PHN Grand Rounds:

COVID-19 and

Pediatric Asthma Presented by:

Deepa Rastogi MD

Dinesh Pillai MD

Shilpa Patel MD MPH

Eduardo Fox MD

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COVID-19 Response (as of April 7,2020)

• Children’s National Hospital is open for business.

• Telehealth is deployed system-wide. Patients can request telehealth during scheduling appointments with the call center.

• Full time specialists available for real time consults – to contact dial Physician Access Line 202-476-4880 (M-F 8a to 5p; hospital operators 202-476-5000 after hours).

• Explore and participate in shared learning opportunities Childrensnational.org/webinars.

• Drive up/walk up specimen collection site (limited to patients age 22 or under as referred by a primary care physician). Childrensnational.org/COVID19testforms.

• Most elective surgeries are postponed.

• Hospital is preparing for a surge in patients and is taking measures to preserve the health of clinical staff in the event of influx.

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Children’s National Resources

Stay informed with the latest resources for providers, staff and patients on the Children’s National Coronavirus (COVID-19) Resources for Primary Care

Practices

https://childrensnational.org/healthcare-providers/refer-a-patient/covid

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Future of Pediatrics 2020: June 16-17 In-Person

Meeting Cancelled, Virtual Series Coming Soon

There is a “Future of Pediatrics” after COVID-19! It is with great sadness we announce that we will not be hosting an in-person event this June. We realize that, even if current COVID-19 restrictions are lifted, our pediatricians are busy focusing on recovery and most would not be able to take two full days away from their practice to participate in CME.

But you can still get your learning, networking and CME! We are busy reimagining our 21st annual Future of Pediatrics program as a virtual learning experience. This ongoing, online series will include CME credit and the same “practical pediatrics for practicing pediatricians” clinical topics that you have come to value.

We will have more information to share soon and we look forward to gathering in-person at the Business of Pediatrics program in December. Thank you, as always, for your commitment to our children, families, and community.

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PCP Town Halls Tuesday, May 12, 2020 @ 12-1PM

Speakers include: Denise Cora-Bramble, M.D., MBA, Bud Wiedermann, M.D., Meghan Delaney,

D.O., Mike Bell, M.D., Hemant Sharma, M.D., Ellie Hamburger, M.D.

Agenda includes:

• Introduction and Acknowledgements

• Infectious Disease

• COVID-19 Testing/ Lab Updates

• Critical Care Overview/ Case Study

• Allergies and COVID-19

• Q&A

Visit www.pediatrichealthnetwork.org for Zoom information.

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COVID-19 Youth and Family Town Halls

Children’s National Hospital will be hosting a series of family and youth town halls to address community needs in response to coronavirus (COVID-19). The youth town halls, “COVID Convos”, are a three-part series for high school students that will focus on adolescent health and the effects of the pandemic. The COVID Convos will be held from 2-3pm on May 6, 7, and 8. . The family town halls are a four part series for families living in the DC region that will focus on how the COVID-19 pandemic is affecting families and identify resources available to them. The Family Town Halls will be held over 4 consecutive Tuesdays from 3-4pm on May 5, 12, 19, and 26. Registration information: Family Town Halls – https://bit.ly/2zJ186L Youth Town Halls “COVID Convos” - https://bit.ly/2yYUSao

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A few notes about today’s Grand Rounds

• All lines are muted throughout the webinar.

• Please use the Chat function to ask questions or make comments.

• To avoid feedback noise, please do not have computer audio and phone audio active at the same time.

• Today’s Webinar recording and slides will be posted to the PHN website following the presentation. www.pediatrichealthnetwork.org

PHN Grand Rounds:

COVID-19 and

Pediatric Asthma Presented by:

Deepa Rastogi MD

Dinesh Pillai MD

Shilpa Patel MD MPH

Eduardo Fox MD

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Meet Our Speakers

Deepa Rastogi, MD Dinesh Pillai, MD Shilpa Patel, MD MPH Eduardo Fox, MD

Today’s presenters have no conflicts to disclose:

• No financial or business interest, arrangement or affiliation that could be perceived as a real or

apparent conflict of interest in the subject (content) of their presentation.

