1. Advances in Pediatric Asthma Care Keyvan Rafei, MD, MBA Division Head, Pediatric Emergency Medicine Chairman, Pediatric Asthma Program

2. Approximately 20 million Americans have asthma. Nine million U.S. children have been diagnosed with asthma. More than four million children have had an asthma attack in the previous year There are approximately 5,000 deaths from asthma annually.

4. Baltimore – Top 20 “most challenging places to live with asthma” – Rankings based on: Prevalence Factors – morbidity/mortality statistics Risk Factors – air quality, smoking laws and more Medical Factors – medicine use and access to doctors

11. Our Population

12. ds 20% Asthma Prevalence in Baltimore schools 640,000 Missed School Days in Maryland ~50% of Baltimore children with asthma had an ED visit in the previous 6 months 3 x higher hospitalization rates for children in Baltimore City than rest of the state and nation

13. “…the U.S. is missing the mark in terms of asthma care” Many Patients in Baltimore Are Uninformed – 68% believe there is a “strong need” for education – Only 14% could name inflammation as the underlying cause of asthma symptoms – Only 13% with persistent asthma take inhaled steroids – Only 27% say their doctor has developed an action plan

14. Acute Asthma

15. Chronic Asthma Acute Asthma

16. Pathophysiology of Asthma Focus of Education and Prevention Reason for ED Visit / Hospitalization

17. Focus of Education Emphasize Chronic Asthma & Asthma Control – Education with 123’s of Asthma – Assessment of Chronic Asthma Control Patient / Parent Perspective  ATAQ Questionnaire Healthcare Provider Perspective  Asthma Control Assessment

18. Needs of Our Population Quality Acute Care Better Asthma Education Improved Asthma Control Self- Management Tools

19. The Acute Care Opportunity

20. Pediatric Asthma Program Mission – To deliver the highest quality care to children with asthma Goal – Develop and implement an evidence-based asthma treatment program – Develop and implement a structured asthma education program – Optimize multi-disciplinary collaboration

21. Extra-Thoracic Airway Intra-Thoracic Airway

22. URI Croup Epiglottitis Asthma Bronchiolitis

23. Inhalation

24. Extra-Thoracic Obstruction e.g. URI, Croup, Epiglottitis – Mild Obstruction End Inspiratory Stridor Clear Exchalation – Moderate Obstruction Stridor throughout Inspiration Clear Exhalation – Severe Obstruction Stridor throughout Inspiration and Exhalation

25. Extra-Thoracic Obstruction Partial relief from obstruction during exhalation Exhalation

26. Exhalation

27. Intra-Thoracic Obstruction e.g. Asthma, Bronchiolitis Mild Obstruction End Expiratory Wheezing Clear Inhalation Moderate Obstruction Wheezing throughout Exhalation Clear Inhalation Severe Obstruction Wheezing throughout Inhalation and Exhalation Critical Obstruction Quite chest

28. Intra-Thoracic Obstruction Partial relief from obstruction during Inhalation Inhalation

29. Asthma Predictive Index One major criteria: – Parent with asthma – Physician diagnosed eczema – Sensitization to allergens in the air (e.g. trees, grasses, weeds, molds, or dust mites) Two minor criteria: – Evidence of food allergies – Increased blood eosinophilia – Wheezing apart from colds Castro-Rodriguez JA, et al. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med 2000; 162: 1403-1406.

30. Asthma Predictive Index One major criteria: – Parent with asthma – Physician diagnosed eczema – Sensitization to allergens in the air (e.g. trees, grasses, weeds, molds, or dust mites) Two minor criteria: – Evidence of food allergies – Increased blood eosinophilia – Wheezing apart from colds Castro-Rodriguez JA, et al. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med 2000; 162: 1403-1406.

31. Nebulizers or MDI’s ?

32. From: Rau JL. The inhalation of drugs: advantages and problems. Respir Care. 2005 Mar;50(3):367-82.

33. Nebulizer TherapyMetered Dose Inhaler

34. Nebulizer TherapyMetered Dose Inhaler Inhaled Aerosol Non-Inhaled Aerosol

35. Nebulizer TherapyMetered Dose Inhaler Inhaled Aerosol Non-Inhaled Aerosol

36. Nebulizer TherapyMetered Dose Inhaler

37. Nebulizer TherapyMetered Dose Inhaler Inhaled Aerosol Non-Inhaled Aerosol

38. Nebulizer TherapyMetered Dose Inhaler Inhaled Aerosol Non-Inhaled Aerosol

39. Nebulizer TherapyMetered Dose Inhaler Inhaled Aerosol Non-Inhaled Aerosol

40. Nebulizer TherapyMetered Dose Inhaler Inhaled Aerosol Non-Inhaled Aerosol

41. Hypoxia and Asthma Severe Asthma – Poor Ventilation Pneumonia – Poor Oxygenation Hypoxic At Triage

42. Hypoxia and Asthma Severe Asthma – Poor Ventilation Pneumonia – Poor Oxygenation Ventilation-Perfusion Mismatch – Develops hypoxia as a side effect of treatment – Hypoxia resolves with time – Frequently normal O2 Sat at Presentation Hypoxic At Presentation

43. AIR BLOOD Small Airways Arterioles Ventilation – Perfusion (VQ) Matched Normal O2 Saturation Ventilation Perfusion

44. AIR Small Airways Arterioles AIR ALBUTEROL (Bronchodilator) BLOOD Ventilation – Perfusion (VQ) Mis-Matched Hypoxic – Low O2 Saturation Asthma Ventilation Perfusion

45. Asthma Education

47. ATAQ – Asthma Therapy Assessment Questionnaire Asthma control from perspective of patient / parent – Asthma symptoms – Missed daily activities – Night-time awakenings – High use of Albuterol Scoring… – 0= Well controlled. – 1–2= Not well controlled. – 3–4= Poorly controlled

48. Asthma Control Assessment Assessment based on two factors… – Impairment Frequency and intensity of symptoms – Risk Likelihood of asthma exacerbations…

49. Asthma Control Assessment Symptom Frequency and Intensity Risk of Exacerbations

51. Advances in Pediatric Asthma Care Keyvan Rafei, MD, MBA Division Head, Pediatric Emergency Medicine Chairman, Pediatric Asthma Program