1. Pediatric Asthma Miami-Dade County Public Schools Physical Education and Health Literacy

2. Objectives Overview of asthma Review guidelines for asthma treatment
Review other management strategies for asthma

3. What is Asthma Disease of chronic airway inflammation Characterized by
Airflow obstruction
Airway hyperresponsiveness

4. Pathophysiology Caused by Inflammation and edema
Bronchial smooth muscle spasm and hypertrophy
Mucous plugging

5. Asthma in Children
Asthma is the most common chronic disorder of childhood
Over 9 million children under the age of 18 in the US have been diagnosed with asthma
The disparity between Black and white non-Hispanic children is increasing
Asthma morbidity and mortality is increasing as well

6. The Burden of Asthma in Children
1 million US children <18 y/o experience some degree of disability due to asthma
Disabling asthma disproportionately affects Blacks and Hispanics, single-parents, lower SES
Disabling asthma lead to ~3 weeks of restrictive activity per year higher than other chronic medical conditions
9.7 school days/year
~9.2 physicians contacts/year

7. Asthma Etiology Asthma is a complex trait Multiple interacting genes
Heritable and environmental factors contribute to its pathogenesis
Multiple interacting genes
At least 20 distinct chromosomal regions with linkage to asthma and asthma related traits have been identified
Chromosome 5q – cytokine gene cluster
ADAM33 – bronchial hyperresponsiveness
PHF11 – total IgE

8. Hygiene Hypothesis Environmental impact on asthma Farm exposure
Day care/siblings
Pets
Early infections

9. Diagnosing Asthma
Clinical diagnosis supported by the certain historical, physical and laboratory findings
History of episodic symptoms of airflow obstruction
Physical: wheeze, hyperinflation
Laboratory: exhaled nitric oxide (eNO), spirometry
Exclude other possibilities

10. Conditions Mimicking Asthma
Obstruction of small airways
Aspiration
Chronic lung disease secondary to prematurity
Bronchiolitis
Cystic Fibrosis
Obstruction of large airways
Foreign body
Congenital malformations
Cardiac disease
Endobronchial tumors
Extrabronchial obstruction
Psychogenic

11. "Rules of Two" is a trademark of the Baylor Health Care System
Rules of TwoTM
Use of a quick-relief inhaler more than: 2 times per week
Awaken at night due to asthma symptoms more than: 2 times per month
Refill of a quick-relief inhaler prescription more than: 2 times per year
"Rules of Two" is a trademark of the Baylor Health Care System

12. Goals of Treatment
SLEEP
LEARN
PLAY

13. Key Components of Asthma Therapy
Assessment and monitoring
Pharmacologic therapy
“Trigger” control
Patient education

14. Inhaled Corticosteroids
Preferred treatment alone or in combination for all persistent categories of asthma
Safe when use is monitored
Reduces asthma symptoms, bronchial hyperreactivity, exacerbations and hospitalizations, need for rescue medications
Improves pulmonary function, quality of life
May prevent airway remodeling

15. Other Management Issues
Environmental control
“Safe” room
Diet
Infant feeding
Sodium
Fatty acids
Antioxidants

16. Is Environmental Control Helpful?
Single allergen reduction not effective
“…Treatment by means of allergen avoidance requires the definition of what patients are allergic to, and additional measures beyond the use of mattress covers and education” Thomas Platts-Mills

17. Diet and Asthma
High sodium diet may result in adverse effects on airway reactivity in patients with asthma
No recommendation to implement low salt diets
Potassium and Magnesium effect unclear
Tartazine exclusion not helpful except perhaps those with proven sensitivity

18. Diet and Asthma Breast feeding
Exclusive breast feeding > 4 months
Protective against recurrent wheeze
Higher odds of asthma in children who are atopic and have a mother with asthma
Maternal avoidance diets during pregnancy does not affect incidence of asthma
Utilization of protein hydrolyzed formulas have not been shown to reduce incidence of asthma
Probiotics supplementation has demonstrated decrease in atopy, but asthma is unknown

19. Diet and Asthma Polyunsaturated fatty acids
Omega 3’s vs. Omega 6’s
Omega 6 fatty acids, present in animal fat, metabolized to arachidonic acid generating potent inflammatory mediators and broncho-constricting agents
Omega 3 fatty acids, found particularly in fatty fish are metabolized to eicosapentaenoic acid (EPA) and docosahexaenoic acid
May competitively inhibit the use of arachidonic acid as a substrate for the production of pro-inflammatory mediators such as prostaglandins and leukotrienes
Theoretical benefit to lung function, but not conclusively proven in studies
Trans fatty acids associated with prevalence of asthma, allergic conjunctivitis, and atopic eczema

20. Diet and Asthma Antioxidants
Epidemiological evidence suggests that antioxidants have a role in asthma
Randomized trials
No current role for Vitamin C in the treatment of asthma
Vitamin E supplementation provides no additional benefit to standard treatment of asthma
No substantiated role for Β-carotene supplementation in asthma

21. Asthma Education Self management education associated with:
Improvements in airflow
Improvements in self-efficacy scales
Reductions in school absence
Reduction in days of restricted activity
Reduction in emergency room visits

22. Summary
Asthma is a disease of chronic airway inflammation; thus, inhaled corticosteroids is the preferred pharmacologic therapy
Persistent asthma (those who break the “rules of two”) need a controller medication
Children with asthma should all be able to sleep, learn, and play