Danielle Gilliam M.D., PGY III University of South Alabama Pediatrics 2011

 Most common childhood chronic disorder  Increase in incidence by 50 % over the last two decades  In 2007, 9% of children 0 to 17 years of age (6.7 million children) had asthma, according to data from the National Health Interview Survey.

 The cost of illness related to asthma is around $6.2 billion per year in the United States.  Each year, an estimated 1.81 million people with asthma require treatment in the emergency department with approximately 500,000 hospitalizations

 Family Hx of asthma  Prematurity  Race ( African and Native Americans )  Low socioeconomic settings  Urban settings ( pollutants )  Increased indoor irritants ( cigarette smoke, dust mites, pets, recycled air )  History of Atopy ( eczema, allergies and chronic rhinitis / sinusitis )

 Cough ( mostly dry and hacking, specially at night ),  Wheezing ( mainly expiratory)  Shortness of Breath  Chest Pain  Precipitating factors [(URIs mostly viral occasionally atypical pneumonia. Bacterial causes very rare)], exercise, cold weather, allergens, cigarette smoke)  Increased AP diameter of the chest with hyperinflation  A silent chest is a medical emergency

 Detailed history of the symptoms  Physical exam  Spirometry with reduced FEV1 < 80 % and FEV/FVC < 65 % indicative of airflow obstruction ( children in which spirometry is not possible a trial of asthma meds should be done if indicated by other sxs )  Ancilliary studies ( bronchoprovocative testing, CXR, sweat chloride test, barium swallow and skin testing)

 Asthma  Bronchiolitis (esp in infants), bronchitis, laryngotracheobronchitis, tracheitis  Foreign body aspiration  Functional abnormalities ( GERD, CF, BPD, immunodeficiency etc )  Structural abnormalities ( laryngo- tracheomalacia, vascular rings, tracheal stenosis / webs, tumors etc )

 Assessment of impairment – Has your asthma awakened you at night or in the early morning? – Have you needed your quick-acting relief medication more than usual? – Have you needed any unscheduled care for your asthma, including calling in, an office visit, or going to the emergency room? – Have you been able to participate in school/work and recreational activities as desired?

 Avoidance of risk factors  Exercise induced bronchospasm : short acting beta agonists ( albuterol ) min prior to activity  Intermittent : Rescue albuterol treatments as needed, systemic corticosteroids reserved for severe exacerbation  Mild Persistent : Low dose inhaled corticosteroids (ICS) (e.g. Pulmicort, Asmanex, Flovent, QVAR)  Moderate persistent : Low to medium dose ICS and either a long acting beta agonists ( Foradil, Serevent ) or a leukotriene modifier ( Singulair )  Severe Persistent : High dose ICS and a long acting beta agonist. Advair ( Fluticasone + Salmeterol )

 Controller medications: ◦ Inhaled corticosteroids, ◦ Inhaled cromolyn or nedocromil,cromolyn ◦ Long-acting bronchodilators (Salmeterol), ◦ Leukotriene antagonists (Montelukast) Rescue medications: Short-acting bronchodilators, Systemic corticosteroids Inhaled ipratropium or atroventipratropium

DrugsProduct Availability Beclomethasone MDI (QVAR) 40 mcg to 80mcg/ inh Fluticasone HFA MDI (Flovent) 44 mcg, 110 mcg, 220 mcg/inh 50 mcg, 100 mcg, 250 mcg/inh Mometasone DPI (Ventolin) 110 mcg, 220 mcg/inh COMBOS Fluticasone + Salmeterol (Advair) Diskus (all have 50 mcg salmet) HFA (all have 21 mcg salmet) 100/50, 250/50, 500/50 mcg/inh 45/21, 115/21, 230/21 Budesonide + Formoterol (Symbicort) HFA and MDI 80/4.5 mcg, 160/4.5 mcg Side Effects: Common= couph, dysphonia, oral candidiasis, upper RTI, throat irritation Serious= decreased growth velocity in children, HPA suppresion, reduced bone mineral density, cataracts (dose and duration dependent) Combo meds= above +Headache, dizziness, palpitations, tremor

 Evaluate treatments every 2-3 months and step down as appropriate or go up on the dose of ICS for recurrent exacerbations  ICS and long acting beta agonists have proven better efficacy compared to alternative treatments ( leukotriene modifiers, cromolyn. theophylline )  Studies have shown MDIs with spacers to be more efficacious and practical than nebulizers in routine application

 Asthma exacerbation is a medical emergency. Don’t delay evaluation and treatment. 1) Early/Immediate Phase : characterized by bronchoconstriction. 2) Late Phase (6-8 hours) : airway inflammation and hyper-responsiveness  Management should emphasize ◦ 1) Initial stabilization ◦ 2) progressive monitoring and treatment ◦ 3)eventually discharge planning

 O2 to keep sats >92%  Bronchodilators : Beta Agonist (Albuterol) : via nebulizer Q minutes times three then Q2 twice if needed and then Q4-6 hrs ATC/PRN If needed more frequently PICU admisision Ipratropium ( Atrovent ) via nebulizer may be given with the first three albuterol treatments then Q4-8 ATC/PRN Levalbuterol ( Xopenex ) : selective beta 2 agonist. Not routinely used. Good alternative for continuous therapy if side effects from albuterol experienced

 Start Corticosteroids if; ◦ No response after one nebulised t/t ◦ Patient is steroid dependent ◦ Has had a recent ER visit for asthma ◦ Previous admission to ICU  Steroid PO (Prednisolone 2mg/k/d) or Steroid IV (Solumedrol 2mg/k IV/IM bolus then 1-2mg/k/d divided Q6) x 3-10 days  If greater than 5 day course, will need to wean

 Continuous Albuterol  Magnesium Sulfate (IV)  IV Terbutaline or Epinephrine  Ketamine  Intubation for respiratory failure  Heliox  Solumedrol IV  Use of ketamine in acute severe asthma  V. J. Sarma 30 DEC 2008  Randomized, Double-Blind, Placebo-Controlled Trial of Intravenous Ketamine in Acute Asthma,  Joseph C Howton MD, John Rose MD, Scott Duffy MD, Tom Zoltanski and M.Andrew Levitt DO  28 November 1994;

 Wean oxygen as tolerated  Advance diet as tolerated and wean IVF accordingly  Social services consult : home nebulizer, supplies, insurance issues  Respiratory Consult : teaching nebulizer / MDI treatments  Prescribe controller meds according to classification  Finish course of antibiotics and steroids  F/U with pediatrician: two to three days