• No unapproved or investigational use of any drugs, commercial products or devices

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Learning Objectives

• Discuss the evolving epidemiology of COVID, particularly as it relates to patients with asthma

• Provide ongoing asthma management, adhering to latest guidelines during the pandemic

• Conduct a thorough video visit for patients with asthma

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Disease Epidemiology

COVID19 Case Growth Rate: Global, US, NY, Region (thru 5.1.20)

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Daily New Cases 4.29.2020 https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html

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Weekly COVID19 Admission Rates (4.25.20) https://gis.cdc.gov/grasp/covidnet/COVID19_3.html

>85 yrs

Overall

<18yrs

United States

Maryland

>85 yrs

<18yrs

Overall 19-49 yrs

19-49 yrs

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Children’s National COVID19 Cases (5.1.2020) Excludes Popup Testing Sites

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Questions?

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Disease Pathophysiology

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What is SARS-CoV2 and COVID-19?

• SARS-CoV2 is a single-stranded RNA virus in the Coronaviridae family

• SARS-CoV2 is responsible for Coronavirus disease 2019

(COVID-19) pandemic

• Virus binds to cells through the ACE2 receptor

• Transmembrane receptor • Quite ubiquitous

• Alveolar cells • Airway epithelial cells • Enterocytes • Endothelial cells

• Following endocytosis, the virus multiplies in the cell, cell undergoes apoptosis, virus is released to infect more cells

Photo credit: NIAID

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Mechanism of viral sepsis due to SARS-CoV2

Li et al. Lancet

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ACE2 receptor, atopy and pediatric asthma

Jackson 2020 JACI

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Questions?

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Disease Presentation

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Pediatric impact of SARS-CoV2 and COVID-19

Ludvigsson 2020 Acta Pediatr Dong et al. 2020 Pediatrics

• Disease burden in children

• 0.02% of all cases in China

• 1.2% in Italy

• 1.7% in US

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COVID-19 presentation in children- symptoms and labs

Zheng et al. 2020 Current Med Sci

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COVID-19 presentation in children- symptoms and labs

Qiu et al. 2020 Lancet

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COVID-19 Presentation in Children

• Fever (41.5%)(most commonly seen in children in close proximity of an infected adult)

• Pharyngeal erythema (46.2%)

• Cough (48.5%)

• Diarrhea (8.8%)

• Fatigue (7.6%)

• Tachypnea (28.7%), tachycardia (42.1%), desats below 92% (2.3%)

Ludvigsson 2020 Acta Pediatr

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COVID-19 Presentation in Children-Imaging

Sun et al. 2020 World J Pediatr

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Pediatric Impact of SARS-CoV2 and COVID-19 on Children

N=6

N=8

N=9 N=2

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Pediatric Impact of SARS-CoV2 and COVID-19 on Children

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COVID-19 and Asthma

Halpin et al. 2020 Lancet Goyal et al. NEJM

• 345 Pediatric cases with info on underlying conditions

• 80 (23%) had 1 underlying condition

• Most common: 40% Chronic lung disease (asthma)

• 25% Cardiovascular disease

• 10% Immunosuppression

• 77% of admitted children had underlying condition (28 of

37)

• 12% of non-admitted children had underlying condition (30 of 258)

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Children’s National COVID19 Patient Characteristics (4.22.2020)

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Questions?

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Management

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Asthma treatment recommendations during COVID-19

Pandemic (NAEPP, GINA, CDC)

• Unclear if any increased risk of COVID-19 morbidity in children with asthma

• Unknown if asthma controller meds (ICS, combo therapy, montelukast, biologics) pose risk when treating COVID-19

• Unknown if COVID-19 increases risk of asthma exacerbations

• Best course of action: Maintain asthma control!

Abrams EM, Szefler SJ. J Peds 2020.

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Asthma treatment recommendations during COVID-19

Pandemic (NAEPP, GINA, CDC)

Well controlled patients

1. Keep on current dosing

Do not step down, unless clear need/concern

Consider spring season

2. Avoid triggers

Allergens – outdoor allergens may be decreased, indoor increased (ETS)

Handwashing

Physical distancing

Review technique frequently

Abrams EM, Szefler SJ. J Peds 2020.

