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Pediatric Asthma

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Pediatric Asthma

  1. 1. 3
  2. 2. 4 Pharmacological Management of Asthma in Children 5 Years and Younger Based on Different Global Guidelines
  3. 3. 5 Asthma is the most common chronic disease of childhood & the leading cause of childhood morbidity from chronic disease as measured by school absences, emergency department visits and hospitalizations. Asthma Typically begins in early childhood, with earlier onset in males than females . Burden of Asthma in Children
  4. 4. 6 Atopy is present in the majority of children with asthma who are over 3 years old, and allergen-specific sensitization is one of the most important risk factors for the development of asthma. However, no intervention has yet been shown to prevent the development of asthma, or modify its long- term natural course.
  5. 5. 7 Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation. NEW!
  6. 6. Children’s Healthcare of Atlanta Pathology of Asthma Inflammation Airway Hyper-responsiveness Airway Obstruction Symptoms of Asthma
  7. 7. 9 Unfortunately…asthma is a major cause of chronic morbidity and mortality throughout the world and there is evidence that its prevalence has increased considerably over the past 20 years, especially in children. Fortunately…asthma can be effectively treated and most patients can achieve good control of their disease. Global Initiative for Asthma (2012)
  8. 8. 10 • Asthma is a common heterogeneous disorder in children, the prevalence of asthma in Western countries is around 10%. • Many young children, approximately 30% of all children, have airway symptoms like cough and wheeze. However, only 1/3 of these children with symptoms will develop asthma later in life.
  9. 9. 11 • Asthma diagnosis in this age group is difficult • Respiratory symptoms (wheezing and cough) also common in children without asthma • Not possible to routinely assess airflow limitation (spirometry) Diagnosis of Asthma in Children 5 Years and Younger
  10. 10. 12 Wheezing—Asthma? Wheezing with upper respiratory infections is very common in small children, but: Many of these children will not develop asthma. Asthma medications may benefit patients who wheeze whether or not they have asthma. All that wheezes is not asthma.
  11. 11. • Parents often use wheezing as a non-specific label to describe any abnormal respiratory noise. • It is important to distinguish wheezing – a continuous, high-pitched musical sound coming from the chest – from other respiratory noises, such as stridor .
  12. 12. 14 • Wheezing is one of the most  problems for which preschool children are seen in the pediatrician's office. • Further, children who wheeze once are likely to wheeze again, making recurrent wheeze a frequent problem. • Many parents who report “wheezing” or “noisy breathing” in their child expect a diagnosis of asthma. However, not all wheezing is asthma
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  14. 14. 16 • Often the first question asked, either by the parent or by the pediatrician, is “Does this wheezing episode represent an asthma diagnosis?” - The main issue still is the difficulty in coming to a correct diagnosis.
  15. 15. 17 • The parent, on the other hand, really wants to know if their child will need medication and treatment beyond the preschool years and is obviously reluctant to subject their child to medication when they appear well most of the time
  16. 16. 18 • Wheezing in preschool children is a heterogeneous condition with multiple phenotypes. Wheezy phenotypes: Epidemiological patterns of wheezing (Time trend-based classification)  Temporal patterns of wheezing (Symptom-based classification)
  17. 17. 19 • Time trend-based classification: this system was based on analysis of data from a cohort study,It included : 1)Transient wheeze (symptoms began and ended before the age of 3 years) 2)Persistent wheeze (symptoms began before the age of 3 years and continued beyond the age of 6 years) 3)Late-onset wheeze (symptoms began after the age of 3 years).
  18. 18. Children’s Healthcare of Atlanta Natural History of Childhood Wheeze Age (Years) WheezingPrevalence Non-atopic wheezers Transient early wheezers IgE-associated wheeze/asthma 0 3 6 11 Martinez. J Allergy Clin Immunol 1999;104:S169-S174.
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  20. 20. 22 Epidemiological patterns of wheezing Transient early wheezing • Describes the pattern of respiratory symptoms starting in the first year of life. Generally, transient wheezing in infants is not associated with a family history of asthma or allergic sensitization. • The primary risk factor for this phenotype seems to be reduced pulmonary function in infancy, which remains low up to the age of 16. 
  21. 21. 23 • Other risk factors for transient wheezing include: prematurity, male gender, prenatal maternal smoking, as well as postnatal exposure to tobacco smoke. • Transient early wheeze characteristically resolves around the age of 3.
  22. 22. 24 • Passive prenatal smoking is associated with lower lung function, probably due to underdevelopment of the bronchial tree, and is the most important and preventable risk factor for early transient wheeze.
  23. 23. 25 • Passive postnatal smoking has a negative effect on all types of respiratory symptoms in infants and preschool children and constitutes a significant risk factor for upper airways infections, bronchiolitis, worsening of asthma symptoms, and decreased lung function.
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  26. 26. 28 Nonatopic wheezing • attacks are principally due to recurrent viral infections. • Nonatopic wheezers have normal lung function in early life but intermittent airways obstruction secondary to viral infections. • The origin of wheezing in these children is not clear.
  27. 27. 29 Persistent 'atopic' wheezing • Develop asthma in later childhood, more often have their first episode of wheeze after the first year of life, discrete attacks with symptom-free intervals, symptoms that worsen at night, frequent symptoms, a family history of asthma, elevated serum IgE and peripheral blood eosinophilia. • They have normal lung function in infancy but develop airways obstruction in the first years of life.
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  29. 29. 31 • In the large majority of wheezing infants, wheezing is transient and benign. These children neither need nor respond to asthma medication and a wait-and-see policy before trying medication is justified.  • The majority of wheezy infants will end up being free of symptoms at the age of 6, and have no indication for maintenance anti-inflammatory drugs
  30. 30. 32 • Eighty percent of the children who wheeze during the first year of life do not wheeze after the age of 3. • Sixty percent of the children that wheeze in the second year of life and 30-40% of those who wheeze in the third year have stopped wheezing when they are older than 3 years of age .
  31. 31. 33 • The medical literature commonly cites epidemiologic criteria such as wheezing in the first 3 years of life, transient versus persistent wheeze, or atopic versus nonatopic, but these categories can be determined only retrospectively and give no guide to treatment, so are not useful for the clinician .
  32. 32. 34 • Prospective allocation of individual children to these phenotypes has been unreliable in ‘real- life’ clinical situations, and the clinical usefulness of these systems remains a subject of active investigation. • Defining wheezing via temporal patterns may be more useful for the busy clinician.
  33. 33. 35 • The European Respiratory Society Task Force recommends differentiating wheezing phenotypes that provide the pediatrician with some evidence that can assist with treatment into: 1)Episodic viral wheezing 2)Multiple-trigger wheezing.
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  35. 35. 37 Episodic viral wheeze (EVW): • The child wheezes only with usually clinically diagnosed viral upper respiratory infections and is otherwise totally symptom free (without symptoms between these episodes). • Recurrent wheezing occurs in a large proportion of children aged 5 years or younger.
  36. 36. 38 Viral-induced wheezing • Many young children may wheeze with viral infections wheezing in this age group is a highly heterogeneous condition, and not all wheezing in this age group indicates asthma. • Therefore, deciding when wheezing with a respiratory infection is truly an initial or recurrent clinical presentation of childhood asthma is difficult .
