CPD 1-CPG for the Management of Childhood Asthma

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Clinical Practice Guidelines for the Management of Childhood Asthma 2014 Prepared by: Marlyna Suhaida Rosly Pegawai Farmasi U44 Hospital Pakar Sultanah Fatimah Checked by: Low Yee Shan Pegawai Farmasi U44 Hospital Pakar Sultanah Fatimah

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Transcript of CPD 1-CPG for the Management of Childhood Asthma

  • Clinical Practice Guidelines for the Management of Childhood Asthma2014Prepared by:Marlyna Suhaida RoslyPegawai Farmasi U44Hospital Pakar Sultanah Fatimah

    Checked by:Low Yee ShanPegawai Farmasi U44Hospital Pakar Sultanah Fatimah

  • *List of Contents:Definition of asthmaDiagnosisSeverity & assessmentGoals of therapyManagement of asthma

  • *Definition of AsthmaA heterogenous condition characterised by paroxysmal or persistent symptoms such as dyspnoea, chest tightness, wheezing & cough against a background of chronic persistent inflammation and/or;structural changes associated with variable airflow inflammation & airway hyper-responsiveness1,2

  • *DiagnosisPresentationDifferential diagnosisInvestigations

  • PresentationRecurrent episodes of one or more of the following symptoms of wheeze, cough, and shortness of breath and chest tightness usually precipitated by allergen exposure, viral infections or exerciseAt least 50% of children will have had one episode of wheezing by the age of six years but less than half of them have asthma. Thus, recommended to define pre-school wheezing into 2 main categories

  • *Presentation (cont.)Wheezing3episodic: children who wheeze with viral infections but are well between episodesmultiple-trigger: children who have discrete exacerbations & also symptoms in between these episodesPresence of atopy (eczema, allergic rhinitis & conjunctivitis) in the child or family supports the diagnosis of asthma4

  • Asthma Predictive Index*Doctor-diagnosedAsthma predictive index can be helpful in predicting asthma in young childrenA child with negative predictive index will have a 95% chance of not having asthma by the age of 6 yearsThose with positive predictive index will only have a 65% chance of having asthma

    Positive index ( > 3 wheezing/year first 3 years) plus 1 major criteria or 2 minor criteriaMajor : Eczema* Parental asthma*Minor : Allergic rhinitis* Wheezing apart from cold Eosinophilia ( 4 %)

  • *Chronic cough and/or wheezing in young children may be due to other conditionDifferential diagnosis for chronic cough and/or recurrent wheezeAdapted from NIH guidelines 2007: EPR 3 Guidelines for the diagnosis and management of asthma: http;//www.nhlbi.nhi.gov/guidelines/asthmaasthgdln.htm

  • InvestigationsDiagnosis of asthma is based on a good history & physical examinationSupportive features in diagnosis of asthma include response to bronchodilator therapy, that is, symptomatic improvement in the younger children or improvement in Peak expiratory flow rate (PEFR) >20% or Forced expiratory volume in 1 sec (FEV1) >12% 5,6Other supportive features of asthma; raised exhaled nitric oxide & positive skin prick tests to aeroallergens7,8,9

  • *Investigations (cont.)Chest x-raySinus x-rayHigh Resolution Computer Tomography (HRCT) thorax scan

    Lung function testsImmune function testEchocardiogramMantoux test

    Investigations that may be necessary to exclude other conditions in atypical cases:

  • Asthma Severity & AssessmentAsthma Management Handbook. National Asthma Council Australia and the Asthma Foundations. Content created (Thursday 16 November 2006). Last updated 31 May 2007

  • Goals of TherapyMaintenance of normal activities including the ability to exerciseNo absence from schoolNo visits to the emergency department or any hospitalisation due to asthma exacerbationNo mortalityNo side effects from medication

  • *Management of AsthmaPatient educationAvoidance of trigger factors Optimisation of pharmacotherapy

  • Patient EducationExplain the disease nature & its treatmentRecognise signs & symptoms of asthma, avoid trigger factors & understand the causal disease mechanismInformation about medications- indications, dosages, timing & technique of using the deviceInstructions on self-management, written asthma plansEducate on exercise; e.g. swimming & sports

  • *Avoidance of trigger factorsSmoking & air pollutants Environmental allergensObesityFood & medication allergyRespiratory tract infectionsExercise

  • *Prevention1.Smoking & air pollutantsEnvironmental tobacco smoke (ETS) risk for developing asthma symptoms at any age during childhood10Infants: frequency of lower respiratory tract infectionChildren: > frequent asthma exacerbationsSmoking during pregnancy results in impaired lung growth in the developing foetus wheezing in early life11Other pollutants: traffic/industry, mosquito coil smoke

  • *Prevention (cont.)

