agonists or
increasing the dose of ICS.
-------
Stepwise Approach to Therapy
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Persistent
Moderate
Severe,
tCS high dose
+ LABA±oral
steroids
Mild
ICS lovrfmsdium dose
+ LABA*(>5y)
ICS medium dose or
ICS/LABA{<5yj
cromolyn/
nedocromil
* Short-acting B2-agonist prn =t short-term use of oral corticosteroids
Copyright © 2003 American Academy of Pediatrics
Whether a patient is on
monotherapy or combination
therapy for asthma, alterations
in pharmacotherapy are often necessary
and should always be considered
to either increase asthma control or
decrease potential side effects from the
pharmacotherapy used. As indicated
previously, short-acting inhalant beta2-
agonists are used for quick relief in all
degrees of asthma requiring long-term
controller medication. Choice of controller
therapy is dictated by the degree of
severity of asthmatic symptoms and
airflow limitation as well as other factors,
including the child's age. In young children
with milder disease, cromolyn, nedocromil,
or leukotriene receptor antagonists (LTRAs)
may be considered first, but an inhaled
corticosteroid in low to high dose is the
preferred pharmacotherapeutic agent,
either alone or in conjunction with other
maintenance therapy, at all ages. LTRAs
can be considered as alternatives to low-
dose inhaled corticosteroids in milder
patients. With increasing degrees of
severity, in addition to consideration of
progressively higher doses of steroids
to enhance control, adding other
maintenance medication including long-
acting beta2-agents (LABA) (preferred),
LTRAs, theophylline, or any combination
thereof can be considered. It is usual to
add a single agent at a time and assess
the effects of doing so before either
withdrawing the agent if apparently
ineffective or adding another class of agent
to the therapy. This is so-called step-up
therapy, which may have to occur from
time to time even for patients who are
generally well controlled on a monotherapy
or combination therapy regimen.
-------
Infants and Young Children—
When to Start Controllers
>3 episodes of wheezing in the last year and
Parental history of asthma or physician diagnosis of
eczema,
Or, 2 of the following
Physician diagnosis of allergic rhinitis, wheezing apart
from colds, peripheral eosinophilia
Courses of oral steroids more often than every 6 wk
Symptoms >2x/wk, nocturnal symptoms >2x/mo
Copyright © 2003 American Academy of Pediatrics
Based on observational studies,
it is the opinion of the Expert
Panel 2 that the initiation of
long-term control therapy should be
considered in infants and young children
who have had more than 3 episodes
of wheezing in the past year that have
lasted more than 1 day and affected
sleep, and who have risk factors for
the development of asthma (parental
history of asthma or physician-diagnosed
atopic dermatitis or 2 of the following:
physician-diagnosed allergic rhinitis,
wheezing apart from cold, peripheral
blood eosinophilia). This is in addition
to previously recommended indications
for starting long-term control therapy—
ie, in infants and young children requiring
symptomatic treatment more than
2 times per week or experiencing severe
exacerbations less than 6 weeks apart.
-------
Comorbid Conditions
Allergic rhinitis
Sinusitis
GERD
Copyright © 2003 American Academy of Pediatrics
Comorbid conditions can complicate
asthma therapy. These conditions
can all act as triggers for asthma and,
if unrecognized and untreated, make the
control of a patient's asthma more difficult.
Clinicians need to be aware of these
potential comorbidities and treat them
as well as the asthma.
GERD = gastroesophageal reflux disease
-------
Consider Referral to an
Asthma Specialist
History of life-threatening exacerbation
Goals of therapy not met after 3-6 mo
Atypical signs and symptoms
Comorbid conditions complicating therapy
or diagnosis
Additional diagnostic testing indicated
Copyright ® 2003 American Academy of Pediatrics
Consideration should be given to
referral to an asthma specialist,
particularly an allergist, in these
particular situations. Any child who has
had a life-threatening asthma exacerbation
is at increased risk of having another and
will often need intensive management.
Children who continue to experience
asthma morbidity after 3 to 6 months
of therapy, such as interference with
exercise, nighttime awakenings more
often than twice monthly, and emergency
department visits, may need more
intensive therapy or evaluation. If the child
is unresponsive to therapy, referral should
be considered even sooner. Some asthma
symptoms and signs may be atypical, and
if the response to therapy is questionable,
further evaluation and testing, such as
bronchoprovocation, may be needed. The
response to therapy may be suboptimal
if there are other conditions present that
complicate the diagnosis such as allergic
rhinitis or sinusitis. Children with persistent
asthma often need additional testing, such
as pulmonary function testing or allergy
skin testing, to optimize their therapy.
-------
Inhaler Delivery Systems
MDI
-CFC
-HFA
- Autohaler
DPI
- Single-dose
- Multidose
Nebulizer
Copyright ©2083 American Academy of Pediatrics
There are 3 major ways inhaled drugs for
asthma are delivered to patients. The most
common and with the longest history is the
pressurized MDI. Most currently available MDIs
contain a chlorofluorocarbon (CFC) propellant,
although with time, as per the Montreal Protocol,
MDIs with a CFC propellant are to be phased
off the market. Some MDIs that have appeared
on the market contain the new, environmentally
friendlier propellant hydrofluoroalkane (HFA). All
MDIs, except one, require a press-and-breathe
technique in which the patient is required to
coordinate actuation of the inhaler with inhalation
of the drug. In one inhaler (the Maxair Autohaler),
this coordination is not necessary—the unit
automatically fires upon inhalation by the patient.
Dry powder inhalers (DPIs) are becoming
increasingly common. Dry powder inhalers do
not require a press-and-breathe technique—the
powder is directly inhaled in to the lungs with a
rapid and forceful inspirator/ maneuver. A limited
number of different DPI devices are available—
some are multidose units (ie, do not require
reloading the device with a dose [eg, Turbuhaler,
Discushaler]) and others are single dose (ie, require
loading the device with a dose each time, like a
capsule [eg, Ventolin Rotocaps, Foradil Aerolizer]).
Children mature enough to be able to take a deep
and rapid inspiration on command (usually not
younger than 4 years) generally can use a DPI.
Finally, asthma medications can be delivered by
a nebulizer, a device that aerosolizes liquids.
Proper technique is vital to the success of inhaled
medications. Technique should be taught in
depth at the time of dispensing and reviewed at
every subsequent visit. There are 2 techniques
for MDI use, the closed-mouth technique and
open-mouth technique. The latter is preferred
but is more difficult for children to do, so the
closed-mouth technique is also taught. The key
to both techniques is a slow, deep inspiration
with a 10-second holding of the breath at the end.
(NOTE: Speaker should describe the 2 techniques
to the audience.)
Techniques for the use of DPIs vary somewhat
with each device. In general DPIs are easier to
use than MDIs because breathing does not need
to be coordinated with actuation of the device.
Regardless of the device, the medication is
delivered with a forceful inspiration, also with
a 10-second holding of the breath at the end.
Spacers or holding chambers should be used
with all steroid MDIs and with any MDI used by
a child who has difficulty coordinating actuation
with inspiration.
-------
Types of Spacers
Tube spacers
- With/without mask
- With/without one-way valve
- Small/large volume
Bag spacers
Other
Photos couriety of Andrew SilK.