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Encourage early telemedicine visit vs. ED

1. Important history

Duration of symptoms

Albuterol use: frequency, number of puffs

Activity/fatigue level

Night time symptoms

2. Telemedicine clinical exam (in context of when last albuterol dose given)

COVID-19 pandemic asthma exacerbation recommendations

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Treatment

1. High dose Albuterol MDI: Increase number of puffs (4-6 puffs minimum) every 4 hours

High albuterol dose for 4 hours around the clock for 24-48 hrs

Unable to make every 4 hours:

Give red zone (3 high doses back to back 15 minutes apart)

Send to ED

2. Consider oral steroids at home : Weigh clinician and parent comfort vs. sending to ED

Able to maintain higher dose albuterol q4hr but still needing >24 hours

Predniso(lo)ne 2 mg/kg/day for 5 days (max dose 60 mg daily)

Dexamethasone: 0.5 mg/kg/day x2 days

Follow up in 24-48 hours

At any time, if not able to make 4 hour mark for Albuterol, must do Red Zone and go to ED

COVID-19 pandemic asthma exacerbation recommendations

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MDI vs. nebulizer concerns during COVID-19 pandemic

Try to minimize nebulizer when possible

Aerosol generating procedure, may increase time suspended in air up to 3 hours

May induce cough

Increased risk of viral lower lung deposition

30-40% asymptomatic carrier rates reported

Consider home environment (elderly family members, ability to isolate neb location)

What to do

Switch to MDI, prescribe aerochambers

ICS in older patients: consider MDI and DPI options

Abrams EM, Szefler SJ. J Peds 2020. Shaker et al., JACI 2020

Amirov I. CAMJ 2020

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Albuterol doses in acute asthma (RED Zone)

Weight

Nebulizer dose

MDI/spacer dose*

5-10kg

2.5 mg INH Q 20 minutes x 3 doses

4 puffs INH Q 20 min x 3 doses

>=10kg to 30 kg

2.5 mg INH Q 20 minutes x 3 doses

6 puffs INH Q20 min x 3 doses

>= 30 kg

5 mg INH Q20 minutes x 3 doses

8 puffs INH Q20 min x 3 doses

* No guidelines available for true equivalency. These are doses used in our Emergency Department.

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MDI shortage

Attempt to cohort MDI for COVID+ patients, early purchases due to COVID concerns

Appears to be pharmacy specific

Call pharmacy directly to understand level of shortage

MDI availability local DC pharmacies:

https://docs.google.com/spreadsheets/d/1mog8Qkqzj8CIWJRdCHpc7JouvzEAkGaoFdo-y9yzDKM/edit#gid=0

What to do:

Prescribe neb treatments and neb machine, mask, tubing

Remind family efficacy of MDI vs. neb

GOAL: Treat the patient

MDI shortage during COVID-19 pandemic

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Other asthma medication considerations

Continue all allergy/eczema medications

Give refills, fill 90 day supplies – minimize community based exposures, family anxiety

Oral steroid concerns: not treating COVID-19, treating asthma

Oral steroids not recommended for COVID-19 infection

Asthma control strongly recommended even if +COVID-19 – TREAT w/ steroids if needed

Other rescue medications

Can consider anticholinergics for exacerbations – weigh comfort level, delivery mechanism

Biologics: convert to home use when safe/possible

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Rescue Meds: In 0ffice concerns during COVID-19 pandemic

Do not use nebulizer without proper precautions in health care setting

N95 mask (surgical mask over N95), gown, eye protection, gloves

Negative pressure room – can re-use room in 30 minutes

No negative pressure room – re-use room in 3 hours

Wipe down entire room with appropriate cleaner

NEED TO REDUCE RISK OF POTENTIAL SPREAD TO HEALTHCARE WORKERS, COMMUNITY

Recommendations:

Have child use albuterol at home prior to coming to clinic

Have families bring home albuterol, aerochamber to clinic

Send to ED for neb treatments

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Other concerns during COVID-19 pandemic

Pulse oximetry home use

NOT RECOMMENDED

May increase stress, anxiety

Sends wrong message, do not want to delay

Asthma Action Plans work when used properly

Excellent ED based care is available - Patient not improving, have them seen in the ED

Other co-morbidities

Obesity: less school = less activity, weight gain. Encourage regular exercise/play at home

Sickle cell disease: keep treating, maintain control, use MDI in lieu of nebs

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Questions?

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Tips for Telehealth Asthma Visits

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Challenges/ Opportunities

Limited Time

• Pick and choose which components to do at the visit

• Can break up the visit as needed

• No shows (choose good time for parents while at home during pandemic)

Lack of Exam

“On the ground” assessment

Environmental Assessment

Telemedicine may be easier for some parents who have previously been difficult to reach

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Intake Symptoms (cough, wheeze, chest pain, exercise intolerance, fatigue)

Triggers (colds, exercise, changes in weather, stress, pets, dust, smoke, strong smells, pollen)

Risk

• # of ED asthma visits in last 12 months

• # of admission in last 12 months

• # of urgent care visits in the last 12 months

• # of systemic steroid courses in last 12 months

Impairment

• daytime symptoms- days/week

• Nighttime awakenings- nights/month

• Albuterol use for symptom control (not counting pre-exercise)- times/week

• Interference with normal activity (none, minor, some, severe)

• School absences due to asthma

Asthma Control Test (ACT)- Can be difficult to do during telehealth visit.