    2.Environmental allergense.g: house dust mite (D. pteronyssinus, D. farinae), cat & dog dander, cockroach, fungi, pollenEarly sensitisation can risk of persistent asthma & bronchial hyperresponsiveness with lung function12 exposure to allergens by environmental intervention can asthma-associated morbidity in children with atopic asthma133.Obesity incidence of asthma in obese children14A strong predictor of the persistence of childhood asthma into adolescence15Requires additional studies to clarify relationship between obesity-asthma for effective intervention

  • *Prevention (cont.)

    4.Food & medication allergye.g: cow's milk, egg, soy & wheat usually resolved by 5 y/o peanuts, tree nuts, fish & shell fish usually persists16Limited data on the effect of food avoidance/supplementation on asthmaDeprivation of food items is not necessary unless there is clear & reproducible link between ingestion of an offending food & allergy symptoms or asthma exacerbationsFood additives (e.g. MSG, sulphites, dyes) may induce lower airway symptoms17

  • *Prevention (cont.)5.Respiratory tract infectionscommonest triggers of asthma exacerbations: rhinovirus, respiratory synctial virus, human metapneumovirus186.Exercisecan trigger asthma symptoms but important for children's growth & developmentExercise intolerance may indicate inadequate asthma control requires further evaluation & treatment optimisation

  • *Optimisation of drug therapyReliever therapyPreventer therapy

  • Algorithm for the long term management of asthmarelieverpreventer

  • Reliever therapyDrug of Choice: short acting 2-agonist (SABA)Routine oral bronchodilator use is discouraged due to:- Narrow therapeutic indexErratic GI absorption that results in variable & inconsistent efficacy20*

  • Preventer therapy Parameters that determine the choice of preventer therapy & duration of treatment21:Age of childFrequency & severity of symptomsAsthma wheeze phenotypeDrug of Choice: Inhaled corticosteroids (ICS)22most appropriate for multi-trigger wheeze & atopic asthmaICS reduce asthma symptoms & prevent asthma associated hospitalisation & asthma related deathStandard ICS dose have not been shown to be beneficial in episodic viral wheeze23 while intermittent high dose provides a modest benefit but with significant adverse effects24*

  • Preventer therapy (cont.) Leukotriene receptor antagonist (LRA)used as a long term preventer in mild persistent asthmaintermittent course may have some clinical benefit in episodic viral wheeze25e.g.: Montelukast Long acting 2-agonist (LABA)added when asthma symptoms cannot be controlled with standard doses of ICS26must be used in combination, NEVER as monotherapycombination of ICS-LABA is superior than ICS-LRA27e.g.: Formoterol, Salmeterol

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  • Reduction in therapyWhen asthma control is achieved for at least three months, a step down approach must be considered from current treatment level.Evaluation of asthma control28

  • *Special Categories of AsthmaIntermittent severe asthmaNocturnal asthmaExercise induced asthma (EIA)Brittle asthmaDifficult asthma

  • Special Categories of AsthmaIntermittent severe asthmasevere, life-threateningfirst sign of an attack should be treated with inhaled SABA + oral steroidrisk factors are not clearly identified; may be associated with atopic disease322.Nocturnal asthmacommonest indicator of suboptimal treatment & instabilitycontrolled by ICSadd LABA to relieve uncontrolled symptoms & morning dip in lung function29

  • Special Categories of Asthma (cont.)3.Exercise induced asthma (EIA)Affects 40-90% of children but often undiagnosed30A transient in airway resistance d/t bronchoconstriction that occurs following 6-8 mins of strenuous exercise31Needs anti-inflammatory therapy optimisationControl further symptoms by administer SABA 10-20 mins before exercise27

  • Special Categories of Asthma (cont.)4.Brittle asthmaunstable asthma which is unpredictableRare, occurs in only 0.05% of all asthmatic patientsType I: persistent & chaotic variability in PEF (usually >40% diurnal variation in PEF for >50% of time) despite considerable medical therapyType II: sporadic sudden falls in PEF on a background of normal lung function & well-controlled asthma32This group of asthma patients should be referred for specialist care5. Difficult asthmaAsthma not controlled in spite of ICS doses of 800 mcg/day of budesonide equivalent33Must rule out other important contributors; e.g. misdiagnosis, poor adherence, poor inhalation technique, co-morbidities & persistent exposure to allergensThis group of asthma patients should be referred for specialist care