Copyright © 2003 American Academy of Pediatrics
Two types of spacers are available:
tube type and bag type. Many brands
of tube spacers exist. The shape of a
tube spacer is often cylindrical or close to
cylindrical. The MDI is placed into one side
of the spacer, and the child inhales the drug
from the other end. The spacer volume can
vary, which can be important when using a
spacer for a young child or infant. A large-
volume spacer for an infant (ie, greater
than 150 ml) would create excessive dead
space and not be as effective as a smaller
volume spacer. Some tube spacers have
a one-way valve, and because of this,
also are referred to as holding chambers.
The one-way valve allows the child to re-
breathe a number of inspiratory/expiratory
cycles without the spacer/chamber being
diluted with expired air. This feature is
particularly important for young children
(ie, infants, toddlers) who are treated with
an MDI with the aid of certain tube-valved
spacers fitted with a mask.
A bag spacer uses a collapsing bag to
receive the aerosol medication from the
MDI. Soon after the actuation of the
MDI into the bag, the child is instructed
to inhale deeply. In doing so, the bag
collapses and visually demonstrates to the
parent and child that an inhalation of drug
occurred. The simple visual feedback of the
bag collapsing helps the child learn how
to use the spacer and, therefore, to take
advantage of an MDI. Children between
the ages of 3 to 7 years often can be
taught how to use an MDI using this kind
of spacer.
-------
Nebulizer Therapy
General
Photo courtesy «f Andrew Silk.
• Available for acute and chronic therapy.
• Helpful in children unable to use an MDI or a DPI.
• Efficacy with MDI may be same, assuming good
cooperation/technique with MDI.
• Advantages and disadvantages clearly exist.
Copyri^rt © 2003 American Academy of Pediatrics
Nebulizers are widely used
therapeutically for various
respiratory disorders to administer
solutions or suspensions of beta-agonists,
anticholinergics, corticosteroids, cromones,
mucolytics, and antibiotics. Nebulizer
therapy is available for acute and chronic
treatment of asthma. Because nebulizers
require neither hand-lung coordination or a
controlled inhalation maneuver, they can be
helpful for children unable to use an MDI
or a DPI. However, the role of the nebulizer
in asthma therapy is a debated one, as
it has been shown that efficacy with the
MDI, even in young children (assuming
good cooperation and technique), may
be the same as with the nebulizer.
Nevertheless, certain advantages as well
as disadvantages exist with nebulization
therapy that need to be appreciated.
There are 2 types of nebulizers: jet (most
commonly used and least expensive) and
ultrasonic (more expensive, faster, more
portable). Most asthma medications can be
used in either type, except for budesonide,
which must be used in a jet nebulizer.
Ultrasonic nebulizers are more fragile than
jet nebulizers.
Nebulized medication can be delivered
with a mouthpiece, a mask, or by blowby
technique. The mouthpiece is the most
effective method of delivery, but it is
important not to breathe through the nose
when using the mouthpiece. Sometimes
nose plugs may be necessary. Mask
delivery is necessary for most young
children and toddlers, although it is not as
effective as mouthpiece delivery. Because
of this, as soon as the child is old enough
to cooperate, a mouthpiece should be
used. Blowby is very ineffective and should
be discouraged unless no other method
will work.
While nebulizers are usually easier to
use than MDIs, the main disadvantages
include increased expense, time in
preparing the medication, and time
in dispensing the medication. DPIs
potentially are much easier to use and
can be given to children as soon as they
are old enough to consistently take a
deep breath on command.
-------
Medications Available
for Nebulization
• Albuterol (0.5% concentrated inhaled solution);
premixed 0.63-, 1.25-, and 2.50-mg/3-ml_ saline)
* Levalbuterol (0.31,0.63 mg; 1.25 mg/ampule)
* Ipratropium (0.5 mg/ampule)
» Cromolyn (20 mg/ampule)
* Budesonide (0.25 or 0.5 mg/respule) (jet only)
Copyright © 2003 American Academy of Pediatrics
An increasing number of medications
have become available for
nebulization therapy. Albuterol is
available as an inexpensive concentrated
inhalation solution and needs to be mixed
with normal saline (usually 2-3 cc). The
saline can be purchased through the
pharmacist or bought over-the-counter.
Albuterol also comes premixed with saline
but is more expensive in this form. All of
the other medications come diluted in their
appropriate diluent and further dilution is
not necessary or recommended. Mixing
of the nebulized medications (eg, albuterol
and cromolyn, albuterol and ipratropium)
is commonly done and does not appear
to alter potency, although not much is
published on this. Budesonide inhalation
suspension, an inhaled corticosteroid, is
the newest medication to become available
for the nebulizer. Although not stated in the
package insert, budesonide and albuterol
appear to be compatible and can be
mixed. All of the listed medications can be
delivered by a jet or an ultrasonic nebulizer
except for budesonide, which should not
be used in an ultrasonic nebulizer.
-------
Peak Flow Meters (PFMs)
Helpful in monitoring asthma
Allow for objective assessment of airway caliber
Should be considered for moderate or severe
persistent asthma (1997,2002 NHLBI National
Asthma Education and Prevention Program
NAEPP guidelines; 1999 Guide for Managing
Asthma in Children)
Daily monitoring recommended for moderate or
severe persistent asthma
Copyright © 2003 American Academy of Pediatrics
Apeak flow meter (PFM) can be
helpful in monitoring asthma in
children. Peak flow measurements
allow for objective assessments of
airway caliber and can be particularly
useful in children who tend not to report
or recognize signs and symptoms of
worsening asthma. The 1999 Guide for
Managing Asthma in Children state,
"Children with moderate or severe
persistent asthma should have a PFM at
home and at school, if feasible." The 1997
NHLBI National Asthma Education and
Prevention Program (NAEPP) guidelines
state, "It is the opinion of the Expert Panel
that peak flow monitoring for patients with
moderate or severe persistent asthma
should be considered because it may
enhance clinician-patient communication
and may increase patient and caregiver
awareness of the disease status and
control." The 2002 update to the guidelines
notes that the available literature is
extremely limited on the value of peak flow
monitoring in asthma management plans,
especially in children.
-------
Asthma in School
Written asthma action plan
Immediate access to medications
Standard emergency protocols
Copyright © 2003 American Academy of Pediatrics
Every student with asthma should
have an asthma action plan as part
of his or her individual health file.
This plan should be established by the
child's asthma care provider in concert
with parents and provided to the school
by the parents. Share the plan with
appropriate faculty and staff in accordance
with the Family Educational Rights and
Privacy Act (FERPA).
Students with asthma need immediate
access to rescue medications at all times.
Ideally this would be accomplished by
allowing students to self-carry and self-
administer rescue medications. However,
not all children are mature enough to do
so, and not all schools allow it even when
the child is competent to do so. Decisions
about who should be allowed to self-carry
and self-administer medications should be
made on a case-by-case basis with input
from the physician, school nurse, and
parents and should not be determined by
blanket policy. Often, keeping medications
locked in the office serves as a deterrent
to use. If the medications are kept in the
office, policies need to be established as
to who has the keys and how to reach
those people any time during the school
day. In addition, policies need to be in place
for after-school and off-school property
activities, including field trips and athletic
participation. Children who self-carry their
rescue inhaler also need to have a spare
inhaler kept in the office in case they forget
their own or run out.
The school needs to establish a standard
emergency protocol for the treatment
of respiratory distress for those students
with asthma who do not have an asthma
action plan.
-------
Asthma Action Plan
* Address triggers.
* Indicate routine and emergency medicines.
* Specify treatment guidelines for acute
exacerbations based on peak flow meter
and/or symptom-based zones.
