asthma in children l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Asthma in Children PowerPoint Presentation
Download Presentation
Asthma in Children

Loading in 2 Seconds...

play fullscreen
1 / 53

Asthma in Children - PowerPoint PPT Presentation


  • 229 Views
  • Uploaded on

Asthma in Children. October 29, 2002 Swedish Family Medicine Jorge Garcia, MD. Case 1: Naomi J. CASE 1

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Asthma in Children' - jacob


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
asthma in children

Asthma in Children

October 29, 2002

Swedish Family Medicine

Jorge Garcia, MD

slide3

CASE 1

  • An 7-year old girl has just moved into town and presents to her doctor. She has history of wheezing and rhinitis and recurrent otitis media since infancy. Over the past 2 years her symptoms have worsened. She complains of coughing and SOB daily and claims to awaken at least once a week in the middle of the night by these symptoms.
slide4

Her family history consists of maternal asthma, and atopy in both parents. Physical exam finds inflamed nose, mild wheezing, otherwise unremarkable. The patient's mother states that her daughter was previously prescribed an albuterol puffer to use prn, which her daughter uses daily and requires monthly refills. The child is able to remain active. In the past year she has had 4 courses of prednisone.

slide5

According to the above information:

How would you classify this patient's severity?Mild intermittent Mild persistent Moderate persistent Severe persistent

slide6

Diagnosis of Asthma Severity

DiagnosisDays w/SxNights w/Sx PEF

(Step)(% personal best) or FEV2

% predicted best)

severe persistent(4) Continual Frequent <60

moderate persistent(3) Daily >5 / month 60-80

mild persistent(2) >2/wk 3 to 4 / month >80

mild intermittent(1)<2 /wk <2 per month >80

suspect asthma with
SUSPECT ASTHMA WITH:
  • Intermittent wheezing, cough, dyspnea.
  • Increased rate of breathing.
  • Sx worse at night and in early morning.
  • Associated with triggers.
  • Onset before age 5. (80%)
wheezing can be caused by
Wheezing can be caused by:
  • URIs
  • Rhinitis
  • Sinusitis
  • CF
  • Cardiac disease
  • GERD
  • Foreign body aspiration...
new asthma dx
New Asthma Dx:
  • Confirm with PFT
  • Consider Allergy testing if the child also has significant allergic rhinitis.
with the diagnosis of asthma

With the diagnosis of Asthma

What are the findings on PFT?

slide14
PFT
  • Increase in forced expiratory volume in one second (FEV1) of 12 percent or more after bronchodilator therapy.
  • variable airflow obstruction (20 percent or more) with serial spirometry or peak expiratory flow (PEF).
  • Not reliable in kids <3-4.
slide15

CASE 1: Naomi J.

  • An 7-year old girl has just moved into town and presents to her doctor. She has history of wheezing and rhinitis and recurrent otitis and sinusitis since infancy. Over the past 2 years her symptoms have worsened. She complains of coughing and SOB daily and claims to awaken at least once a week in the middle of the night by these symptoms.
slide16

Her family history consists of maternal asthma, and atopy in both parents. Physical exam finds inflamed nose, mild wheezing, otherwise unremarkable. The patient's mother states that her daughter was previously prescribed an albuterol puffer to use prn, which her daughter uses daily and requires monthly refills, but the patient is able to remain active. In the past year she has had 4 courses of prednisone.

obtain a history to rule out triggers
Obtain a history to rule out triggers
  • What are some possible triggers of RAD?
obtain a history to rule out triggers19
Obtain a history to rule out triggers.
  • What are some possible triggers of RAD?
slide20

dust mites and mold spores, pollen

animal dander,

cockroaches,

indoor and outdoor pollutants,

irritants (e.g., tobacco smoke, smoke from wood-burning stoves or fireplaces, perfumes, cleaning agents),

pharmacologic triggers (e.g., aspirin or other nonsteroidal anti-inflammatory drugs, beta blockers and sulfites),

physical triggers (e.g., exercise, hyperventilation, cold air)

physiologic factors (e.g., stress, gastroesophageal reflux, respiratory infection [viral, bacterial] and rhinitis).