  • Inhaler DevicesInhalation is the preferred route of administrationDelivery system according to the childs age

    Home nebuliser therapy: expensive & less efficient than spacer devices

  • *Assessment of severity of acute asthma exacerbation for children

  • Adapted from British Guidelines on the Management of Asthma. The British Thoracic Society & Scottish Intercollegiate Guidelines Network (SIGN) May 2006.

  • *Algorithm for management of acute exacerbation of bronchial asthma in children

  • 1st line treatment for acute asthmaAdminister rapidly after a quick history, physical examination, & vital examination

  • To hasten recoveryshould be given earlyParenteral route for children who are vomiting/unable to tolerate orally/ children with moderate to severe or life threatening acute exacerbationsduration: 3-5 days (weaning only if course of steroids 14 days)For patients with moderate to severe acute asthma exacerbation/ those not responding to SABA aloneFor children with severe/life-threatening asthma unresponsive to maximal dose of bronchodilators+steroid (in a HDU or PICU setting)Adjunct treatment in severe/life-threatening exacerbations unresponsive to initial standard treatment

  • Long term Asthma Monitoring & Follow Up1. Maintain patient with the lowest dose of maintenance therapy once asthma control is achieved2. Issues need to be addressed on each follow up visit:Degree of asthma controlCompliance to asthma therapy (frequency & technique)Asthma education3. Identify and closely monitor patients with high risk of developing near fatal asthma (NFA) or fatal asthma

  • Evaluation of asthma control19

  • Asthma Action Plan (AAP) A written asthma action plan detail for the individual patient on the daily management (medication & environmental control strategies) & how to recognise & handle worsening asthma AAP should include35:Recommended doses & frequencies of daily medicationsMedicine adjustment instructions at home in response to particular signs, symptoms, peak flow measurementEmergency contact numbersA list of trigger factors that may cause an asthma attack, thus, to help inform others & the patient of what triggers to avoidPEF monitoring is recommended for moderate to severe asthma

  • ReferencesReddel HK, Taylor R, Bateman ED, Boulet LP, Homer A, et al. An Official American Thoracic Society/European Respiratory Society Statement: Asthma Control and Exacerbations. Standardising Endpoints for Clinical Asthma Trials and Clinical Practice on behalf of the American Thoracic Society/European Respiratory Society Task Force on Asthma Control and Exacerbations. AmJRCCM 2009;180:59-99.Becker A, Berube D, Chad Z, Dolovich M, Ducharme F et al. Canadian Paediatric Asthma Consensus Guidelines 2003 (updated to December 2004) CMAJ 2005;173:S12-S14.Brand PLP, Baraldi E, Bisgaard AL, Boner JA, Castro-Rodriguez et al. ERS TASK FORCE: Definition, assessment and treatment of wheezing disorders in preschool children: an evidence based approach. Eur Respir J 2008; 32: 1096-1110.Bosquet J, Kjellman NI. Predictive value of tests in childhood allergy. J Allergy Clin Immunol 1986; 78: 1019-1022.Mueller GA, Eigen H. Pediatricfunction testing in asthma. Pediatr Clin North Amer 1992; 39: 1243-1258.Pellegrino R, Viegi G, Brusasco V, Crapo RO, Burgos F et al. Series ATS/ERS Task Force: standardisation of lung function testing. Interpretative strategies for lung function tests. ERJ 2005; 26: 948-968.Chan EY, Dundas I, Bridge PD, Healy MJ, McKenzie SA. Skin prick testing as a diagnostic aid for childhood asthma. Pediatr Pulmon 2005; 39: 558-562.Baraldi E, Dario C, Ongaro R et al. Exhaled nitric oxide concentrations during treatment of wheezing during exacerbations in infants and young children. Am J Respir Crit Care Med 1999; 159: 1284-1288.Moeller A, Franklin P, Hall GL. Et al. Inhaled fluticasone dipropionate decreases level of nitric oxide in recurrent wheezy infants. Pediatric Pulmonol 2004; 38: 250-255.Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M, Morgan WJ. Asthma and wheezing in the first six years of life. The group Health Medical Associates. N Engl J Med 1995; 332; 133-138 .11 .Milner AD, Rao H, Greenough A. The effects of antenatal smoking on lung function and respiratory symptoms in infants and children. Early human development 2007; 83: 707-711.Platts-Mills TAE, Rakes GP, Heymann PW. The relevance of allergen exposure to the development of asthma in childhood. J Allergy Clin Immunol 2000; 105: S503-S508.Morgan WJ, Crain EF, Gruchalla RS, OConnor GT, Kattan M, Evans R et al. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med 2004; 351: 1068-1080.Belamaric PF, Luder E, Kahan M, Mitchell H, Islam S, Lynn H, Crain EF. Do obese inner city children with asthma have more symptoms than non-obese children with asthma. Pediatrics 2000; 106: 1436-1441.Shore SA, Fredberg JJ. Obesity, smooth muscle, and airway hyperresponsiveness. J Allergy Clin Immunol 2005; 115: 925-927.Hourihane JO, Roberts SA, Warner JO. Resolution of peanut allergy: case control study. BMJ 1998; 316: 1271-1275.17.Bird JA, Burks AW. Food allergy and asthma. Primary Care Respiratory Journal 2009; 18(4): 258-265.18.Yadav R. Viruses associated with acute exacerbation of bronchial asthma among children in University Malaya Medical Centre. Malaysian J Paed Child Health 2012; 18(1): online.