* Indicate emergency contacts.
* Place plan in student's health record.
Copyright © 2003 American Academy of Pediatrics
T
his slide outlines the contents of an
asthma action plan.
Every effort should be made to have a
written asthma plan on every student with
persistent asthma. The plan needs to be
reviewed and updated periodically, based
on stability of symptoms. All medicines
should be checked for expiration dates.
-------
Healthy School Environment
Prohibit tobacco use at all times.
Reduce exposure to asthma triggers.
Keep temperature and humidity at appropriate
settings.
Replace carpeting with hard surface flooring.
Schedule maintenance during off-school hours.
Use integrated pest management.
Copyright © 2003 American Academy of Pediatrics
Environmental control is important in
managing asthma at home; providing
a healthy indoor environment at
school is just as important.
Prohibit tobacco use at all times on all
school property, on school buses, and
at school-sponsored events off school
grounds.
Reduce exposure to irritants and
allergens and improve indoor air quality
by eliminating tobacco smoke, reducing
dust and debris from construction or
remodeling, reducing dust mites by
removing carpeting and frequent damp
dusting, reducing animal dander by
prohibiting furry animals in the classroom,
and keeping coats outside the classroom.
Such instructions should be part of the
asthma action plan.
Maintaining humidity below 50% will
reduce dust mites and molds. Regular
scheduled maintenance of heating,
ventilation, and air conditioning (HVAC)
systems can improve air quality. Schools
should repair any water leaks or damage
to prevent mold infestation and develop
an indoor air quality team using the EPA
Indoor Air Quality Tools for Schools kit.
Try to schedule major maintenance
projects, such as resurfacing gym floors
and painting, at times when school is
not in session, such as summer and
spring break. Maintenance tasks such as
lawn mowing should be performed after
school hours. The use of integrated pest
management techniques can reduce the
need for pesticides, which can be irritating
to airways and trigger asthma symptoms.
-------
Asthma Triggers in School
Allergens—dust mites, animal dander, moid, pollen
Irritants—cold air, paint, cleaning solution, chalk
dust, cigarette smoke, auto and bus exhaust
Exercise—especially in cold weather
Copyright ©2003 American Academy of Pediatrics
Asthma triggers do not stop at home.
The school environment cannot
be ignored and must be monitored,
especially for students with persistent
asthma.
-------
Asthma in Schools
Goal: Effective Communication
* Form links among school, home, and health care
providers.
• Observe and report symptoms, medication use.
• Review difficulties students may have with daily
school management plan.
• Resolve problems with school performance related
to asthma.
» Encourage active student participation in school
activities.
Copyright © 2003 American Academy of Pediatrics
Obtain written parental permission
for school staff and the asthma care
provider to share student health
information. Parents should sign release
of record forms at school and the health
care provider's office. It is required by
FERPA that written releases be signed
to exchange this information. Educate,
support, and involve family members
and school staff in efforts to reduce
asthma symptoms and school absences.
Provide an asthma action plan for your
patients to take to school. Inform parents
about education programs such as those
mentioned in this presentation.
Community clinicians or school nurses can
teach school staff symptoms and signs of
uncontrolled asthma and encourage them
to report such signs and symptoms to the
school nurse.
Assist students with aspects of their
asthma management program, including
having the school nurse review inhaler
and peak flow technique and perhaps
providing maintenance medications at
school. Evaluate asthma control and school
performance and make corrections where
necessary to allow for full participation and
minimize absences.
The Family Educational Rights and Privacy
Act (FERPA) regulations apply to any school
information sent to outside agencies or
providers. The Health Insurance Portability
and Accountability Act (HIPAA) regulations
apply to records sent from any outside
agencies to schools.
-------
-------
Overview
Summary
Asthma is a chronic disease of the tubes that carry air to the lungs. These airways become
narrow and their linings become swollen, irritated, and inflamed. In patients with asthma,
the airways are always irritated and inflamed, even though symptoms are not always
present. The degree and severity of airway inflammation varies over time.
Symptoms of asthma include
• Wheezing
• Coughing
• Shortness of breath
• Tightness in the chest
If you are concerned your child may have asthma, talk to your health care provider. She will test
your child's airway function. It is important to remember that asthma is a complicated disease to
diagnose, and the results of airway function testing may be normal even if your child has asthma.
Asthma Triggers
Certain things cause asthma "attacks" or make asthma worse. These are called triggers. Some
common asthma triggers are
• Infections of the airways
• Allergens
• Irritants in the environment (outside or indoor air you breathe)
• Exercise
• Stress
Decreasing your child's exposure to triggers will help decrease symptoms and the need for asthma
medications.
Asthma Medications
Children with asthma symptoms that occur only once in a while are given medications only
when needed to relieve the symptoms. These are called quick-relief medications. Children with
asthma whose symptoms occur more often need to take medications every day. These are called
controller medications.
There is no one magic medication that controls all asthma. Sometimes it is necessary to take
several medications at the same time to control and prevent symptoms. Your health care provider
will choose the best medications for your child and talk to you about when to use them.
Most asthma medications can be inhaled directly into the lungs. Inhalation has major advantages
over other ways of taking medication because the medicine passes straight into the airways. As a
result, side effects are reduced or avoided altogether. In addition, asthma medications work much
faster when inhaled than when taken orally.
-------
Peak Flow Meter
To help control asthma, your child may need to use a peak flow meter. This is a handheld device
that measures how fast a person can blow air out of the lungs. The peak flow meter uses 3
colors—green, yellow, and red, like traffic lights—to show if the airway is opening or closing up. It
also has a scale to help you determine if your child's asthma is getting better or worse. Peak flow
rates decrease (the numbers on the scale go down) when your child's asthma is getting worse
or is out of control. Peak flow rates increase (the numbers on the scale go up) when the asthma
treatment is working and the airways are opening up.
Asthma and School
Children spend a significant part of their day at school. That is why it is so important that asthma
symptoms are well managed while they are there. It is also important that you are aware of your
child's symptoms and any problems with how your child's asthma is managed in school. Because
exercise is so important to a child's overall health, every effort should be made to keep your child
active in school sports while also keeping asthma symptoms under good control.
As you can see, asthma is a complicated yet treatable condition. By using medications, avoiding
triggers and environments that can cause asthma attacks, and carefully managing symptoms,
children with asthma can lead normal and healthy lives.
If you have any questions about your child's health, symptoms of asthma, or how your child's
asthma is being managed, talk to your health care provider. He or she is the best source of
information about your child's health.
American Academy of Pediatrics |||
DEDICATED TO THE HEALTH OF ALL CHILDREN
Copyright © 2003
-------
Origins of Asthma / References
Slide 5
National Institutes of Health, National Heart, Blood, and Lung Institute, National Asthma
Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and
Management of Asthma. Bethesda, MD: National Institutes of Health;1991
Slides
Centers for Disease Control and Prevention. Measuring childhood asthma prevalence
before and after the 1997 redesign of the National Health Interview Survey—United States.
MMWR Morb Mortal Wk/y Hep. 2000;49:908-911
Slides
Mallol J, Asher M:l, Williams H, Clayton T, Beasley R. ISAAC findings in children aged 14
years: an overview. Allergy Clin Immunol Int. 1999;11:176-182
Slide 25
Stein RT, Sherrill D, Morgan WJ, et al. Respiratory syncytial virus in early life and risk of
wheeze and allergy by age 13 years. Lancet. 1999;354:541-545
Slide 27
Strachan DP. Hay fever, hygiene, and household size. BMJ. 1989:299:1259-1260
Slides 31 and 32
Matricardi PM, Rosmini F, Riondino S, et al. Exposure to foodborne and orofecal microbes
versus airborne viruses in relation to atopy and allergic asthma: epidemiological study.