  37. 37. 39 • Wheezing episodes are generally associated with a clinical diagnosis of viral upper respiratory tract infection (URTI). Rhinovirus, respiratory syncytial virus (RSV), coronavirus, parainfluenza virus, and adenovirus are commonly cited in research studies • Possible underlying factors include preexisting impaired lung function, tobacco smoke exposure, prematurity, and atopy
  38. 38. 40 The commonest clinical pattern, especially in pre- school children and infants, is episodes of wheezing, cough and difficulty breathing associated with viral upper respiratory infections (colds), with no persisting symptoms. Most of these children will stop having recurrent chest symptoms by school age.
  39. 39. 41 Repeated episodes commonly occur seasonally, and some children experience severe symptoms from these wheezing episodes.. In most children episodic viral wheezing declines over time, but it can persist into school age or become multiple-trigger wheezing.
  40. 40. 42 It does not appear that children with episodic viral wheezing have an increased risk of atopy or respiratory symptoms after age 14 years. Additionally, there is no evidence that treatment with any particular drug in a preventive manner will prevent future airway remodeling, airflow obstruction, or prevent asthma
  41. 41. 43 A minority of those who wheeze with viral infections in early life will go on to develop wheezing with other triggers so that they develop symptoms between acute episodes (interval symptoms) similar to older children with classical atopic asthma Children who have persisting or interval symptoms are most likely to benefit from therapeutic interventions.
  42. 42. 44 Multiple trigger wheeze (MTW):  Viral illness is not the only trigger for wheezing episodes, which can also include other triggers such as exercise , smoke and allergen exposure.  Patients in this category demonstrate symptoms between episodes.
  43. 43. 45  Multiple trigger wheeze is associated with more airflow obstruction than episodic viral wheeze, and the airway pathology (eosinophilic inflammation and remodelling) is similar to childhood and adult asthma.  By contrast, episodic viral wheeze is not associated with evidence of eosinophilic inflammation, so the use of inhaled corticosteroids in this group is questionable.
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  46. 46. 48 What are the broad treatment strategies for children with preschool wheeze? Before any drugs are prescribed for either episodic viral wheeze or multiple trigger wheeze, it is essential to ensure that the home environment is optimal, particularly that the child is not exposed to tobacco smoke; parental smoking “not in front of the children” does not protect them from harm A birth cohort study found that air pollution can increase vulnerability to preschool wheeze
  47. 47. 49
  48. 48. 50 Treating episodic viral wheeze • Intermittent symptoms should be treated with intermittent therapy (and in practice this is likely to be what parents do anyway). • Intermittent symptoms are best treated with intermittent therapy, with short-acting bronchodilators usually being first-line therapy. • If additional therapy is required, ICSs, leukotriene modifiers, or combination therapy are options.
  49. 49. 51 • If treatment needs to be escalated beyond intermittent β2 agonist or anticholinergic because of failure to control symptoms, the next options are intermittent leucotriene receptor antagonist (montelukast), intermittent inhaled corticosteroids, or both. • Treatment was initiated at the onset of symptoms of a respiratory tract infection and continued for a minimum of a week or until symptoms had disappeared for 48 hours.
  50. 50. 52 • Studies suggest that a trial of montelukast in preschool children with troublesome viral induced wheeze is worth attempting. • Intermittent ICS for the treatment of episodic viral wheezing is partially effective as a strategy for the treatment of mild episodic viral wheeze of childhood.
  51. 51. 53 • No current evidence favors maintenance low- dose ICS in the prevention and management of episodic mild viral-induced wheeze • There is no evidence to support the use of regular inhaled corticosteroids in preschool children who do not wheeze between viral colds.
  52. 52. 54 • In those children with really severe episodic wheeze who require repeated admission to hospital or have prolonged disruptive symptoms managed at home, however, a trial of prophylactic inhaled corticosteroids can be given. • Trials should be short, however, with close monitoring of symptoms and rapid stopping if there is no improvement or decreasing doses as tolerated .
  53. 53. 55 • Treatment should be reviewed and discontinued if there is no benefit. • There is no evidence to suggest the optimal duration of the therapeutic trial, but six to eight weeks would seem a reasonable time period. • If the viral wheezing improves on treatment, regular attempts should still be made to reduce the dose.
  54. 54. 56 • Whatever the context of therapeutic trials in preschool children, they should be for a fixed time period (such as six to eight weeks) and discontinued at the end of the agreed period to see if symptoms recur or in fact have resolved and treatment has become unnecessary
  55. 55. 57 • Any preschool child with acute episodes of episodic viral induced wheeze who is well enough to stay in the community should not be prescribed oral prednisolone • it is likely that prednisolone will continue to be prescribed in this small subgroup of children in hospital. really severe preschool viral wheeze
  56. 56. 58 • Importantly, there is no evidence to support the use of antibiotics for the treatment of episodic viral wheeze unless the pediatrician believes a bacterial infection is present.
  57. 57. 59 • Treating multiple-trigger wheeze with continuous, standard-dose ICS is more successful than it is in episodic viral wheeze. • Given preschool children with a history of wheezing, cough, and other symptoms responsive to bronchodilators who remain symptomatic, a trial of preventive therapy is warranted. Treating multiple-trigger wheeze
  58. 58. 60 • Preschool children who have wheeze or cough responsive to bronchodilator treatment and breathlessness on most days even when they do not have a viral cold should be considered for a trial of preventive drug treatment, either inhaled corticosteroids or a leucotriene receptor antagonist (montelukast). • Long acting β2 agonists are not licensed for use in preschool children.  
  59. 59. 61 Pragmatic regimen for trial of treatment • In a recent 2014 review, researchers recommend a 3-step approach for preschoolers with multiple- trigger wheeze: Step 1: Trial of inhaled corticosteroids or montelukast in standard dose for a defined period, usually four to eight weeks Step 2: Stopping treatment because symptoms have not improved or have disappeared.
  60. 60. 62 Pragmatic regimen for trial of treatment Stop treatment; either there has been no improvement, in which case further escalation is not valuable, referral for consideration of further investigation is recommended , or symptoms have disappeared; in the latter case, it is not possible to know if this was spontaneous or as a result of treatment. Step 3: Restart treatment only if symptoms recur; then reduce treatment to the lowest level that
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  62. 62. 64
  63. 63. 65  Wheezing episodes in young children should be treated initially with inhaled short-acting beta2- agonists, regardless of whether the diagnosis of asthma has been made.  A trial of controller therapy should be given if the symptom pattern suggests asthma & respiratory symptoms are uncontrolled and/or wheezing episodes are frequent or severe. .
  64. 64. 66 Therapeutic trial A trial of treatment for at least 2–3 months with as- needed short-acting beta2-agonist (SABA) and regular low dose inhaled corticosteroids (ICS) may provide some guidance about the diagnosis of asthma (Evidence D). Response should be evaluated by symptom control (daytime and night-time), and the frequency of wheezing episodes and exacerbations.