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Modified Exam for Telemedicine Visit

Observe eyes, face, neck, chest, skin, and respiratory effort

Consider having patient/ parent adjust clothing observe chest and suprasternal area (depending on age of patient).

Can count respiratory rate

Sample Exam

• General: patient activity, ? Well or sick appearing

• HEENT: can comment on conjunctivae, nasal drainage, allergic shiners

• Lungs: No increased work of breathing, ? audible wheezing, ? able to sing or converse without dyspnea

• Cardiovascular: Pink, no cyanosis

• Abdomen: deferred or observation about “belly breathing”

• Neurological: normal gait, alert and oriented

• Skin: There were no obvious rashes or lesions noted. ? eczema, ? acanthosis

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Medication and Spacer

Technique

Confirm medications- ask family to get medications

Spacer – where is it stored, patient familiarity, sizing, ask families to demonstrate technique

Teaching Technique is billable

• HFA/spacer (Link to IMPACT DC videos): https://vimeo.com/channels/impactdc

• Breath-activated devices (https://www.qvar.com/redihaler/redihaler-and-childhood-asthma)

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Quick Video Home Visit (Trigger Assessment)

Environmental assessment- can use triggers identified during intake to tailor assessment but may consider:

• Bedroom/ sleeping space

• Smoke Exposure

• Pests

• Dust

• Moisture, Mold, Smells

• Pets

• Carpet and flooring

Evidence for interventions?

• No strong evidence for single trigger elimination

• Mild to moderate evidence for multi-component interventions but need more research

COVID-19 and resources for increased family needs List of compiled resources (food, unemployment help):

https://wamu.org/story/20/03/19/your-guide-to-getting-unemployment-and-other-relief-in-d-c-virginia-and-maryland/

DC COVID-19 CONNECT (comprehensive guide put together by GW Medical Students – available in multiple languages) and updated daily: https://bit.ly/2UUv87S

Free internet: Comcast is giving free internet connection for low-income families for 60 days. Families just need to visit www.internetessentials.com or call 1-855-846-8376 (Eng) or 1855-765-6995 (Sp).

https://corporate.comcast.com/press/releases/comcast-extends-comprehensive-covid-19-response-policies-to-june-30

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Additional Resources

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Additional Resources

Formulary for Medicaid

Steroid equivalency

Landlord Letter Template

Changes you can make at home

Asthma Action Plan

IMPACT DC Provider Resources:

https://childrensnational.org/departments/impact-dc-asthma-clinic/resources-for-providers

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Referrals

IMPACT DC: www.impact-dc.org

Severe Asthma Clinic: pulmasthma@childrensnational.org

IMPACT DC – How to refer

1. By email: IMPACTDC@childrensnational.org

2. By phone: 202-476-3970

3. Through eCW referral [Impact DC under Provider & Send fax].

• Just need patient info and contact info – IMPACT DC team will do the rest.

• All patients in the ED or admitted should be referred to IMPACT DC.

• Patients with asthma impairment, missing school days, or poor asthma education should also be referred.

• Locations include: CNMC main campus, CHC-Anacostia, and THEARC.

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Severe Asthma Clinic – How to Refer

• Sees patients with uncontrolled Moderate Persistent Asthma or worse

• Incorporate PFTs

• ID/Treat co-morbidities (tonsillar hypertrophy, GERD, allergic rhinitis, etc.)

• Step up therapy/consider biologics

• To refer, email pulmasthma@childrensnational.org (Provide patient information, contact number)

• Patients can be referred to IMPACT DC and Severe Asthma Clinic

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Consider referral for any of the following:

>1 hospitalization

Admitted to ICU for at least 24 hours

Child >5 years requiring step 4 care or higher

Child <5 years requiring step 3 care or higher

Uncontrolled asthma after 3-6 months of active therapy and appropriate monitoring

Other complicating co-morbidities

Aerodigestive Clinic – How to Refer

Who to refer: Refractory ‘asthma’ symptoms (not responding to asthma therapies)

Patients requiring evaluation by >2 of the following specialties:

• ENT, GI, Pulmonary, Speech

Able to coordinate flexible bronchoscopy, rigid bronchoscopy and EGD at same time

• Concern for EOE, anatomical problems, etc.