BMJ. 2000;320:412-417
Slide 34
Ball TM, Castro-Rodriguez JA, Griffith KA, Holberg CJ, Martinez FD, Wright AL. Siblings,
day-care attendance, and the risk of asthma and wheezing during childhood. N EnglJ Med.
2000:343:538-543
Slides 38 and 39
Ernst P, Cormier Y. Relative scarcity of asthma and atopy among rural adolescents raised
on a farm. Am J Respir Crit Care Med. 2000:161:1563-1566
Slide 41
Gereda JE, Leung DY, Liu AH. Levels of environmental endotoxin and prevalence of atopic
disease. JAMA. 2000;284:1652-1653
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Origins of Asthma / References
Slide 42
Gereda JE, Leung DY, Thatayatikom A, et al. Relation between house-dust endotoxin
exposure, type 1 T-cell development, and allergen sensitisation in infants at high risk of
asthma. Lancet. 2000;355:1680-1683
Diagnosis/ References
Slides
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
National Institutes of Health, National Heart, Lung, and Blood Institute, National Asthma
Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis
and Management of Asthma. Bethesda, MD: National Institutes of Health; 1997. NIH Publ.
No. 97-4051
Slides 4 and 5
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
SlideB
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
National Institutes of Health, National Heart, Lung, and Blood Institute. Practical Guide for
the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health;
1997. NIH Publ. No. 97-4053
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Slide 7
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
Slides
National Institutes of Health, National Heart, Lung, and Blood Institute. Practical Guide for
the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health;
1997. NIH Publ. No. 97-4053
Slides
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
Slide 12
National Institutes of Health, National Heart, Lung, and Blood Institute. Practical Guide for
the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health;
1997. NIH Publ. No. 97-4053
Slide 13
American Thoracic Society. Lung function testing: selection of reference values and
interpretative strategies. Am Rev Respir Dis. 1991; 144:1202-1218
Slide 14
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
Slide 15
American Thoracic Society. Lung function testing: selection of reference values and
interpretative strategies. Am Rev Respir Dis. 1991; 144:1202-1218
-------
Diagnosis/ References
Slide 18
American Thoracic Society, Committee on Proficiency Standards for Clinical Pulmonary
Function Laboratories. Guidelines for methacholine and exercise challenge testing—1999.
Am J Respir Crit Care Med. 2000;161:309-329
Slide 19
Smart BA. Allergy testing using in vivo and in vitro techniques. Immunol Allergy Clin North
Am. 1999:19:35-45
Strunk RC. Defining asthma in the preschool-aged child. Pediatrics. 2002;109:357-361
Walshaw MJ, Evans CC. Control of house dust mite antigen in bedding. Lancet. 1990;335:
911-912.
Slide 20
Burrows B, Martinez FD, Halonen M, Barbee Cline MG. Association of asthma with serum
IgE levels and skin-test reactivity to allergens. N EnglJ Med. 1989;320:271-277
Slide 21
National Institutes of Health, National Heart, Lung, and Blood Institute. Practical Guide for
the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health;
1997. NIH Publ. No. 97-4053
Strunk RC. Defining asthma in the preschool-aged child. Pediatrics. 2002;109:357-361
Slide 22
Martinez FD. Development of wheezing disorders and asthma in preschool children.
Pediatrics. 2002)109:362-367
Taussig LM, Wright AL, Morgan WJ, Harrison HR, Ray CG. The Tucson Children's
Respiratory Study. I. Design and implementation of a prospective study of acute and
chronic respiratory illnesses in children. Am J Epidemiol. 1989;129:1219-1231
Slide 23
Martinez FD. Development of wheezing disorders and asthma in preschool children.
Pediatrics. 2002;109:362-367
Slide 24
Martinez FD. Development of wheezing disorders and asthma in preschool children.
Pediatrics. 2002;109:362-367
Strunk RC. Defining asthma in the preschool-aged child. Pediatrics. 2002;109:357-361
-------
Slide 26
Castro-Rodriguez JA, Holberg CJ, Wright AL, Martinez FD. A clinical index to define risk of
asthma in young children with recurrent wheezing. Am J Respir Crit Care Med. 2000; 162:
1403-1406
Martinez FD. Development of wheezing disorders and asthma in preschool children.
Pediatrics. 2002; 109:362-367
Slide 27
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
National Institutes of Health, National Heart, Lung, and Blood Institute. Practical Guide for
the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health;
1997. NIH Publ. No. 97-4053
National Institutes of Health, National Heart, Lung, and Blood Institute, National Asthma
Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis
and Management of Asthma. Bethesda, MD: National Institutes of Health; 1997. NIH Publ.
No. 97-4051
Slide 28
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
National Institutes of Health, National Heart, Lung, and Blood Institute. Practical Guide for
the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health;
1997. NIH Publ. No. 97-4053
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Non-pharmacologic Approaches/ References
Slide 1
Wood RA, Eggleston PA. Nonpharmacologic approaches to the management of asthma.
In: Naspitz CK, Szefler SJ, Tinkelman D, Warner JO, eds. Textbook of Pediatric Asthma:
An International Perspective. London, England: Martin Dunitz; 2001:237-256
Slide 2
National Institutes of Health, National Heart, Lung, and Blood Institute, National Asthma
Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis
and Management of Asthma. Bethesda, MD: National Institutes of Health; 1997. NIH Publ.
No. 97-4051
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention
Program. Guidelines for the Diagnosis and Management of Asthma. Update on Selected
Topics—2002. J Allergy Clin Immunol. 2002; 110 suppl:S141-S219
Slides
Platts-Mills TA, Vaughan JW, Carter MC, Woodfolk JA. The role of intervention in
established allergy: avoidance of indoor allergens in the treatment of chronic allergic
disease. J Allergy Clin Immunol. 2000; 106:787-804
Sporik R, Platts-Mills TA. Allergen exposure and the development of asthma. Thorax.
September 2001 ;56(suppl 2):ii58-ii63
Slide 6
National Institutes of Health, National Heart, Lung, and Blood Institute, National Asthma
Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis
and Management of Asthma. Bethesda, MD: National Institutes of Health; 1997. NIH Publ.
No. 97-4051
Slides 7,8, and 10
Arlian LG, Platts-Mills TA. The biology of dust mites and the remediation of mite allergens
in allergic disease. J Allergy Clin Immunol. 2001 ;107(suppl 3):S406-S413
Slides 11,12, and 13
Chapman MD, Wood RA. The role and remediation of animal allergens in allergic diseases.
J Allergy Clin Immunol. 2001 ;107(suppl 3):S414-S421
-------
Slide 14
Chapman MD, Wood RA. The role and remediation of animal allergens in allergic diseases.
J Allergy Clin Immunol. 2001 ;107(suppl 3):S414-S421
Wood RA, Johnson EF, Van Natta ML, Chen PH, Eggleston PA. A placebo-controlled trial
of a HEPA air cleaner in the treatment of cat allergy. Am J Respir Crit Care Med. 1998; 158:
115-120
Slide 15
Almqvist C, Larsson PH, Egmar AC, Hedren M, Malmberg P, Wickman M. School as a risk
environment for children allergic to cats and a site for transfer of cat allergen to homes. J
Allergy C/in Immunol. 1999;103:1012-1017
Chapman MD, Wood RA. The role and remediation of animal allergens in allergic diseases.