  65. 65. 67 Therapeutic trial Marked clinical improvement during treatment, and deterioration when treatment is stopped, support a diagnosis of asthma. Due to the variable nature of asthma in young children, a therapeutic trial may need to be repeated in order to be certain of the diagnosis
  66. 66. 68
  67. 67. 69  Preschool wheeze should be divided into “episodic viral” and “multiple trigger” according to the history, and these categories, which can change over time, should be used to guide treatment  No treatment has been shown to prevent progression of preschool wheeze to school age asthma, so treatment is driven solely by current symptoms
  68. 68. 70  In all but the most severe cases, episodic symptoms should be treated with episodic treatment  If trials of prophylactic treatment are contemplated, they should be discontinued at the end of a strictly defined time period because many respiratory symptoms remit spontaneously in preschool children
  69. 69. 71 • Young children who present with symptoms of cough, wheeze, and shortness of breath may have either viral-associated respiratory problems that may not persist into later childhood or may have an asthmatic pattern of airway inflammation that may subsequently develop into asthma • Further, the younger the child the less likely true inflammation will be present
  70. 70. 72 • In preschool children many will no longer have symptoms when becoming school aged, it is important to remember that not all children with multiple-trigger wheeze have asthma pathophysiology. • Both phenotypes are lacking, however, in that they will not identify children who will go on to develop asthma, children who will outgrow their symptoms
  71. 71. 73 Does preschool wheezing lead to asthma?
  72. 72. 74
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  74. 74. 76
  75. 75. 77 Diagnosis of asthma in children 5 years and younger
  76. 76. 78 • Spirometric lung function are difficult to perform in young children, because active cooperation is a prerequisite for successful measurements.  • In preschool children, therefore, the diagnosis is usually purely clinical.
  77. 77. 79 The diagnosis of asthma in preschool children is based on recognising a characteristic pattern of episodic respiratory symptoms and signs in the absence of an alternative explanation, the diagnosis is usually purely clinical.
  78. 78. 80 Does wheezing mean that I have asthma?
  79. 79. 81 What is Asthma? A clinical diagnosis Diagnosing Asthma-Not Easy
  80. 80. 82 • Diagnosis of asthma is a clinical one….there is no standardised definition of the type, severity or frequency of symptoms, nor of the findings on investigation. Clinical Diagnosis of Asthma
  81. 81. 83 • It may be difficult to make a confident diagnosis of asthma in children 5 years and younger, because episodic respiratory symptoms such as wheezing and cough are also common in children without asthma, particularly in those 0–2 years old.   • Furthermore, it is not possible to routinely assess airflow limitation in this age group. Clinical Diagnosis of Asthma
  82. 82. 84
  83. 83. 85 Probability of asthma diagnosis
  84. 84. 86 • Many young children wheeze with viral infections, and deciding when a child should be given controller treatment is difficult. • A diagnosis of asthma in young children is therefore based largely on symptom patterns combined with a careful clinical assessment of family history and physical findings.
  85. 85. 87 • A positive family history of allergic disorders or the presence of atopy or allergic sensitization provide additional predictive support . • Early allergic sensitization increases the likelihood that a wheezing child will develop persistent asthma .
  86. 86. 88 Symptoms suggestive of asthma in children 5 years and younger 1. Episodic Symptom patterns (wheeze, cough, breathlessness typically manifested by activity limitation, and nocturnal symptoms or awakenings) . 2. Presence of risk factors for development of asthma- history of other allergic disease (eczema or allergic rhinitis) or asthma in first-degree relatives . 3. Therapeutic response to controller treatment. (Clinical improvement during 2–3 months of controller treatment, and worsening after cessation).
  87. 87. 89 • A probability-based approach, based on the pattern of symptoms during and between viral respiratory infections, may be helpful for discussion with parents/carers . • This approach allows individual decisions to be made about whether to give a trial of controller treatment. • It is important to make decisions for each child individually, to avoid either over- or under-
  88. 88. 90
  89. 89. Children’s Healthcare of Atlanta Diagnosis *BTS/SIGN (May 2008). British Guideline on the Management of Asthma • Clinical features that increase the probability of asthma: – More than one of the following symptoms especially if frequent, worse at night/early morning/after exercise/exposure to triggers etc. • Wheeze • Cough • difficulty breathing, • chest tightness • Atopic disorder • FH of atopic disorder/asthma • Improvement in symptoms or lung function with adequate therapy • Clinical features that lowerthe probability of asthma: – Symptoms with URTI only – no interval symptoms – isolated cough in the absence of wheeze or difficulty breathing – history of moist cough – prominent dizziness, light- headedness, peripheral tingling – repeatedly normal physical examination of chest when symptomatic – normal PEFR/spirometry when symptomatic – no response to a trial of asthma therapy – clinical features pointing to alternative diagnosis
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  94. 94. Children’s Healthcare of Atlanta Diagnosis II high probability of asthma: – start a trial of treatment – review and assess response • reserve further testing for those with a poor response   • low probability of asthma – consider more detailed investigation and specialist referral intermediate probability of asthma • In children with an intermediate probability of asthma who cannot perform spirometry, offer a trial of treatment for a specified period: ― if treatment is beneficial, treat as asthma and arrange a review ― if treatment is not beneficial, stop asthma treatment, and consider tests for alternative conditionsm and specialist referral.
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  96. 96. 101 Pharmacological Management of Asthma in Children 5 Years and Younger Based on Different Global Guidelines
  97. 97. (ICS)
  98. 98. 104
  99. 99. 105 • Delivers medication directly to the airways • Minimizes systemic side effects • Faster onset of action – Rescue medications • Recommended by asthma guidelines Advantages of Inhaled Therapy in Patients With Asthma
  100. 100. 106 Pharmacokinetics of Inhaled Drugs
  101. 101. 107 Inhaled therapy constitutes the cornerstone of asthma treatment in this young age group.
