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خدا نیکوست
Treatment of Treatment of Children AsthmaChildren Asthma
Dr. Fatemeh Behmanesh
Key elements to optimal Key elements to optimal
asthma managementasthma management
Assess severityAssess severity
• The classification of asthma severity is based on the
following parameters:
Frequency of day time symptoms
Frequency of might time symptoms
Degree of air flow obstruction by spirometry or
PEF variability
• Asthma severity categorized as
Mild intermittent
Mild persistent
Moderate persistent
Sever persistent
FOR ADULTS AND CHILDREN AGE > 5 YEARS WHO CAN USE A
SPIROMETER OR PEAK FLOW METER
CLASSIFICATIONSTEPDAYS WITH SYMPTOMSNIGHTS WITH SYMPTOMS
FEV1 or PEF[*] % Predicted Normal
PEF Variability )%(
Severe persistent4ContinualFrequent≤60>30
Moderate persistent3Daily>1/wk>60<–80>30
Mild persistent2
>2/wk, but <1 time/day>2/mo≥8020–30
Mild intermittent1≤2/wk<2/mo≥80<20
Classification of Asthma Severity
Stepwise Approach for Managing Infants and Young Children Stepwise Approach for Managing Infants and Young Children (≤5 Yr of Age) with Acute or Chronic Asthma; Treatment(≤5 Yr of Age) with Acute or Chronic Asthma; Treatment
Classify Severity: Clinical Features Before Treatment Or Adequate ControlMedications Required To Maintain Long-Term Control
Symptoms/Day
Symptoms/Night Daily Medications Step 4 Severe persistent
Step 3 Moderate persistent
Step 2 Mild persistent Step 1 Mild intermittent
Continual Frequent
Daily>1 night/wk
>2/Week but<1 /day>2 nights/mo
2days/wk2nights/mo
• Preferred treatment- High-dose inhaled corticosteroids AND- Long-acting inhaled β2-agonistsAND, if needed,- Corticosteroid tablets or syrup long term (2 mg/kg/day, generally do not exceed 60 mg/day).(Make repeat attempts to reduce
systemic corticosteroids and maintain control with high-dose inhaled corticosteroids.)• Preferred treatment- Low-dose inhaled corticosteroids and long-acting inhaled β2-agonists
OR- Medium-dose inhaled corticosteroids.• Alternative treatment- Low-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline.If needed (particularly in patients with recurring severe exacerbations):• Preferred treatment- Medium-dose inhaled corticosteroids and long-acting β2-agonists.• Alternative treatment - Medium-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline. Preferred treatment - Low-dose inhaled corticosteroid (with nebulizer or MDI with holding chamber with or without face mask or DPI). Alternative treatment - Cromolyn (nebulizer is preferred or MDI with holding chamber)OR leukotriene receptor antagonist. No daily medication needed.
Quick Relief All Patients
Bronchodilator as needed for symptoms. Intensity of treatment will depend on severity of exacerbation. - Preferred treatment: Short-acting inhaled β2-agonists by nebulizer or face mask and space/holding chamber- Alternative treatment: Oral β2-agonist With viral respiratory infection - Bronchodilator q 4–6 hr up to 24 hr (longer with physician consult); in general, repeat no more than once every 6 wk- Consider systemic corticosteroid if exacerbation is severe or patient has history of previous severe exacerbations Use of short-acting β2-agonists >2 times/wk in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate
(increase) long-term-control therapy.
• Treat all persistent asthma with anti-anti-
inflammatory controller medicationinflammatory controller medication.
• the type and amounts of daily controller
medication are determined by asthma severityasthma severity.
• Three strikes rule: • Symptom or uses quick-relif medication at
least 3 times per week. • Awakens at might due to asthma at least 3
times per months. • Experiences asthma exacerbations at least 3
times per year. • Or require short courses of systemic cortico-
steroids at least 3 times a year. Patient should receive daily controller therapyPatient should receive daily controller therapy
• Controller therapy can be considered for children
who present with frequent exacerbation
At least 2 exacerbation occuring < 6 week
apart
• All levels of persistent asthma should be treated with daily medications include: ICS LABA Leukotriene modifiers Nonsteroidal anti-inflamatory agents Sustained – release theophylline Anti- IgE (omalizumab, Xolair) approved by add-
on therapy for patients with moderate to sever allergic asthma.