Email: Aerodigestive@childrensnational.org

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Severe Asthma Clinic

Inpatient

Sleep Clinic

IMPACT DC Community Pediatricians

Allergy/ Immunology

Aerodigestive Clinic

Ciliary Dysfunction Clinic EoE Clinic Laryngoscopy EGD DLB

Bronchoscopy Ciliary Biopsy

FESS/FEES

nNO Video

Microscopy Genetics

PSG/Treatment

Food Allergies EoE Treatment

SPT RAST

AIT Immune W/U

Functional Studies PFTs, FeNO +/- CXR, PSG

Screening Labs (no OCS x 4 weeks)

CBC w/ Differential IgE, Vit D+/- IgA

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Medication USE WITH

SPACER?** Total Daily Dose

0-4 years 5-11 years ≥12 years Beclamethasone

(QVar Redihaler)

40 or 80 mcg/puff

NO

(has built in

spacer, but can

be manually

converted to

use with a

spacer) – Qvar

HACK

NA (L): 80-160 mcg

(M):>160-320 mcg

(H):>320 mcg

(L): 80-240 mcg

(M):>240-480 mcg

(H): > 480 mcg

Budesonide Nebules

(Pulmicort)

0.25, 0.5 or 1 mg

NO

(nebulized) (L): 0.25-0.5 mg

(M):>0.5-1 mg

(H): > 1 mg

(L): 0.5mg

(M):1 mg

(H): 2 mg NA

Fluticasone HFA/MDI

(Flovent HFA)

44, 110, 220mcg/puff

YES (L): 176 mcg

(M): > 176-352mcg

(H): > 352 mcg

(L): 88-176 mcg

(M): > 176-352 mcg

(H): > 352 mcg

*REQUIRES PRE-AUTH

(L): 88-264 mcg

(M): > 264-440 mcg

(H): > 440 mcg

Fluticasone DPI:

(Flovent Diskus)

50, 100 or 250 mcg/puff

NO NA

(L): 100-200 mcg

(M): > 200-400 mcg

(H): > 400 mcg

(L): 100-300 mcg

(M): > 300-500 mcg

(H): > 500 mcg Fluticasone*

(Arnuity Ellipta)

50, 100, 200 mcg

* once daily dosing

NO

NA 50mcg available but not

FDA approved

(L): 100mcg

(M): NA

(H): 200mcg

Mometasone

(Asmanex Twisthaler)

DPI: 110mcg,

220mcg/inhalation

NO

NA (L): 100-110 mcg

(M): >200-440 mcg

(H): > 440 mcg

(L): 100-220mcg

(M): >200-440 mcg

(H): > 440 mcg (Asmanex HFA)

HFA: 100 mcg,

200mcg/inhalation

YES

DPI – Dry Powder Inhaler HFA – Hydrofluoroalkane MDI – Metered-dose inhaler

(L): Low daily dose (M): Medium daily dose (H): High daily dose

BID: twice a day mcg – microgram mg - milligram

NA – Not available (not approved, no data available, or safe and efficacy not established in this age group)

Note: Doses are per NAEPP update in September 2012 except for (*)

Inhaled Corticosteroids Equivalency Chart for AmeriHealth DC (beginning February 2020) Notes: Based on consensus opinion of IMPACT DC. Preferred (due to age considerations and inhaler design) and covered medications are highlighted in BOLD.

Also it is preferred to administer 2 puffs of HFA per dose (not 1 puff with each dose). For reference, the guidelines above are from the NAEPP 2012 Update. More recent ICS dosing guidelines from GINA 2018 are below (http://ginasthma.org):

From AmeriHealth • AmeriHealth Caritas DC enrollees age 11 and younger can continue to fill Flovent HFA prescription without prior –authorization. • AmeriHealth Caritas DC enrollees age 12 and older can continue to fill Flovent HFA prescriptions through February 1, 2020 without prior-authorization. After this date, Flovent HfA prescriptions for this group of enrollees will only be filled when there is an approved prior -authorization request based on medical necessity by the treating provider. Note: For any AmeriHealth Caritas DC enrollee impacted by this change (those age 12 and over) who has an active prescription for Flovent, the pharmacies can use the 72-hour hold over supply code to process these prescriptions. We will send a communication out to the pharmacy network regarding the change.

Spring Medicaid Formulary 2020 - DC

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Spring Medicaid Formulary 2020 - MD

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Questions?

For more information, visit our website:

http://pediatrichealthnetwork.org

Email us at:

phn@childrensnational.org

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