  102. 102. Asthma therapy Controllers  Inhaled corticosteroids  Inhaled long-acting b2- agonists  Oral anti-leukotrienes  Oral theophyllines Relievers  Inhaled fast-acting b2-agonists
  103. 103. Beclomethasone Budesonide Fluticasone Inhaled corticosteroids
  104. 104. 110 Controller medication • Daily medications for all persistent asthma Long term control Anti-inflammatory Reliever or Quick-relief medication • Bronchodilators - As needed for all asthma severity levels Used PRN and preventative for EIA Bronchodilators Oral corticosteroid bursts Controller vs. Reliever Meds
  105. 105. 111 Rescue Medications
  106. 106. 112 o Relaxes muscles in the airways to help relieve asthma symptoms o Should be taken as needed for symptoms o Need to wait 1-2 minutes between puffs for best deposition of medication in the lungs o Overuse is a big warning sign indicating the child’s asthma may not be well controlled “Relievers” (Bronchodilators)
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  109. 109. Children’s Healthcare of Atlanta Guidelines from around the world
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  111. 111. Clinical Control of Asthma in Children 5 Years and Younger Asthma is controlled (all of the following): 1)No (or minimal) daytime symptoms 2)No limitations of activity (Child is fully active, plays and runs without limitations of symptoms) 3)No nocturnal symptoms (including no nocturnal coughing during sleep) 4)No (or minimal) need for rescue medication
  112. 112. 118 A. Symptom control In the past 4 weeks, has the child had: Well- controlled Partly controlled Uncontrolled • Daytime asthma symptoms for more than few minutes, more than once/week? Yes No None of these 1-2 of these 3-4 of these • Any activity limitation due to asthma? (runs/plays less than other children, tires easily during walks/playing) Yes No • Reliever needed* more than once a week? Yes No • Any night waking or night coughing due to asthma? GINA assessment of asthma control in children ≤5 years Level of asthma symptom control
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  115. 115. Children’s Healthcare of Atlanta Pharmacotherapy Recommendations for Children 0 to 2 Years Intermittent βIntermittent β22-agonists-agonists First choice despite conflicting evidenceFirst choice despite conflicting evidence LTRALTRA Daily controller therapy for viral wheezing (long- orDaily controller therapy for viral wheezing (long- or short-term treatment)short-term treatment) Nebulized or inhaledNebulized or inhaled corticosteroidscorticosteroids Daily controller therapy for persistent asthmaDaily controller therapy for persistent asthmaaa First-line treatment when there is evidenceFirst-line treatment when there is evidence of atopy/allergyof atopy/allergy Oral corticosteroidsOral corticosteroidsbb Acute and frequently recurrent obstructive episodesAcute and frequently recurrent obstructive episodes a Especially if severe or requiring frequent oral corticosteroid therapy; b eg, 1 to 2 mg/kg/day prednisone for 3 to 5 days during acute and frequently recurrent obstructive episodes. . PRACTALL EAACI / AAAAI Consensus Report Asthma diagnosis: >3 episodes of reversible bronchial obstruction within 6 months
  116. 116. 122 • Consider a diagnosis of asthma if >3 episodes of reversible bronchial obstruction have been documented within the previous 6 months • Intermittent β2 agonists are first choice (inhaled, jet nebulizers in the US and oral in Europe) • LTRA daily controller therapy for viral wheezing (long- or short-term treatment) Asthma treatment in children aged 0–2 years
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  120. 120. 126 • Nebulized or inhaled (metered-dose inhaler and spacer) corticosteroids as daily controller therapy for persistent asthma, especially if severe or requiring frequent oral corticosteroid therapy • Evidence of atopy/allergy lowers the threshold for use of ICS and they may be used as first-line treatment in such cases • Use oral corticosteroids (e.g. 1–2 mg/kg prednisone) for 3–5 days during acute and frequently recurrent obstructive episodes Asthma treatment in children aged 0–2 years
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  122. 122. 128
  123. 123. Children’s Healthcare of Atlanta INSUFFICIENT CONTROLb Pharmacologic Treatment (Children >2 Years) ICS (200µg BDP equivalent) LTRAa (Dose depends on age) INSUFFICIENT CONTROLc Increase ICS dose (800 µg BDP equivalent) OR Add LTRA to ICS OR Add LABA INSUFFICIENT CONTROLc StepUpTherapytoGainControl Stepdownif appropriate Stepdownif appropriate Consider other options •Theophylline •Oral corticosteroids a LTRA may be particularly useful if the patient has concomitant rhinitis; b Check compliance, allergy avoidance, and reevaluate diagnosis; c Check compliance and consider referring to specialist. ICS=inhaled corticosteroids; LTRA=leukotriene receptor antagonist; BDP=beclomethasone dipropionate; LABA=long-acting β2-agonist. Increase ICS dose (400 µg BDP equivalent) OR Add ICS to LTRA PRACTALL EAACI / AAAAI Consensus Report OR
  124. 124. 130 Asthma treatment in children aged >2 years - 5 years • ICS are the first choice, budesonide 100– 200 μg × 2 or fluticasone 50–125 μg × 2 by MDI • Short-acting β2 agonists, salbutamol 0.1 mg/dose or terbutaline 0.25 mg/dose 1–2 puffs at 4-h intervals as needed • LTRA can be used as monotherapy instead of ICS if symptoms are intermittent or mild persistent • If full control is not achieved with ICS, add LTRA montelukast 4 mg granules or 4 mg chewing tablet
  125. 125. 131 Asthma treatment in children aged >2 years - 5 years • If control still not achieved consider the following (nonsequential) options:   1.Add LABA at least intermittently (although note lack of published evidence supporting use in this age group)    2.Increase ICS dose    3.Add theophylline
  126. 126. 132 PRACTALL consensus report advocates montelukast as an initial controller therapy for mild persistent asthma at an age-dependent dose in pediatric patients Promotes its use in viral-induced wheezing in children 0-5 years. Some studies have shown that montelukast may be used as short course therapy for viral-induced asthma exacerbations or ‘episodic asthma’.
  127. 127. 133 LTRA may be an especially appropriate choice in patients with concomitant asthma and rhinitis. •Another indication for LTRAs is as an alternative agent for exercise-induced asthma due to its quick onset and prolonged duration of action.
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  129. 129. 135 May 2009 Global Strategy for the Diagnosis and Management of Asthma in Children 5 Years and Younger May, 2009
  130. 130. Environmental control As needed rapid-acting β2-agonists Controlled on as needed rapid-acting β2- agonists Partly controlled on as needed rapid-acting β2- agonists Uncontrolled on β2-agonists prn. or partly controlled on a low-dose inhaled glucocorticosteroid Controller options Leukotriene modifier Low-dose inhaled glucocorticosteroid plus leukotriene modifier Low-dose inhaled glucocorticosteroid Double low-dose inhaled glucocorticosteroid Continue as needed rapid-acting β2-agonists Asthma Management Approach Based on Control for Children 5 Years and Younger Oral glucocorticosteroids should be used only for treatment of acute severe exacerbations of asthma. Green shaded boxes represent the preferred treatment options.
  131. 131. 137 A pressurized metered dose inhaler with a valved spacer (with or without a face mask depending on the child’s age) is the preferred delivery system (Evidence A). A low-dose inhaled glucocorticosteroid is recommended as the preferred initial treatment to control asthma (Evidence A).
  132. 132. 138 If low-dose inhaled glucocorticosteroid does not control symptoms, and the child is using optimal technique and is adherent to therapy, doubling the initial dose of ICS may be the best option (Evidence C). (….continued)
  133. 133. 139  When doubling the initial dose of ICS fails to achieve and maintain asthma control, the child’s inhalation technique and compliance with the medication regimen should be carefully assessed and monitored.  Use of oral glucocorticosteroids should be restricted to the treatment of acute severe exacerbations, whether viral-induced or otherwise (Evidence D).
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  135. 135. 141 • Inhaled corticosteroids are the most effective preventer drug for adults and older children for achieving overall treatment goals. • There is an increasing body of evidence demonstrating that, at recommended doses, they are also safe and effective in children under five with asthma.
  136. 136. Children’s Healthcare of Atlanta Dose, drug, &Dose, drug, & route dependentroute dependent Corticosteroids for Asthma: Benefits and Risks ReducesReduces inflammationinflammation Most effectiveMost effective long-term controllong-term control medication formedication for asthma*asthma* DecreasesDecreases morbidity / mortalitymorbidity / mortality Generally knownGenerally known and can beand can be monitoredmonitored BenefitsBenefits RisksRisks
  137. 137. 143 Placebo-controlled studies of inhaled gluco- corticosteroids in children 5 years and younger with asthma provide statistically significant clinical effects on (Evidence A): 1. Number of symptom-free days 2. Reduced symptoms 3. Need for additional medication 4. Caregiver burden 5. Systemic glucocorticosteroid use 6. Exacerbations
  138. 138. Children’s Healthcare of Atlanta –This is not a table of equivalence –A low daily dose is defined as the dose that has not been associated with clinically adverse effects in trials that included measures of safety ‘Low dose’ inhaled corticosteroids (mcg/day) for children ≤5 years GINA 2015, Box 6-6 Inhaled corticosteroid Low daily dose (mcg) Beclometasone dipropionate (HFA) 100 Budesonide (pMDI + spacer) 200 Budesonide (nebulizer) 500 Fluticasone propionate (HFA) 100 Ciclesonide 160 Mometasone furoate Not studied below age 4 years Triamcinolone acetonide Not studied in this age group GINA 2015, Box 6-6
  139. 139. 145 Frequency of dosing of inhaled corticosteroids • Give inhaled corticosteroids initially twice daily (except ciclesonide which is given once daily). • Most current ICS are slightly more effective when taken twice rather than once daily,but may be used once daily in some patients with milder disease and good or complete control of their asthma
  140. 140. Children’s Healthcare of Atlanta Lower ICS Doses Are Associated With Fewer Risks Response Pedersen et al. Allergy. 1997;52:1-34. Dose Therapeutic Effects Favorable Benefit:Risk Ratio Undesirabl e Effects
  141. 141. 147 • Although dose–response curves have not been established for every ICS formulation and for all age-groups, efficacy appears to reach a plateau for most patients and outcomes around or below medium dose range .
