1. An Update in Pediatric Asthma DR.NUFOUD AL- SHAMMARI CONSULTANT PEDIATRIC PULMONOLOGIST CHAIRPERSON OF MUBARK AL-KABEER HOSPITAL KUWAIT

2. ASTHMA WHY ARE WE CONCERNED?

3. Why are we Concerned?  Currently, asthma represents the most common chronic diseases in children.  The prevalence is predicted to increase substantially over the next two decades.  Asthma imposes a significant burden on the health care system.  Asthma costs are directly related to patient’s level of asthma control.

4. Why are we concerned ?  Predicting patients at highest risk for increased health care could facilitate improved clinical management and in turn could reduce the economic burden of this disease.  Poorly controlled asthma is expensive  Investment in prevention is likely to yield cost savings in emergency care.  It is a major cause of school and work absence.

5. Mortality Morbidity Asthma

6. What is Asthma ???  Asthma is a common and potentially serious chronic disease that can be controlled but not cured.  It is a heterogeneous disease, usually characterized by chronic airway inflammation.  Asthma causes symptoms such as : -Wheezing -Shortness of breath -Chest tightness and cough

7. What is Asthma ???  Symptoms are associated with variable expiratory airflow i.e. difficulty breathing air out of the lungs due to : -Bronchoconstriction ( airway narrowing ) -Airway wall thickening -Increased mucus  Symptoms may be triggered or worsened by factors such as viral infections, allergens, tobacco smoke, exercise and stress.

8. Source: Peter J. Barnes, MD Asthma Inflammation

9. History and patterns of symptoms Measurements of lung function -spirometry -Peak expiratory flow Measurement of airway responsiveness Measurements of allergic status to identify risk factors. Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly How can we diagnose Asthma?

10. Can we Prevent Asthma? The development and persistence of asthma are driven by gene-environment interactions. Allergen avoidance if directed at a single allergen have not been affective Current recommendations are: -Avoid exposure to tobacco -Encourage Vaginal Delivery -Advise breast-feeding for its general health benefits

11. Can asthma be treated ??  Asthma can be effectively treated.  When asthma is well controlled, patients :  Need less reliever medications.  Be physically active.  Have normal or near normal lung function.  Avoid serious asthma exacerbations.

12. Patients at increased risk of asthma-related death should be identified -Any history of near-fatal asthma requiring intubation and ventilation -Hospitalization or emergency care for asthma in last 12 months. -Not currently using ICS, or poor adherence with ICS. -Currently using or recently stopped using OCS(indicated the severity of recent events) Who are the patients at risk of asthma related death?

13. Over-use of SABAs, especially if more than 1 canister/month -Lack of written asthma action plan -History of Psychiatric disease or psychosocial problems. -Confirmed food allergy in patient with asthma. Flag these patients for more frequent review.

14. All patients should have a written asthma action plan -The aim is to show the patient how to recognize and respond to worsening asthma -It should be individualized for the patient’s medications, level of asthma control and health literacy -Based on symptoms and/or PEF(children: only symptoms) Written asthma action plans

15. The action plan should include: -The patient’s usual asthma medications -When/how to increase reliever and controller or start OCS -How to access medical care if symptoms fail to respond Why? -When combined with self-monitoring and regular medical review, action plans are highly effective in reducing asthma mortality and morbidity.

19. What’s new in GINA 2015 (1)  Add-on tiotropium by soft-mist inhaler is a new ‘other controller option’ for Steps 4 and 5, in patients ≥18 years with history of exacerbations  Tiotropium was previously described in GINA as an add-on option on the basis of clinical trial evidence.  It is now included in recommendations and the stepwise figure following approval for asthma by a major regulator.

20. GINA 2015 – changes to Steps 4 and 5 © Global Initiative for Asthma GINA 2015, Box 3-5, Steps 4 and 5 *For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS **For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy # Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of exacerbations; it is not indicated in children <18 years. Other controller options RELIEVER STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 Low dose ICS Consider low dose ICS Leukotriene receptor antagonists (LTRA) Low dose theophylline* Med/high dose ICS Low dose ICS+LTRA (or + theoph*) As-needed short-acting beta 2 -agonist (SABA) Low dose ICS/LABA* Med/high ICS/LABA Refer for add-on treatment e.g. anti-IgE PREFERRED CONTROLLER CHOICE Add tiotropium# High dose ICS + LTRA (or + theoph*) Add tiotropium# Add low dose OCS As-needed SABA or low dose ICS/formoterol**

21. What’s new in GINA 2015 (2)  Management of asthma in pregnancy  Monitor for respiratory infections and manage them appropriately, because of increased risk of exacerbations  Management of asthma during labor and delivery  Give usual controller, and SABA if needed, e.g. following hyperventilation  Watch for neonatal hyperglycaemia (especially in preterm babies) if high doses of SABA used in previous 48 hours  Breathing exercises  Evidence level down-graded from A to B following review of quality of evidence and a new meta-analysis (Freitas, Cochrane 2013)  The term breathing exercises’ is used, rather than ‘breathing techniques’, to avoid any perception that a specific technique is recommended

22. What’s new in GINA 2015 (3)  Mild or moderate exacerbations  Dry powder inhalers as effective as puffer and spacer for delivery of SABA in worsening asthma or exacerbations (Selroos, Ther Deliv. 2014)  Note that studies did not include patients with severe acute asthma  Life-threatening or severe acute asthma in primary care  While arranging transfer to acute care facility, give inhaled ipratropium bromide as well as SABA, systemic corticosteroids, and oxygen if necessary  Pre-school children with acute exacerbations or wheezing episodes  Clarification that parent-administered oral steroids or high dose ICS are not generally recommended for pre-school children with acute wheezing or exacerbations  Respiratory infections and wheezing occur very frequently in this age-group  There is substantial concern about the risk of systemic side-effects, especially with repeated use  A new flow-chart for pre-school children is included in GINA 2015

23. GINA 2015, Box 6-8

24. Other changes for clarification in GINA 2015 update  Assessment of risk factors: over-usage of SABA  High usage of SABA is a risk factor for exacerbations (Patel et al, CEA 2013)  Very high usage (e.g. >200 doses/month) is a risk factor for asthma-related death (Haselkom, JACI 2009)  Beta-blockers and acute coronary events  If cardioselective beta-blockers are indicated for acute coronary events, asthma is not an absolute contra-indication.  These medications should only be used under close medical supervision by a specialist, with consideration of the risks for and against their use  Asthma-COPD Overlap Syndrome (ACOS)  The aims of the chapter are mainly to assist clinicians in primary care and non-pulmonary specialties in diagnosing asthma and COPD as well as ACOS, and to assist in choosing initial treatment for efficacy and safety  A specific definition cannot be provided for ACOS at present, because of the limited populations in which it has been studied  ACOS is not considered to represent a single disease; it is expected that further research will identify several different underlying mechanisms

25. Conclusion Asthma is a chronic disease that carries significant morbidity and mortality. Controlling asthma will improve peoples’ live’ and reduce cost

26. Thank You!!