J Allergy Clin Immunol. 2001 ;107(suppl 3):S414-S421
Slide 16
Arruda LK, Vailes LD, Ferriani VP, Santos AB, Pomes A, Chapman MD. Cockroach allergens
and asthma. J Allergy Clin Immunol. 2001; 107:419-428
Eggleston PA, Arruda LK. Ecology and elimination of cockroaches and allergens in the
home. J Allergy Clin Immunol. 2001;107(suppl 3):S422-S429
Slide 17
Arruda LK, Vailes LD, Ferriani VP, Santos AB, Pomes A, Chapman MD. Cockroach allergens
and asthma. J Allergy Clin Immunol. 2001 ;107:419-428
Eggleston PA, Arruda LK. Ecology and elimination of cockroaches and allergens in the
home. J Allergy Clin Immunol. 2001;107(suppl 3):S422-S429
Rosenstreich DL, Eggleston P, Kattan M, et al. The role of cockroach allergy and exposure
to cockroach allergen in causing morbidity among inner-city children with asthma.
NEnglJMed. 1997;336:1356-1363
Slide 18
Rosenstreich DL, Eggleston P, Kattan M, et al. The role of cockroach allergy and exposure
to cockroach allergen in causing morbidity among inner-city children with asthma.
N Engl J Med. 1997;336:1356-1363
Slide 19
Arruda LK, Vailes LD, Ferriani VP, Santos AB, Pomes A, Chapman MD. Cockroach allergens
and asthma. J Allergy Clin Immunol. 2001 ;107:419-428
Eggleston PA, Arruda LK. Ecology and elimination of cockroaches and allergens in the
home. J Allergy Clin Immunol. 2001;107(suppl 3):S422-S429
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Non-pharmacologic Approaches/ References
Slides 20 and 21
Bush RK, Portnoy JM. The role and abatement of fungal allergens in allergic diseases.
J Allergy Clin Immunol. 2001 ;107(suppl 3):S430-S440
Slide 23
Exposure to indoor tobacco smoke. In: Institute of Medicine, Committee on the
Assessment of Asthma and Indoor Air. Clearing the Air: Asthma and Indoor Air Exposures.
Washington, DC: National Academy Press; 2000:263-297
Slide 25
Platts-Mills TA, Vaughan JW, Carter MC, Woodfolk JA. The role of intervention in
established allergy: avoidance of indoor allergens in the treatment of chronic allergic
disease. J Allergy Clin Immunol. 2000;106:787-804
Slides 26 and 27
Joint Task Force on Practice Parameters. Practice parameters for allergen immunotherapy.
JAIIeryClin Immunol. 1996;98:1001-1011
World Health Organization. Allergen immunotherapy: therapeutic vaccines for allergic
diseases. Geneva: January 27-29 1997. Allergy. 1998;53(suppl 44): 1-42
Slide 28
World Health Organization. Allergen immunotherapy: therapeutic vaccines for allergic
diseases. Geneva: January 27-29 1997. Allergy. 1998;53(suppl 44): 1-42
Slide 29
Abramson MJ, Puy RM, Weiner JM. Is allergen immunotherapy effective in asthma? A
meta-analysis of randomized controlled trials. Am J Respir Crit Care Med. 1995;151:969-974
Slide 30
World Health Organization. Allergen immunotherapy: therapeutic vaccines for allergic
diseases. Geneva: January 27-29 1997. Allergy. 1998;53(suppl 44): 1-42
Slide 31
Des Roches A, Paradis L, Menardo JL, Bouges S, Daures JP, Bousquet J. Immunotherapy
with a standardized Dermatophagoides pteronyssinus extract. VI. Specific immunotherapy
prevents the onset of new sensitization in children. J Allergy Clin Immunol. 1997;99:450-453
-------
Slide 32
Jacobsen L, Dreborg S, Moller C, et al. Immunotherapy as a preventative treatment (PAT)
[abstract]. J Allergy Cl/n Immunol. 1996;97:232
Slides 33 and 34
Joint Task Force on Practice Parameters. Practice parameters for allergen immunotherapy.
J Allergy Clin Immunol. 1996;98:1001-1011
World Health Organization. Allergen immunotherapy: therapeutic vaccines for allergic
diseases. Geneva: January 27-29 1997. Allergy. 1998;53(suppl 44): 1-42
-------
Pharmacologic Management/ References
Slide 2
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
Slide 4
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention
Program. Guidelines for the Diagnosis and Management of Asthma. Update on Selected
Topics—2002. J Allergy Clin Immunol. 2002; 110 suppl:S141-S219
Slides
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
SlideB
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention
Program. Guidelines for the Diagnosis and Management of Asthma. Update on Selected
Topics—2002. J Allergy Clin Immunol. 2002; 110 suppl:S141-S219
Payne DN, Balfour-Lynn IM. Children with difficult asthma: a practical approach. J Asthma.
2001 ;38:189-203
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Slides 7,8, and 9
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
Slide 10
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
Guyatt GH, Juniper EF, Griffith LE, Feeny DH, Ferrie PJ. Children and adult perceptions
of childhood asthma. Pediatrics. 1997;99:165-168
Lemanske RF Jr, Allen DB. Choosing a long-term controller medication in childhood
asthma. The proverbial two-edged sword. Am J Respir Crit Care Med. 1997; 156:685-687
Miles A, Sawyer M, Kennedy D. A preliminary study of factors that influence children's
sense of competence to manage their asthma. J Asthma. 1995;32:437-444
Simons FD. Management of persistent asthma in childhood. In: FitzGerald JM, Ernst P,
Boulet LP, O'Byrne PM, eds. Evidence-Based Asthma Management. Hamilton, Ontario: BC
Decker Inc; 2001:121-136
Spahn JD, Szzefler SJ. Childhood asthma: new insights into management. J Allergy Clin
Immunol. 2002; 109:3-13
van Grunsven PM. The magnitude of fear of adverse effects as a reason for
nonparticipation in drug treatment: a short review. J Asthma. 2001 ;38:113-119
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Pharmacologic Management/ References
Slide 13
Bisgaard H. Use of inhaled corticosteroids in pediatric asthma. Pediatr Pu/monol Suppl.
1997;15:27-33
Caplin C, Macarthur RC, Stephens D, Feldman W, Parkin PC. Effectiveness of prophylactic
inhaled steroids in childhood asthma: a systematic review of the literature. J Allergy Clin
Immunol. 1997; 100:452-457
Fish JE, Peters SP. Airway remodeling and persistent airway obstruction in asthma.
J Allergy Clin Immunol. 1999; 104:509-516
Keeley D. Asthma in children. Clin Evid. 2000;3:163-172
Keeley D. Asthma in children. Clin Evid. 2001 ;5:189-204
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention
Program. Guidelines for the Diagnosis and Management of Asthma. Update on Selected
Topics—2002. J Allergy Clin Immunol. 2002; 110 suppl:S141-S219
Nelson HS. Corticosteroid dosing and asthma control. Ann Allergy Asthma Immunol.
2001 ;86:599-602
Stempel DA, Mauskopf J, Mclaughlin T, Yazdani C, Stanford RH. Comparison of asthma
costs in patients starting fluticasone propionate compared to patients starting montelukast.