  • References19.Niggemann B, Wahn U. Three cases of adolescent near-fatal asthma: what do they have in common? J asthma 1992; 29(3): 217-220.20.Selective beta2 agonist-side effects. British National Formulary (5th ed.) London. BMJ Publishing Group Ltd and Royal Pharmaceutical Society Publishing. March 2008.Bis gaard H, Szefler S. Prevalence of asthma-like symptoms in young children. Pediatr Pulmonol 2007; 42: 723-728.Castro-Rodriguez JA, Rodrigo GJ. Efficacy of inhaled corticosteroids in infants and pre-schoolers with recurrent wheezing and asthma. N Eng J Med 2000; 343: 1054-1963.Wilson N, Sloper K, Silverman M. Effect of continuous treatment topical corticosteroid on episodic viral wheeze in pre-school children. Arch Dis Child 1995; 72: 317-320.McKean M, Ducharme F. Inhaled steroids for episodic viral wheeze of childhood. Cochrane Database Syst Rev 2000; (2): CD001107. Review. Bisgaard H, Zielen S, Garcia-Garcia ML et al. Montelukast reduces asthma exacerbations in 2 to 5 year-old children with intermittent asthma. Am J Respir Crit Care Med 2005; 171: 315-322.Lemanske RF, Mauger DT, Sorkness CA et al. Step up therapy for children with uncontrolled asthma receiving inhaled corticosteroids. N Eng J Med 2010; Mar 18; 362(11): 975-985.Ducharme FM, Lasserson TJ, Cates CJ. Long acting beta2 agonists versus anti-leukotrienes as add-on therapy to inhaled corticosteroids for chronic asthma. Cochrane Database Syst Rev 2006; CD003137. Review.Asthma Management Handbook. National Asthma Council Australia and the Asthma Foundations. Content created 16 November 2006. Last updated 31 May 2007.Bacharier LB, Philips BR, Bloomberg GR et al. Severe intermittent wheezing in preschool children: a distinct phenotype. J Allergy Clin Immunol 2007; 119: 604-610.Milgrom H, Taussig LM. Keeping children with exercise induced asthma active. Pediatrics 1999; 104: e38.Hallstrand TS, Curtis JR, Koepsell TD et al. Effectiveness of screening examinations to detect unrecognised exercise induced bronchoconstriction. J Paediatr 2002; 141: 343-348.Khajolia R. Exercise induced asthma: fresh insights and an overview. Malaysian Fam Physician 2008; 3(1): e1985-2274.Ayres JG, Miles JF, Barnes PJ. Brittle asthma. Thorax 1998; 53: 315-321.Mitchell I, Tough SC, Semple LK, Green FH, Hessel PA. Near-fatal asthma: study of risk factors: a population-based. Chest 2002; 121: 1407-1413.Global Initiative for Asthma (GINA) A Pocket Guide for Physicians and Nurses Based on Global Strategy for Asthma Management & Prevention for Adults & Children Older than 5 Years Old, 2009.

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