• Most potent and effective medication is corticosteroids Acute (systemically) Chronic (inhalation)
• First line treatment for persistent asthma
• Reduce asthma symptoms
• Improve lung function
• Reduce AHR
• Reduce “rescue” medication use
• Reduce urgent care visits & hospitalization
• Lower the risk of death
ICS
Estimated Comparative Daily Dosages for Estimated Comparative Daily Dosages for Inhaled CorticosteroidsInhaled Corticosteroids
DRUGLOW DAILY DOSEMEDIUM DAILY DOSEHIGH DAILY DOSE
AdultChild[*]AdultChild[*]AdultChild[*]
Beclomethasone CFC 42 or 84 μg/puff168–504 μg84–336 μg504–840 μg336–672 μg>840 μg>672 μg
Beclomethasone HFA 40 or 80 μg/puff80–240 μg80–160 μg240–840 μg160–320 μg>480 μg>320 μg
Budesonide DPI 200 μg/inhalation200–600 μg200–400 μg600–1,200 μg400–800 μg>1,200 μg>800 μg
Inhalation suspension for nebulization (child dose)
0.5 μg1.0 μg2.0 μg
Flunisolide 250 μg/puff500–1,000 μg500–750 μg1,000–2,000 μg1,000–1,250 μg>2,000 μg>1,250 μg
Fluticasone MDI: 44, 110, or 220 μg/puff88–264 μg88–176 μg264–660 μg175–440 μg>660 μg>440 μg
DPI: 50, 100, or 250 μg/inhalation100–300 μg100–200 μg300–600 μg200–400 μg>600 μg>400 μg
Triamcinolone acetonide 100 μg/puff400–1,000 μg400–800 μg1,000–2,000 μg800–1,200 μg>2,000 μg>1,200 μg
* Children ≤ 12 years of age
• Two classes of leukotrene modifiers:
Inhibitors of leukotriene synthesis: zileuton
Leukotriene receptor antagonists:
o Montelukast
o Zafirlukast
Leukotrience pathway modifiers Leukotrience pathway modifiers
1. Zileuton: • Not upproved for children < 12 year• 4 times daily • Elevated liver function enzymes
2. Montelukast • Approved for children 1 year • One daily
3. Zafirlukast • Approved in children 5 year• Twic daily
Leukotriene modifiers are considered Leukotriene modifiers are considered
alternative controllers for mild alternative controllers for mild
persistent asthma persistent asthma
Considered on alternative monotherapy
controller agent for older children and adults
with mild persistent asthma.
No longer considered a first line agent for
small children
Sustained- Release TheophyllineSustained- Release Theophylline
• Daily controller medication • Not as monotherapy for persistent asthma • Add- on agent for patients suboptimally
controlled on ICS therapy alone • Salmetrol • For moterol • In patients with nocturnal asthma • Low dose ICS with LABA for moderate persistent
asthma in older children and adult • High dose ICS + LABA for sever persistent asthma
LABA LABA
Non-steroidal Anti- Inflammatory AgentsNon-steroidal Anti- Inflammatory Agents
• Cromolyn and nedocromil• Non- corticosteroid anti- inflammatory • Reduce exercise- induced bronchospasm • For mild persistent asthma • Adminstered frequently 2-4 times/day • Not nearly as effective daily contoller as ICS • For mild persistent asthma
Anti IgE (omalizumal)Anti IgE (omalizumal)
• Humanized monoclonal antibody that binds IgE
• FDA approved for patients > 12 year old
• For moderate to sever asthma
• For Patients with inadequate disease control with
ICS or oral corticosteroids
• Every 2-4 week
Step-up, step up- Down ApproachStep-up, step up- Down Approach
• Initiating higher-level controller therapy • Step down after good asthma control
• Decrease ICS dose about 25% every 2-3 months • If control is not maintained, step up, review patient medication technique
Adherence Environment
Quick – Reliever medicationsQuick – Reliever medications
• Rescue medications:
Short acting inhaled -agonist
Inhaled antichilinergics
Short course systemic corticosteriods
• For management of acute asthma
SABASABA• Rapid onset of action• 4-6 hr duration of action • First choice for acute asthma symptom • For preventing exercise induced bronchospasm • It is helpful to monitor the frequency of SABA • Use
1. At least 1 MDI/Month • Indicate Inadequate Asthma Control
2. Al least 3 MDI/ year
Anticholinergic AgentsAnticholinergic Agents
• Ipratropium bromide • Tretament of acute sever asthma • Combination with SABA
• Improve lung function • Reduce the rate of hospitalization
• MDI, Nebulizer formulation • Approved by FDA for children > 12 year of age
26
Management acute asthmaManagement acute asthma
The home
The emergency department
The hospital
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Home ManagementHome Management
Home treatment based on changes in PEF valuesGreen zoneYellow zoneRed zone
In children too young or otherwise incapable of performing PFT, sing & symptoms to be evaluated: (e.g., color changes, respiratory rate, location/extent of retractions, duration of inspiratory/ expiratory phases, presence or absence of cough/wheezing)
28
……Home ManagementHome Management
Note signs and symptoms: Degrees of cough, breatlessness, wheeze and chest tightness, corrolate imperfectly with severity of exacebration. Accessory muscle use and suprasternal retraction suggest severed exacebration.