Respir Med. 2001 ;95:227-234
Suissa S, Ernst P. Inhaled corticosteroids: impact on asthma morbidity and mortality.
J Allergy Clin Immunol. 2001 ;107:937-944
Waalkens HJ, Van Essen-Zandvliet EE, Hughes MD, et al. Cessation of long-term treatment
with inhaled corticosteroid (budesonide) in children with asthma results in deterioration.
The Dutch CNSLD Study Group. Am Rev Respir Dis. 1993;148:1252-1257
Slide 14
Agertoft L, Pederson S. Effect of long-term treatment with inhaled budesonide on adult
height in children with asthma. N Engl J Med. 2000;343:1064-1069
The Childhood Asthma Management Program Research Group. Long-term effects of
budesonide or nedocromil in children with asthma. N Engl J Med. 2000;343:1054-1063
Eid N, Morton R, Olds B, Clark P, Sheikh S, Looney S. Decreased morning serum cortisol
levels in children with asthma treated with inhaled fluticasone propionate. Pediatrics.
2002;109:217-221
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention
Program. Guidelines for the Diagnosis and Management of Asthma. Update on Selected
Topics—2002. J Allergy Clin Immunol. 2002; 110 suppl:S141-S219
O'Connell EJ, Berlow BA. Inhaled corticosteroids: maximizing clinical benefit in children
with asthma. Pediatr Asthma Allergy Immunol. 2000;14:173-189
Pederson S. Do inhaled corticosteroids inhibit growth in children? Am J Respir Crit Care
Med. 2001:164:521-535
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Slide 15
Edwards AM, Howell JB. Inhaled sodium cromoglycate in the management of asthma:
should it be consigned to history? [editorial] Clin Exp Allergy. 2001 ;31:1338-1340
Sorkness CA. Cromolyn, nedocromil, leukotriene modifiers, and alternative
anti-inflammatory agents in the treatment of pediatric asthma. In: Murphy S, Kelly HW,
eds. Pediatric Asthma. New York, NY: Marcel Dekker Inc; 1999:433-462
Tasche MJ, Uijen JH, Bernsen RM, de Jongste JC, van der Wouden JC. Inhaled disodium
cromoglycate (DSCG) as maintenance therapy in children with asthma: a systematic
review. Thorax. 2000;55:913-920
Slide 16
National Asthma Education and Prevention Program. Expert panel report: guidelines for the
diagnosis and management of asthma. Update on selected topics—2002. J Allergy Clin
Immunol. 2002;110(suppl):S141-S219
Salvi SS, Krishna MT, Sampson AP, Holgate ST. The anti-inflammatory effects of
leukotriene-modifying drugs and their role in asthma. Chest. 2001 ;119:1533-1546
Sorkness CA. Cromolyn, nedocromil, leukotriene modifiers, and alternative
anti-inflammatory agents in the treatment of pediatric asthma. In: Murphy S, Kelly HW,
eds. Pediatric Asthma. New York, NY: Marcel Dekker Inc; 1999:433-462
Slide 17
Blake K. Theophylline. In: Murphy S, Kelly HW, eds. Pediatric Asthma. New York, NY:
Marcel Dekker Inc; 1999:363-431
Tomac N. Aminophylline in the treatment of bronchial asthma. Ann Allergy Asthma
Immunol. 1999;83:422-423
Slide 20
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention
Program. Guidelines for the Diagnosis and Management of Asthma. Update on Selected
Topics—2002. J Allergy Clin Immunol. 2002; 110 suppl:S141-S219
-------
Pharmacologic Management/ References
Slide 21
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
Slide 22
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention
Program. Guidelines for the Diagnosis and Management of Asthma. Update on Selected
Topics—2002. J Allergy Clin Immunol. 2002; 110 suppl:S141-S219
Slide 24
Brand PL, Duiverman EJ, Waalkens HJ, van Essen-Zandvliet EE, Kerrebijn KF. Peak
flow variation in childhood asthma: correlation with symptoms, airway obstruction, and
hyperresponsiveness during long-term treatment with inhaled corticosteroids. Dutch
CNSLD Study Group. Thorax. 1999;54:103-107
Mendoza GR. Peak flow monitoring. J Asthma. 1991;28:161-177
Slide 25
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
-------
Slide 26
Brand PL, Duiverman EJ, Waalkens HJ, van Essen-Zandvliet EE, Kerrebijn KF. Peak flow
variation in childhood asthma: correlation with symptoms, airways obstruction, and
hyperresponsiveness during long-term treatment with inhaled steroids. Dutch CNSLD
Study Group. Thorax. 1999;54:103-107
Garrison MM, Christakis DA, Harvey E, Cummings P, Davis RL. Systemic corticosteroids
in infant bronchiolitis: a meta-analysis. Pediatrics. 2000;105(4). Available at: http://
www.pediatrics.org/cgi/content/full/105/4/e44
Keeley D. Asthma in children. Clin Evid. 2000;3:163-172
Keeley D. Asthma in children. Clin Evid. 2001 ;5:189-204
Keeley D. Higher dose inhaled corticosteroids in childhood asthma. BMJ. 2001;322:504-505
Mendoza GR. Peak flow monitoring. J Asthma. 1991;28:161-177
Nuhoglu Y, Bahceciler NN, Barlan IB, Basaran M. The effectiveness of high-dose inhaled
budesonide therapy in the treatment of acute asthma exacerbations in children. Ann
Allergy Asthma Immunol. 2001)86:318-322
Tang N, Wang E. Bronchiolitis. Clin Evid. 2001 ;5:214-222
Volovitz B, Bentur L, Finkelstein Y, et al. Effectiveness and safety of inhaled corticosteroids
in controlling acute asthma attacks in children who were treated in the emergency
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1998;102:605-609
Volovitz B, Soferman R, Blau H, Nussinovitch M, Varsano I. Rapid induction of clinical
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1998;101:464-469
Wilson NM, Silverman M. Treatment of acute, episodic asthma in preschool children using
intermittent high dose inhaled steroids at home. Arch Dis Child. 1990:65:407-410
Slide 27
American Academy of Pediatrics, Provisional Committee on Quality Improvement.
Practice parameter: the office management of acute exacerbations of asthma in children.
Pediatrics. 1994; 93:119-126
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Slides 28 and 29
American Academy of Allergy, Asthma, and Immunology; National Heart, Lung, and Blood
Institute; American Academy of Pediatrics; National Asthma Education and Prevention
Program. Pediatric Asthma: Promoting Best Practice—Guide for Managing Asthma in
Children. Milwaukee, Wl: American Academy of Allergy, Asthma, and Immunology; 1999.
Available at: http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm.
Accessed March 17, 2003
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Pharmacologic Management/ References
Slide 30
Castro-Rodriguez JA, Holberg CJ, Wright AL, Martinez FD. A clinical index to define risk of
asthma in young children with recurrent wheezing. Am J Hespir Crit Care Med. 2000; 162:
1403-1406
McCarthy TP, Lenney W. Management of asthma in pre-school children. Brit J Gen Pract.