  142. 142. 148 BDP and budesonide are approximately equivalent in clinical practice, although there may be variations with different delivery devices. At present a 1:1 ratio should be assumed when changing between BDP and budesonide. Fluticasone provides equal clinical activity to BDP and budesonide at half the dosage.
  143. 143. 149 • Administration of ICS at or above 400 micrograms BDP a day or equivalent may be associated with systemic side effects. • Monitor growth (height and weight centile) of children with asthma on an annual basis.
  144. 144. 150 • The clinical benefit of ICS must be balanced against potential risks, with linear growth remaining the dominant concern. • Several studies in older children have consistently demonstrated a modest but significant effect (~1 cm in the first year) • Risks for subcapsular cataracts or bone mineral density reduction in childhood are very low.
  145. 145. 151 • While the use of ICS may be associated with adverse effects (including the potential to reduced bone mineral density) with careful ICS dose adjustment this risk is likely to be outweighed by their ability to reduce the need for multiple bursts of oral corticosteroids. • The lowest dose of inhaled corticosteroids compatible with maintaining disease control should be used.
  146. 146. Children’s Healthcare of Atlanta Choosing an Inhaler Device A pressurized metered-dose inhaler (MDI) with a valved spacer (with or without a face mask, depending on the child’s age) is the preferred delivery system Choosing an Inhaler Device Age group Preferred device Alternative device Younger than 4 years Pressurized metered-dose inhaler plus dedicated spacer with face mask Nebulized with face mask 4-5 years Pressurized metered-dose inhaler plus dedicated spacer with mouth piece Pressurized metered-dose inhaler plus dedicated spacer with mouth piece, or Nebulizer with mouthpiece or face mask
  147. 147. 153 • Candidiasis of the throat and mouth may occur, particularly with higher doses of inhaled corticosteroids. • Strategies to reduce the risk include use of a spacer and rinsing the mouth with water or cleaning the teeth following inhalation .
  148. 148. 154
  149. 149. Children’s Healthcare of Atlanta 155
  150. 150. Children’s Healthcare of Atlanta Management <5Year Step 1 • SABA Step 2 • Inhaled steroids if: – exacerbation of asthma in the last 2 years requiring oral steroids – using inhaled β2 agonists three times a week or more – symptomatic three times a week or more – waking one night a week *Titrate steroid dose to lowest dose at which effective treatment maintained • Leukotriene agonists if inhaled steroids not tolerated
  151. 151. Children’s Healthcare of Atlanta Management <5 Step 3 • If taking inhaled steroid, add in leukotriene antagonist • If taking leukotriene antagonist, add inhaled steroid • If <2 year proceed to Step 4 Step 4 • Refer to respiratory paediatrician
  152. 152. Children’s Healthcare of Atlanta Children < 5 years BTS 2014 • Step 1: Short acting Beta agonist • Step 2: Inhaled Steroid (200-400mcg/day) or Leukotriene receptor antagonist • Step 3: ICS or LRA • Step 4: Refer to paeds British Thoracic guidelines recommend the use of LTRAs for children aged less than 5 years, they are indicated as either monotherapy or add on therapy.
  153. 153. 160
  154. 154. © Global Initiative for Asthma GINA Global Strategy for Asthma Management and Prevention 2015 This slide set is restricted for academic and educational purposes only. Use of the slide set, or of individual slides, for commercial or promotional purposes requires approval from GINA. Diagnosis and management of asthma in children 5 years and younger GINA 2015
  155. 155. Children’s Healthcare of Atlanta • Over the past 20 years, the Global Initiative for Asthma (GINA) has regularly published and annually updated a global strategy for asthma management and prevention that has formed the basis for many national guidelines. • A probability-based approach to diagnosis and treatment for wheezing children replaces previous classifications by wheezing phenotype 162
  156. 156. Children’s Healthcare of AtlantaGINA 2015, Box 6-5 (3/8) Infrequent viral wheezing and no or few interval symptoms Symptom pattern consistent with asthma and asthma symptoms not well-controlled, or ≥3 exacerbations per year Symptom pattern not consistent with asthma but wheezing episodes occur frequently, e.g. every 6–8 weeks. Give diagnostic trial for 3 months. Asthma diagnosis, and not well-controlled on low dose ICS Not well- controlled on double ICS First check diagnosis, inhaler skills, adherence, exposures CONSIDER THIS STEP FOR CHILDREN WITH: RELIEVER Other controller options PREFERRED CONTROLLER CHOICE As-needed short-acting beta2-agonist (all children) Leukotriene receptor antagonist (LTRA) Intermittent ICS Low dose ICS + LTRA Add LTRA Inc. ICS frequency Add intermitt ICS Daily low dose ICS Double ‘low dose’ ICS Continue controller & refer for specialist assessment STEP 1 STEP 2 STEP 3 STEP 4 Stepwise approach – pharmacotherapy (children ≤5 years)
  157. 157. For initiating treatment, asthma severity should be classified The initial treatment should correspond to the appropriate severity category.
  158. 158. 165 Make an initial assessment of the pattern of asthma (infrequent intermittent, frequent intermittent, or persistent) in children aged 0-5 years not taking regular preventers
  159. 159. INTERMITTENT Step 1 PERSISTENT Step 2 (Mild) Step 3 (Moderate) Step 4 (Severe) Severity is classified before therapy begins
  160. 160. 167 Category Pattern and intensity of symptoms (when not taking regulartreatment) Infrequent intermittent asthma Symptom-free for at least 6 weeks at a time (flare-ups up to once every 6 weeks on average but no symptoms between flare- ups) Frequent intermittent asthma Flare-ups more than once every 6 weeks on average but no symptoms between flare-ups Persistent asthma Mild At least one of: •Daytime symptoms†  more than once per week but not every day •Night-time symptoms†  more than twice per month but not every week Moderate Any of: •Daytime symptoms†  daily •Night-time symptoms†  more than once per week •Symptoms sometimes restrict activity or sleep Severe Any of: •Daytime symptoms†  continual •Night-time symptoms†  frequent •Flare-ups frequent •Symptoms frequently restrict
  161. 161. 168 Asthma Severity Assessment 1. Intermittent vs. Persistent asthma: a. Persistent asthma is diagnosed if the child has any of the following: o Symptoms more than twice per week during the day o Symptoms twice per month at night o Any exercise limitation o FEV1 less than 80% predicted (for children over 5 years) o Two or more steroid bursts for asthma in 12 months 2. Treat Persistent asthma with a daily controller medication such as inhaled corticosteroids
  162. 162. Children’s Healthcare of Atlanta Diagnosis Symptom control & risk factors Inhaler technique & adherence Parent preference Asthma medications Non-pharmacological strategies Treat modifiable risk factors Symptoms Exacerbations Side-effects Parent satisfaction Control-based asthma management cycle in children ≤5 years GINA 2015, Box 6-5 (1/8)
  163. 163. 170 A. Symptom control In the past 4 weeks, has the child had: Well- controlled Partly controlled Uncontrolled • Daytime asthma symptoms for more than few minutes, more than once/week? Yes No None of these 1-2 of these 3-4 of these • Any activity limitation due to asthma? (runs/plays less than other children, tires easily during walks/playing) Yes No • Reliever needed* more than once a week? Yes No • Any night waking or night coughing due to asthma? GINA assessment of asthma control in children ≤5 years Level of asthma symptom control
  164. 164. Once treatment is established, the emphasis is on assessing asthma control to determine if the goals for therapy have been met and if adjustments in therapy (step up or step down) would be appropriate.