If PEF<50% predicted: initial treatmentInhaled short-acting β2 agonist: up to three treatment of 2-4
puff 20-min intervales byMDIMDI + Spacer deviceDPIHand nebulizer
29
……Home ManagementHome Management
After 1 hour
Good response
Incomplete response
Poor response
30
Good Response (Mild Episode)Good Response (Mild Episode)
PFE>80% predicted
No wheezing or shortness of breath
Response to β2 agonist sustained for 4 hours
May continue β2 agonist every 3-4h for 24-48h
For patients on inhaled corticosteroids, double dose
for 7-10 days and contact clinician
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Incomplete Response (Moderate Episode)Incomplete Response (Moderate Episode)
PEF 50%-80% predicted
Persistent wheezing and shortness of breath
Add oral corticosteroid
Continue β2 agonist
Contact clinician urgently (this day)
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Poor Response (Sever Episode)Poor Response (Sever Episode)
PEF<50% predicted
Marked wheezing 8 shortness of breath
Add oral corticosteroid
Repeat β2 agonist immediately
Call your doctor
Proceed to emergency department
33
Office or Emergency Department ManagementOffice or Emergency Department Management
A brief history of the events leading up to the exacerbation and the
medications used both chronically and acutely to treat
Physical examination: RR, PR, Pluse oximetry, use of accessory
muscle, air flow, wheezing, (1÷E), verbalization, puls paradoxus.
Studies: PEF, FEV1, ABG
Routine CXRnot nessary unless complication (e.g., pneumothorax,
pneumomediastinum, aspiration)
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Respiratory arrest imminentRespiratory arrest imminent
Intubate and mechanically ventilate with 100% O2.
Nebulized β2 agonist and anticholinergic
IV corticosteroid.
Admit to ICU
Continuous monitoring
Intensive asthma management
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… …Respiratory arrest imminentRespiratory arrest imminent
Improved
Admit to hospital ward
O2 to maintain good saturation
Nebulized β2 agnoist +/- anticholinergic
PO or IV corticoesteroid
Monitor vital signs, O2 saturation, FEV1 or PEF
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… …Respiratory arrest imminentRespiratory arrest imminent
Improved
Discharge to home
Continue home treatment with inhaled β2 agonist
Consider need for oral corticosteroids or controller
medication
Educate patient in medication use and action plans
Arrange follow-up
37
Emergency department managementEmergency department management
Give nebulized albuterol with o2 at 6 liters flow, 2.5mg per
dose q 20min.
O2 to achieve saturation>90%
Give corticosteroid po or IV if FEV1 or PEF<50%
Or
If the patient was recently receiving corticosteroids
Or
If the patient in historically a high risk patient
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ReassessReassess
Physical examination: RR, HR, Pulse oximetry, use of
accessory muscles, airflow, wheezing, (1÷E)
verbalization, pulsus paradoxus
Studies; PEF, FEV1
Mild exacerbation
Moderate exacerbation
Sever exacerbation
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Mild ExacerbationMild ExacerbationFEV1 or PEF>80%
Good responseMaintained without repeated treatments during ER
PE: Normal
Discharge to homeContinue home treatment with inhaled β2 agonist
Consider need for oral corticosteroids or controller medicationE ducat patient in medication use and action plus
Arrange follow up
40
Moderate ExacerbationModerate Exacerbation
FEV1 or PEF>50% but <80%
In complete response to treatment
PE: RR, Wheezing present, mild to moderate
accessory muscle use,
O2 satiration 91-95%
1:E<1:2
PP=10-25mmHg
41
… …Moderate ExacerbationModerate Exacerbation
Admit to Hospital Ward
02 up to 02 sat >95%
Nebulized β2 agonist +/- anticholinergic
Po or IV corticosteroid
Monitor vital signs, 02 saturation, FEV1 or PEF
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… …Moderate ExacerbationModerate Exacerbation
Improved
Discharge to home
Continue home treatment with inhaled β2 agonist
Consider need for oral corticosteroid or controller
medication
Educate patient in medications and action plan
Arrange follow up
43
Sever ExacerbatisSever Exacerbatis
FEV1 or PEF<50%Poor response to treatmentPE: RR, Wheezing present, poor airflowModerate-sever accessory muscle use, 02 sat<91%PP>25mmHg
Admit to ICUContinuous monitoringIntensive asthma management
44
… …Sever ExacerbatisSever Exacerbatis
Improved
Admit to hospital ward
O2 to maintain good saturation
Nebulized β2 agnoist +/- anticholinergic
PO or IV corticoesteroid
Monitor vital signs, O2 saturation, FEV1 or PEF
45
… …Sever ExacerbatisSever Exacerbatis
Improved
Discharge to home
Continue home treatment with inhaled β2 agonist
Consider need for oral corticosteroids or controller
medication
Educate patient in medication use and action plans
Arrange follow-up
46
Therapy of EIA Therapy of EIA
Useful prophylactic approaches
ClassDrugDose inhaledTime delayDuration
Long- acting 2 agonistSalmeterol1 inhalation DPI20 min8-10 hr
Short-acting 2 agonistAlbuterol2 puffs MDI15 min3-4 hr
AntileukotrieneMontelukast10 mg orally30 min8-10 hr
Mast cell stabilizersCromolyn2 puffs MDI15 min1.5-2 hr
Duration of protection may decrease with regularly scheduled use