1992;42:429-434
Morton RL, Sheikh S, Corbett ML, Bid NS. Evaluation of the wheezy infant. Ann Allergy
Asthma Immunol. 2001 ;86:251-256
Roorda RJ, Mezei G, Bisgaard H, Maden C. Response of preschool children with asthma
symptoms to fluticasone propionate. J Allergy Clin Immunol. 2001 ;108:540-546
Von Mutius E. Presentation of new GINA guidelines for paediatrics. The Global Index on
Asthma. Clin Exp Allergy. 2000;30(suppl 1):6-10
Slide 31
Keeley D. Asthma in children. Clin Evict. 2000;3:163-172
Keeley D. Asthma in children. Clin Evid. 2001 ;5:189-204
Mace SE. Bronchiolitis: an update. Resid Staff Physician. 2002;48:50-54, 57
Tang N, Wang E. Bronchiolitis. Clin Evid. 2001)5:214-222
Slide 33
Brand PL, Duiverman EJ, Waalkens HJ, van Essen-Zandvliet EE, Kerrebijn KF. Peak
flow variation in childhood asthma: correlation with symptoms, airway obstruction, and
hyperresponsiveness during long-term treatment with inhaled corticosteroids. Dutch
CNSLD Study Group. Thorax. 1999;54:103-107
Mendoza GR. Peak flow monitoring. J Asthma. 1991 ;28:161-177
Slide 36
Inman MD. Exercise-induced bronchoconstriction. In: FitzGerald JM, Ernst P, Boulet LP,
O'Byrne PM, eds. Evidence-Based Asthma Management. Hamilton, Ontario: BC Decker
Inc; 2001:219-231
McFadden ER, Gilbert IA. Exercise-induced asthma. N Engl J Med. 1994;330:1362-1367
Milgrom H, Taussig LM. Keeping children with exercise-induced asthma active. Pediatrics.
1999;104(3). Available at: http://www.pediatrics.Org/cgi/content/full/104/3/e38
Price JF. Choices of therapy for exercise-induced asthma in children. Allergy.
2001;56(suppl):12-17
Weiler JM. Exercise-induced asthma: a practical guide to definitions, diagnosis, prevalence,
and treatment. Allergy Asthma Proc. 1996; 17:315-325
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Slide37
Inman MD. Exercise-induced bronchoconstriction. In: FitzGerald JM, Ernst P, Boulet LP,
O'Byrne PM, eds. Evidence-Based Asthma Management. Hamilton, Ontario: BC Decker
Inc; 2001:219-231
Left JA, Busse WW, Pearlman D, et al. Montelukast, a leukotriene-receptor antagonist, for
the treatment of mild asthma and exercise-induced bronchoconstriction. N EnglJ Med.
1998;339:147-152
McFadden ER, Gilbert IA. Exercise-induced asthma. N EnglJ Med. 1994;330:1362-1367
Milgrom H, Taussig LM. Keeping children with exercise-induced asthma active. Pediatrics.
1999; 104(3). Available at: http://www.pediatrics.org/cgi/content/fall/10473/e38
Morris MJ, Deal LE, Bean DR, Grbach VX, Morgan JA. Vocal cord dysfunction in patients
with exertional dyspnea. Chest. 1999;116:1676-1682
Nelson JA, Strauss L, Skowronski M, Ciufo R, Novak R, McFadden ER Jr. Effect of long-
term salmeterol treatment on exercise-induced asthma. N EnglJ Med. 1998;339:141-146
Pearlman DS, Ostrom NK, Bronsky EA, Bonucelli CM, Hanby LA. The leukotriene D4-
receptor antagonist zafirlukast attenuates exercise-induced bronchoconstriction in children.
J Pediatr. 1999;134:273-279
Price JF. Choices of therapy for exercise-induced asthma in children. Allergy.
2001;56(suppl):12-17
Weiler JM. Exercise-induced asthma: a practical guide to definitions, diagnosis, prevalence,
and treatment. Allergy Asthma Proc. 1996;17:315-325
Slide 38
Guyatt GH, Juniper EF, Griffith LE, Feeny DH, Ferrie PJ. Children and adult perceptions
of childhood asthma. Pediatrics. 1997;99:165-168
Kare A, Kucukarslan S, Birdwell S. Consumer perceived risk associated with prescription
drugs. Drug InfJ. 1996;30:465-472
Kelly HW, Murphy S. Helping children adhere to asthma treatment regimens.
Pediatr Asthma Allergy Immunol. 2001 ;15:25-29
Miles A, Sawyer M, Kennedy D. A preliminary study of factors that influence children's
sense of competence to manage their asthma. J Asthma. 1995;32:437-444
van Grunsven PM. The magnitude of fear of adverse effects as a reason for
nonparticipation in drug treatment: a short review. J Asthma. 2001;38:113-119
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Asthma and Schools/ References
Slide 2
Coover L, Vega C, Persky V, et al. A collaborative model to enhance the functioning of the
school child with asthma. Chest. 1999;(suppl 1)116:1935-1955
Freeman NC, Schneider D, McGarvey P. School-based screening for asthma in third-grade
urban children: the Passaic asthma reduction effort survey. Am J Public Health. 2002;92:
45-46
Slide 11
Hootman J. Quality Nursing Interventions in the School Setting: Procedures, Models, and
Guidelines. Scarborough, ME: National Association of School Nurses; 1996
Slide 17
Almqvist C, Larsson PH, Egmar AC, Hedren M, Malmberg P, Wickman M. School as a risk
environment for children allergic to cats and a site for transfer of cat allergen to homes.
J Allergy C/in Immunol. 1999;103:1012-1017
Almqvist C, Wickman M, Perfetti L, et al. Worsening of asthma in children allergic to cats,
after indirect exposure to cat at school. Am J Respir Crit Care Med. 2001 ;163:694-698
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ADDITIONAL RESOURCES
Note: Any of these items can be accessed from the Section on Allergy and Immunology Web site
at www.aap.org/sections/allergy/index.htm.
Materials for Parents and Children
• Guide to Your Child's Allergies and Asthma
• Pediatric Environmental Health
• Care of the Young Athlete
• How to Help Your Child With Asthma
• What is a Pediatric Allergist-lmmunologist?
• Emergency Information Form for Children with Special Needs
• The Allergy Test
Materials for Schools
• School Nurse Allergy Tool Kit
• Students With Chronic Illnesses
• School Asthma Management Plan
• How Asthma-Friendly Is Your School?
• Asthma and Physical Activity in School
• Guide to Asthma Management in School
• SchoolAsthmaAllergy.com (www.schoolasthmaallergy.com)
Clinical References
• Best articles relevant to pediatric allergy and immunology (published annually in the August issue
of Pediatrics (www.pediatrics.org)
• Pediatric Asthma Virtual Journal (www.pediatric-asthma.org)
• The Allergy Report
• Asthma Management in Pediatric Offices Survey
• Short asthma diagnosis and management guides
• Guide for Managing Asthma in Children
• National Asthma Education and Prevention Program Expert Panel II Report: Guidelines for the
Diagnosis and Management of Asthma—updates on selected topics
American Academy of Pediatrics
DEDICATED TO THE HEALTH OF ALL CHILDREN"
Copyright © 2003 SPEAKER S KIT
-------
Evaluation Tools
• eQIPP Asthma PediaLink Module (www.eqipp.org)
• Functional Outcomes Project (Children's Health Survey on Asthma)—measurement tools to
assess the effect of disease and medical treatment on the lives of children and their families
General
• National Heart, Lung, and Blood Institute (www.nhlbi.nih.gov)
• Centers for Disease Control and Prevention (www.cdc.gov)
• Actions Against Asthma: A Strategic Plan for the Department of Health and Human Services
(http://aspe.hhs.gov/sp/asthma/)
Related Organizations
• American Academy of Allergy, Asthma, and Immunology (www.aaaai.org)
• American College of Allergy, Asthma & Immunology (www.acaai.org)
• American Lung Association (www.lungusa.org)
• Asthma and Allergy Foundation of America (www.aafa.org)
• Allergy & Asthma Network Mothers of Asthmatics (www.aanma.org)
• American Association of Immunologists (http://12.17.12.70/aai/default.asp)
• Consortium of Children's Asthma Camps (www.asthmacamps.org)
• Joint Council of Allergy, Asthma and Immunology (www.jcaai.org)
• National Association of School Nurses (www.nasn.org)
• Pollen.com (www.pollen.com)
• US Environmental Protection Agency (www.epa.gov)
• US Food and Drug Administration (www.fda.gov)
SPEAKER'S KIT
-------
SYSTEM REQUIREMENTS
Windows®
486 or higher processor, Microsoft® Windows 95/98/2000 or Windows NT Workstation operating
system 3.51 or 4.0, VGA graphics card, and CD-ROM drive.