  165. 165. Children’s Healthcare of Atlanta Stepwise Approach to Therapy: Gaining Control STEP4STEP4 Severe PersistentSevere Persistent STEP3STEP3 Moderate PersistentModerate Persistent STEP2STEP2 Mild PersistentMild Persistent STEP1STEP1 IntermittentIntermittent 11 22 11.. Start high andStart high and step down.step down. 2. Start at initial2. Start at initial level of severity;level of severity; gradually stepgradually step up.up.
  166. 166. Guidelines recommend a stepwise approach
  167. 167. How do we apply the stepwise approach? • Start treatment at the step most appropriate to initial severity • Achieve early control Maintain control by stepping up treatment as necessary.
  168. 168. Stepping down Ensure regular review of patients as treatment is stepped down Decide which drug to step down first and at what rate When control is good, step down
  169. 169. Children’s Healthcare of Atlanta Stepwise approach – pharmacotherapy (children ≤5 years) GINA 2015, Box 6-5 (3/8) Infrequent viral wheezing and no or few interval symptoms Symptom pattern consistent with asthma and asthma symptoms not well-controlled, or ≥3 exacerbations per year Symptom pattern not consistent with asthma but wheezing episodes occur frequently, e.g. every 6–8 weeks. Give diagnostic trial for 3 months. Asthma diagnosis, and not well-controlled on low dose ICS Not well- controlled on double ICS First check diagnosis, inhaler skills, adherence, exposures CONSIDER THIS STEP FOR CHILDREN WITH: RELIEVER Other controller options PREFERRED CONTROLLER CHOICE As-needed short-acting beta2-agonist (all children) Leukotriene receptor antagonist (LTRA) Intermittent ICS Low dose ICS + LTRA Add LTRA Inc. ICS frequency Add intermitt ICS Daily low dose ICS Double ‘low dose’ ICS Continue controller & refer for specialist assessment STEP 1 STEP 2 STEP 3 STEP 4
  170. 170. Children’s Healthcare of Atlanta Step 1 (children ≤5 years) – as needed inhaled SABA GINA 2015, Box 6-5 (5/8) Infrequent viral wheezing and no or few interval symptoms Symptom pattern consistent with asthma and asthma symptoms not well-controlled, or ≥3 exacerbations per year Symptom pattern not consistent with asthma but wheezing episodes occur frequently, e.g. every 6–8 weeks. Give diagnostic trial for 3 months. Asthma diagnosis, and not well-controlled on low dose ICS Not well- controlled on double ICS First check diagnosis, inhaler skills, adherence, exposures CONSIDER THIS STEP FOR CHILDREN WITH: RELIEVER Other controller options PREFERRED CONTROLLER CHOICE As-needed short-acting beta2-agonist (all children) Leukotriene receptor antagonist (LTRA) Intermittent ICS Low dose ICS + LTRA Add LTRA Inc. ICS frequency Add intermitt ICS Daily low dose ICS Double ‘low dose’ ICS Continue controller & refer for specialist assessment STEP 1 STEP 2 STEP 3 STEP 4
  171. 171. Children’s Healthcare of Atlanta Step 2 (children ≤5 years) – initial controller + as-needed SABA GINA 2015, Box 6-5 (6/8) Infrequent viral wheezing and no or few interval symptoms Symptom pattern consistent with asthma and asthma symptoms not well-controlled, or ≥3 exacerbations per year Symptom pattern not consistent with asthma but wheezing episodes occur frequently, e.g. every 6–8 weeks. Give diagnostic trial for 3 months. Asthma diagnosis, and not well-controlled on low dose ICS Not well- controlled on double ICS First check diagnosis, inhaler skills, adherence, exposures CONSIDER THIS STEP FOR CHILDREN WITH: RELIEVER Other controller options PREFERRED CONTROLLER CHOICE As-needed short-acting beta2-agonist (all children) Leukotriene receptor antagonist (LTRA) Intermittent ICS Low dose ICS + LTRA Add LTRA Inc. ICS frequency Add intermitt ICS Daily low dose ICS Double ‘low dose’ ICS Continue controller & refer for specialist assessment STEP 1 STEP 2 STEP 3 STEP 4
  172. 172. Children’s Healthcare of Atlanta Step 3 (children ≤5 years) – medium dose ICS + as-needed inhaled SABA GINA 2015, Box 6-5 (7/8) Infrequent viral wheezing and no or few interval symptoms Symptom pattern consistent with asthma and asthma symptoms not well-controlled, or ≥3 exacerbations per year Symptom pattern not consistent with asthma but wheezing episodes occur frequently, e.g. every 6–8 weeks. Give diagnostic trial for 3 months. Asthma diagnosis, and not well-controlled on low dose ICS Not well- controlled on double ICS First check diagnosis, inhaler skills, adherence, exposures CONSIDER THIS STEP FOR CHILDREN WITH: RELIEVER Other controller options PREFERRED CONTROLLER CHOICE As-needed short-acting beta2-agonist (all children) Leukotriene receptor antagonist (LTRA) Intermittent ICS Low dose ICS + LTRA Add LTRA Inc. ICS frequency Add intermitt ICS Daily low dose ICS Double ‘low dose’ ICS Continue controller & refer for specialist assessment STEP 1 STEP 2 STEP 3 STEP 4
  173. 173. Children’s Healthcare of Atlanta Step 4 (children ≤5 years) – refer for expert assessment GINA 2015, Box 6-5 (8/8) Infrequent viral wheezing and no or few interval symptoms Symptom pattern consistent with asthma and asthma symptoms not well-controlled, or ≥3 exacerbations per year Symptom pattern not consistent with asthma but wheezing episodes occur frequently, e.g. every 6–8 weeks. Give diagnostic trial for 3 months. Asthma diagnosis, and not well-controlled on low dose ICS Not well- controlled on double ICS First check diagnosis, inhaler skills, adherence, exposures CONSIDER THIS STEP FOR CHILDREN WITH: RELIEVER Other controller options PREFERRED CONTROLLER CHOICE As-needed short-acting beta2-agonist (all children) Leukotriene receptor antagonist (LTRA) Intermittent ICS Low dose ICS + LTRA Add LTRA Inc. ICS frequency Add intermitt ICS Daily low dose ICS Double ‘low dose’ ICS Continue controller & refer for specialist assessment STEP 1 STEP 2 STEP 3 STEP 4
  174. 174. 181
  175. 175. Children’s Healthcare of Atlanta Step 1 (children ≤5 years) – as needed inhaled SABA GINA 2015, Box 6-5 (5/8) Infrequent viral wheezing and no or few interval symptoms Symptom pattern consistent with asthma and asthma symptoms not well-controlled, or ≥3 exacerbations per year Symptom pattern not consistent with asthma but wheezing episodes occur frequently, e.g. every 6–8 weeks. Give diagnostic trial for 3 months. Asthma diagnosis, and not well-controlled on low dose ICS Not well- controlled on double ICS First check diagnosis, inhaler skills, adherence, exposures CONSIDER THIS STEP FOR CHILDREN WITH: RELIEVER Other controller options PREFERRED CONTROLLER CHOICE As-needed short-acting beta2-agonist (all children) Leukotriene receptor antagonist (LTRA) Intermittent ICS Low dose ICS + LTRA Add LTRA Inc. ICS frequency Add intermitt ICS Daily low dose ICS Double ‘low dose’ ICS Continue controller & refer for specialist assessment STEP 1 STEP 2 STEP 3 STEP 4
  176. 176. Children’s Healthcare of Atlanta • Preferred option: as-needed inhaled SABA – Provide inhaled SABA to all children who experience wheezing episodes – Not effective in all children • Other options – Oral bronchodilator therapy is not recommended (slower onset of action, more side-effects) – For children with intermittent viral-induced wheeze and no interval symptoms, if as-needed SABA is not sufficient, consider intermittent ICS.. Step 1 (children ≤5 years) – as-needed inhaled SABA GINA 2015
  177. 177. 184 • Oral preparations of beta2 agonists have been used extensively in the past with children but are less effective than inhaled preparations and have more side-effects
  178. 178. 185 The use of albuterol syrup has fallen out of favor over the past decade with the advent of better modalities of targeted, inhaled delivery systems (e.g., MDI with spacer/holding chamber, nebulizer solution). • AAAAI Guidelines (2004, p88) prefer inhaled beta2-agonists to oral because higher concentrations are delivered more effectively to the airways, the onset of action is substantially shorter, and systemic side effects can be avoided or minimized. • Authors concluded lack of updated information was a possible reason that community-based PCPs continued to prescribe syrup. Special Consideration – Albuterol Syrup
  179. 179. 186 • Salbutamol is the commonly used inhaled bronchodilator therapy in children. • It is a short- acting ß-2 agonist, has a rapid onset of action (within five minutes) and usually provides 4– 6 hours of bronchodilation. • It should be used as a reliever therapy and is in the first step of all guidelines on asthma management.
  180. 180. 187 • Prescribe an inhaled short-acting β2 agonist as short term reliever therapy for all patients with symptomatic asthma. • No benefits have been shown from regular dosing. • Good asthma control is associated with little or no need for short-acting β2 agonist.
  181. 181. 188 • Increasing use of SABA treatment or the use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate asthma control and the need for initiating or intensifying anti-inflammatory therapy. • Regularly scheduled, daily, chronic use of SABA is not recommended.
  182. 182. 189 • It is important that while reviewing a patient with asthma, the practitioner establishes how often the child needs the reliever therapy. • Need for frequent bronchodilator therapy, especially for interval symptoms such as exercise intolerance or night coughs, may indicate escalation of therapy – i.e. initiation of step 2 of asthma management.
  183. 183. 190 • Anyone prescribed more than one short acting bronchodilator inhaler device a month should be identified and have their asthma assessed urgently and measures taken to improve asthma control if this is poor. • Thus, patients overusing inhaled short-acting beta2 agonists should have their asthma management reviewed
  184. 184. Children’s Healthcare of Atlanta Step 2 (children ≤5 years) – initial controller + as-needed SABA GINA 2015, Box 6-5 (6/8) Infrequent viral wheezing and no or few interval symptoms Symptom pattern consistent with asthma and asthma symptoms not well-controlled, or ≥3 exacerbations per year Symptom pattern not consistent with asthma but wheezing episodes occur frequently, e.g. every 6–8 weeks. Give diagnostic trial for 3 months. Asthma diagnosis, and not well-controlled on low dose ICS Not well- controlled on double ICS First check diagnosis, inhaler skills, adherence, exposures CONSIDER THIS STEP FOR CHILDREN WITH: RELIEVER Other controller options PREFERRED CONTROLLER CHOICE As-needed short-acting beta2-agonist (all children) Leukotriene receptor antagonist (LTRA) Intermittent ICS Low dose ICS + LTRA Add LTRA Inc. ICS frequency Add intermitt ICS Daily low dose ICS Double ‘low dose’ ICS Continue controller & refer for specialist assessment STEP 1 STEP 2 STEP 3 STEP 4
  185. 185. Children’s Healthcare of Atlanta • Indication – Child with symptom pattern consistent with asthma, and symptoms not well-controlled, or ≥3 exacerbations per year – May also be used as a diagnostic trial for children with frequent wheezing episodes • Preferred option: regular daily low dose ICS + as- needed inhaled SABA – Give for ≥3 months to establish effectiveness, and review response Step 2 (children ≤5 years) – initial controller + as-needed SABA GINA 2015
  186. 186. Children’s Healthcare of Atlanta STEP 2: Initial controller treatment plus as-needed SABA • Preferred option: regular daily low dose ICS plus as-needed SABA • Regular daily, low dose ICS is recommended as the preferred initial treatment to control asthma in children 5 years and younger (Evidence A). • This initial treatment should be given for at least 3 months to establish its effectiveness in achieving good asthma control. 193
  187. 187. Children’s Healthcare of Atlanta • Other options depend on symptom pattern – Persistent asthma – regular leukotriene receptor antagonist (LTRA) leads to modest reduction in symptoms and need for OCS compared with placebo – Intermittent viral-induced wheeze – regular LTRA improves some outcomes but does not reduce risk of exacerbations – Frequent viral-induced wheeze with interval symptoms – consider episodic or as-needed ICS,194 Step 2 (children ≤5 years) – initial controller + as-needed SABA
  188. 188. Children’s Healthcare of Atlanta • An ICS at low dose is the preferred option • Generally ICS are more effective than LTRA in direct comparisons • LTRA are recommended as second option (GINA < 5, NAEPP, SIGN < 5 years) 195 STEP 2: Initial controller treatment plus as-needed SABA
  189. 189. Children’s Healthcare of Atlanta • Add inhaled corticosteroid 200-40 micrograms/day*† or leukotriene receptor antagonist if inhaled corticosteroid cannot be used. • Start at dose of inhaled corticosteroid appropriate to severity of disease 196 Step 2: Regular preventer therapy BTS
  190. 190. • In most guidelines , LTRA are recommended as second choice after low-dose ICS, or occasionally as ‘alternative first-line treatment’ (PRACTALL), for the initial step of chronic treatment. • In the context of the next treatment steps, they are also effective as add-on medications .