This presentation was prepared in Microsoft Powerpoint®. Microsoft PowerPoint Viewer is
included if you do not have this software on your computer.
Macintosh®
PowerPC™ processor, System 7.5 to 9.x, 16 MB of RAM to run program individually, 24 MB
of RAM to run program from a network or from the CD-ROM, 9 MB hard disk space, and
CD-ROM drive.
-------
Asthma Slide Presentation Kit on CD-ROM
INSTALLATION INSTRUCTIONS—PC
If you have Microsoft9 PowerPoint® 97 or higher installed on your system:
1. Insert the disc into the CD-ROM drive.
2. Open the PowerPoint program located on your computer.
3. Select File>0pen and locate your CD-ROM drive.
4. Open the Presentations folder and elect a PowerPoint (.ppt) file to launch and/or save a
slide show.
If you have Microsoft PowerPoint 95 installed on your system, or if you do not have any version
of PowerPoint:
1. Insert the disc into the CD-ROM drive.
2. Select the Start menu, choose Run, type D7PPView97.exe and then click OK (if your CD-ROM
drive is not D, use the appropriate letter).
3. Follow the on-screen instructions.
4. To view an Asthma slide show, go to Start>Programs and click on the Microsoft PowerPoint
Viewer 97 icon. Once the viewer is open, locate your CD-ROM drive, open the Presentations
folder and select a PowerPoint (.ppt) file to launch a slide show.
INSTALLATION INSTRUCTIONS—MACINTOSH
If you have Microsoft® PowerPoint® 98 or higher installed on your system:
1. Insert the disc into the CD-ROM drive.
2. Open the PowerPoint program located on your computer.
3. Select File>0pen and locate your CD-ROM drive.
4. Open the Presentations folder and select a PowerPoint (.ppt) file to launch and/or save a
slide show.
If you have an earlier version of Microsoft PowerPoint installed on your system, or if you do not
have any version of PowerPoint:
1. Insert the disc into the CD-ROM drive.
2. Double-click the file Microsoft PowerPoint View.sit found on the CD-ROM. This will run a utility
that will uncompress the Viewer and supporting files. If you do not have Stuffit Expander for
Macintosh you will need to download that from www.aladdinsys.com.
3. Open the folder Microsoft PowerPoint Viewer.
4. Double-click the Microsoft PowerPoint Viewer file and the Viewer will launch.
TECHNICAL SUPPORT
Should you have any questions or problems installing this product, please call the American
Academy of Pediatrics at 888/227-1770, fax 844/228-1281, or e-mail pubs@aap.org.
-------
Asthma Speaker's Kit
To create a customized presentation from the Powerpoint® files on the Speaker's Kit, you will first
need to copy the files to your computer's hard drive. To do this, please follow the Copy to Hard
Drive Instructions below. For information on installing the free PowerPoint Viewer included on the
CD-ROM, please consult the PowerPoint Viewer Installation Instructions. PLEASE NOTE that if
you do not have the full version of PowerPoint 97 or higher, you will be able to view the contents
of the Asthma Speaker's Kit files as well as copy them to your hard drive, but you will not be able
to customize them in any way.
COPY TO HARD DRIVE INSTRUCTIONS—PC
1. Insert the disc into the CD-ROM drive.
2. Double-click on the My Computer icon on your desktop. Double-click on the hard drive letter to
which you would like to copy the Speaker's Kit.
3. Go to the File menu in the upper left-hand corner and select New Folder. Assign the folder
a name.
4. Click on the Back button to bring up the whole My Computer list. Double-click on the CD-ROM
drive to bring up a list of the Asthma Speaker's Kit PowerPoint files. From the Edit menu,
choose Select All.
5. From the Edit menu, choose Copy.
6. Go to the New Folder that you created in Step 3. Double-click on it to open the folder. Go to
Edit and select Paste. All the Speaker's Kit files will be copied into the new folder.
7. When the copying process is complete, go to the Edit menu and choose Select All. Click with
your RIGHT mouse button on the highlighted files and select Properties from the pop-up menu.
8. From the window that appears, remove the check from the Read-only box in the Attributes
area.
9. To access the Speaker's Kit files, open your Powerpoint program. Select FiloOpen and locate
the folder to which you had copied the Speaker's Kit files. From here, select a file to view and
click the Open button.
COPY TO HARD DRIVE INSTRUCTIONS—MACINTOSH
1. Insert the disc into the CD-ROM drive.
2. Within your hard drive, go to the File menu and select New Folder. Assign the folder a name.
3. With the contents of the CD-ROM showing, use your mouse to select all the files. Click and
hold your mouse button down on the highlighted area, and drag the files to the folder you
created in Step 2.
4. To access the Speaker's Kit files, open your PowerPoint program. Select File>Open and locate
the folder to which you had copied the Speaker's Kit files. From here, select a file to view and
click the Open button.
-------
POWERPOINT VIEWER INSTALLATION INSTRUCTIONS—PC
If you have Microsoft® PowerPoint9 95 installed on your system, or if you do not have any version
of PowerPoint:
1. Insert the disc into the CD-ROM drive.
2. Select the Start menu, choose Run, type DVPPView97.exe and then click OK (if your CD-ROM
drive is not D, use the appropriate letter).
3. Follow the on-screen instructions.
4. To view the Asthma slide show, go to Start>Programs and click on the Microsoft PowerPoint
Viewer 97 icon. Once the viewer is open, locate your CD-ROM drive, open the Presentations
folder, and select a PowerPoint (.ppt) file to launch a slide show.
POWERPOINT VIEWER INSTALLATION INSTRUCTIONS—MACINTOSH
If you have an earlier version of Microsoft0 PowerPoint® installed on your system, or if you do not
have any version of PowerPoint:
1. Insert the disc into the CD-ROM drive.
2. Double-click the file Microsoft PowerPoint View.sit found on the CD-ROM. This will run a utility
that will uncompress the Viewer and supporting files. If you do not have Stuffit Expander for
Macintosh you will need to download that from www.aladdinsys.com.
3. Open the folder Microsoft PowerPoint Viewer.
4. Double-click the Microsoft PowerPoint Viewer file and the Viewer will launch.
TECHNICAL SUPPORT
Should you have any questions or problems installing this product, please call the American
Academy of Pediatrics at 888/227-1770, fax 844/228-1281, or e-mail pubs@aap.org.
Copyright © 2003 American Academy of Pediatrics
-------
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