  191. 191. Children’s Healthcare of Atlanta Step 3 (children ≤5 years) – medium dose ICS + as-needed inhaled SABA GINA 2015, Box 6-5 (7/8) Infrequent viral wheezing and no or few interval symptoms Symptom pattern consistent with asthma and asthma symptoms not well-controlled, or ≥3 exacerbations per year Symptom pattern not consistent with asthma but wheezing episodes occur frequently, e.g. every 6–8 weeks. Give diagnostic trial for 3 months. Asthma diagnosis, and not well-controlled on low dose ICS Not well- controlled on double ICS First check diagnosis, inhaler skills, adherence, exposures CONSIDER THIS STEP FOR CHILDREN WITH: RELIEVER Other controller options PREFERRED CONTROLLER CHOICE As-needed short-acting beta2-agonist (all children) Leukotriene receptor antagonist (LTRA) Intermittent ICS Low dose ICS + LTRA Add LTRA Inc. ICS frequency Add intermitt ICS Daily low dose ICS Double ‘low dose’ ICS Continue controller & refer for specialist assessment STEP 1 STEP 2 STEP 3 STEP 4
  192. 192. Children’s Healthcare of Atlanta STEP 3: Additional controller treatment, plus as-needed SABA • If 3 months of initial therapy with a low dose ICS fails to control symptoms, or if exacerbations persist, check the following before any step up in treatment is considered. 1)Confirm that the symptoms are due to asthma rather than a concomitant or alternative condition . 2)Check and correct inhaler technique. 3)Confirm good adherence with the prescribed dose. 4)Enquire about risk factors such as allergen or tobacco smoke exposure 199
  193. 193. Children’s Healthcare of Atlanta • Indication – Asthma diagnosis, and symptoms not well-controlled on low dose ICS – First check symptoms are due to asthma, and check adherence, inhaler technique and environmental exposures • Preferred option: medium dose ICS with as-needed inhaled SABA • Other options – Consider adding LTRA to low dose ICS Step 3 (children ≤5 years) – medium dose ICS + as-needed inhaled SABA GINA 2015 GINA 2015
  194. 194. Step 3: • ICS can be increased to a medium dose, or a second medication can be added. • For children younger than 5 years, increasing ICS is the commonest approach (GINA < 5, and NAEPP); SIGN suggests ICS + LTRA, while PRACTALL suggests either doubling ICS or ICS +LTRA.
  195. 195. Children’s Healthcare of Atlanta Step 4 (children ≤5 years) – refer for expert assessment GINA 2015, Box 6-5 (8/8) Infrequent viral wheezing and no or few interval symptoms Symptom pattern consistent with asthma and asthma symptoms not well-controlled, or ≥3 exacerbations per year Symptom pattern not consistent with asthma but wheezing episodes occur frequently, e.g. every 6–8 weeks. Give diagnostic trial for 3 months. Asthma diagnosis, and not well-controlled on low dose ICS Not well- controlled on double ICS First check diagnosis, inhaler skills, adherence, exposures CONSIDER THIS STEP FOR CHILDREN WITH: RELIEVER Other controller options PREFERRED CONTROLLER CHOICE As-needed short-acting beta2-agonist (all children) Leukotriene receptor antagonist (LTRA) Intermittent ICS Low dose ICS + LTRA Add LTRA Inc. ICS frequency Add intermitt ICS Daily low dose ICS Double ‘low dose’ ICS Continue controller & refer for specialist assessment STEP 1 STEP 2 STEP 3 STEP 4
  196. 196. Children’s Healthcare of Atlanta • Indication – Asthma diagnosis, and symptoms not well- controlled on medium dose ICS – First check symptoms are due to asthma, and check adherence, inhaler technique and environmental exposures • Preferred option: continue controller treatment and refer for expert assessment Step 4 (children ≤5 years) – Continue controller treatment and refer for expert assessment GINA 2015
  197. 197. Children’s Healthcare of Atlanta • Other options (preferably with specialist advice) – Higher dose ICS and/or more frequent dosing (for a few weeks) – Add LTRA, theophylline or low dose OCS (for a few weeks only) – Add intermittent ICS to regular daily ICS if exacerbations are the main problem – ICS/LABA not recommended in this age group 204 Step 4 (children ≤5 years) – refer for expert assessment
  198. 198. 205 • GINA <5 does not recommend LABA for children <5 years because of the lack of data. • In the absence of data of safety and efficacy in children younger than 5 years, it is probably better to be cautious, until such data are produced. • All documents agree that LABA should only be prescribed in combination with ICS and are therefore relevant as add on treatment.
  199. 199. • The need for additional controller treatment should be re-evaluated at each visit and maintained for as short a period as possible, taking into account potential risks and benefits. • There are insufficient data about the efficacy and safety of inhaled combination ICS/long-acting beta2- agonist (LABA) products in this age group to recommend their use.
  200. 200. -- There is no clear evidence of benefit with sodium cromoglicate in children aged <5 -- Theophyllines have some beneficial effect -- Antihistamines and ketotifen are ineffective.
  201. 201. 208 Actions to consider: 1. Assess whether the medications are being taken as prescribed. 2. Assess whether the medications are being inhaled with correct technique. 1. Adjust medications, as needed; either step up if control is inadequate or step down if control is maximized, to achieve the best control with the lowest dose of medication.
  202. 202. 209 REVIEWING RESPONSE AND ADJUSTING TREATMENT • Asthma-like symptoms remit in a substantial proportion of children of 5 years or younger, so the need for continued controller treatment should be regularly assessed (e.g. every 3–6 months) . • If therapy is discontinued, schedule a follow-up visit 3–6 weeks later to check whether symptoms have recurred .
  203. 203. 210 • In practice, we have no drug strategies to reduce future risk of asthma; neither early use of continuous nor intermittent inhaled corticosteroids reduces the risk of progression to school age asthma • If inhaled drugs are prescribed, repeated education of the parents in the correct use of spacers is essential. • If inhaled drugs in particular do not seem to be working, check that they are being properly administered rather than escalate treatment.
  204. 204. 212 • Inhaled medications is a waste of money if not used properly • Poor technique is a barrier to good control • Check at each visit • Don’t rely on patient’s knowledge – ask them to demonstrate
  205. 205. 213
  206. 206. 214
  207. 207. 215 Spacers/Holding Chambers
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  209. 209. 217
  210. 210. 218 ©1998, Respironics Inc. ©1998, Respironics Inc. With SpacerWith Spacer Without SpacerWithout Spacer
  211. 211. 219
  212. 212. 220 Spacers/Holding Chambers • Recommended with all medium to high dose ICS • Enhance delivery, especially with children • Improves coordination and medication delivery – some provide auditory feedback • Minimize adverse effects from ICS – decrease oral bioavailability – reduce oral candidias (thrush) – dysphonia, and bad taste
  213. 213. Children’s Healthcare of Atlanta Fate of inhaled drugs – Good Technique Swallowed GI tract Deposited in lung Lungs Metabolism or absorption from the lung Liver Oral bioavailability Absorption from gut First-pass metabolism Systemic Circulation Mouth pharynx mucociliary clearance 80% 20% Schematic representation of potential dose distribution A Guide to Aerosol Delivery Devices for Respiratory Therapists. American Association for Respiratory Care. 1st Edition. Page 1. Webpage: http://www.aarc.org/education/aerosol_devices/ Adapted from Barnes et al. AJRCCM 1998;157:S1-S53
  214. 214. Children’s Healthcare of Atlanta Swallowed GI tract Deposited in lung Lungs Metabolism or absorption from the lung Liver Oral bioavailability Absorption from gut First-pass metabolism Systemic Circulation Mouth pharynx mucociliary clearance 95% 5% Schematic representation of potential dose distributionAdapted from Barnes et al. AJRCCM 1998;157:S1-S53 A Guide to Aerosol Delivery Devices for Respiratory Therapists. American Association for Respiratory Care. 1st Edition. Page 1. Webpage: http://www.aarc.org/education/aerosol_devices/ Fate of inhaled drugs – Poor Technique
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