Kitchen sink.

slide22

“Treatment of children with asthma should begin with the most aggressive therapy necessary to achieve control, followed by "stepping down" to the minimal therapy that will maintain control.”

moderate persistent asthma step 3
Moderate Persistent Asthma (Step 3)
  • High dose corticosteroid inhaler daily.
  • Long acting daily bronchodilators.
  • Short acting bronchodilator for symptoms.
asthma treatment by severity
Asthma treatment by severity:
  • Step 1; mild, intermittent
  • days with symptoms: <2 times per week
  • nights with symptoms <2 per month
  • PEF>80% predicted.
asthma treatment by severity step 1 mild intermittent
Asthma treatment by severity:Step 1; mild, intermittent
  • No daily preventive meds needed: treat symptoms only.
  • Treatment should be required no more than 2/week.
  • Short acting beta-2 agonist: Albuterol MDI with face mask or spacer.
  • Cost: $30-50/ canister.
step one

Step one:

One inhaler...

asthma treatment by severity step 2 mild persistent
Asthma treatment by severity:Step 2; mild, persistent
  • Days with symptoms >2 times per week
  • Nights with symptoms: >2 per month but less than 5 times/month.
  • percent predicted PEF >80%.
asthma treatment by severity step 2 mild persistent28
Asthma treatment by severity:Step 2; mild, persistent
  • Daily anti-inflammatory medications:
  • Cromolyn (Intal) inhaler $47.00 Nedocromil (Tilade) inhaler $36.00
  • or Low- to medium dose inhaled corticosteroid [range of prices: Budesonide (Pulmicort Turbuhaler DPI), 200 µg per puff $19.00 to Fluticasone (Flovent), 44 µg per puff $47.00 (13-g canister)]
asthma treatment by severity step 2 mild persistent29
Asthma treatment by severity:Step 2; mild, persistent
  • Short-acting bronchodilatoras needed for symptoms. Intensity of treatment depends on severity of exacerbation:
  • Inhaled short-acting beta2 agonist by nebulizer or spacer/holding chamber and face maskor Oral beta2 agonist.
step two

Step two:

Two inhalers...

treatment of asthma by severity moderate persistent asthma step 3
Treatment of Asthma by severity: Moderate Persistent Asthma (Step 3)
  • Day time symptoms:Daily
  • Night time symptoms>5 times per month
  • PEF >60 to <80%
treatment of asthma by severity moderate persistent asthma step 332
Treatment of Asthma by severity: Moderate Persistent Asthma (Step 3)
  • High dose corticosteroid inhaler daily.
  • Long acting daily bronchodilators.
  • Short acting bronchodilator for symptoms.
step 3

Step 3:

Rx with…?

step 334

Step 3:

3 inhalers...

high dose corticosteroid inhaler daily
High dose corticosteroid inhaler daily.
  • Beclomethasone (Vanceril DS MDI), 84 µg per puff $42.00
  • Fluticasone (Flovent 220 µg per puff $95.50
  • Reduce to lower dose once symptoms controlled.
long acting daily bronchodilators
Long acting daily bronchodilators.
  • Salmeterol (Serevent MDI) $42.00 (Serevent Diskus DPI) $43.50
  • Short acting bronchodilators for rescue only: Albuterol.
step 4 severe and persistent sx
Step 4: Severe and persistent Sx
  • Days with symptoms: Continual
  • nights with symptoms: Frequent
  • PEF <60% predicted.
usually add oral pred to step 3 medications

Usually add oral pred to Step 3 medications.

Treatment can be variable in step 4.

step 4 severe persistent
Step 4; severe, persistent
  • Daily anti-inflammatory medications:
        • High-dose inhaled corticosteroid with spacer/ holding chamber and face maskand
        • If needed, add systemiccorticosteroids (0.25 to 2 mg per kg per day) and reduce to lowest daily or alternate-day dosage that stabilizes symptoms.
what is the role of antileukotrienes
What is the role of Antileukotrienes ?
  • “In patients with chronic asthma who are symptomatic while receiving moderate-to-high doses of inhaled beclomethasone, the addition of 2 to 4 times the licensed dose of antileukotriene (AL) agents reduces the rate of exacerbations that require systemic corticosteroids. Insufficient evidence exists that AL confers benefit over doubling the dose of corticosteroids or that it has an inhaled corticosteroid-sparing effect.”
  • Cochrane Database Syst Rev. 2002;(1):CD003133
what is the role of antileukotrienes42
What is the role of Antileukotrienes ?
  • They are new drugs, and expensive.
  • The doses that seem to work are higher than marketed recommendations.
  • They may help in Step 3 and 4, to reduce exacerbations, and reduce need to increase dose of inhaled steroids.
  • No worrisome side effects…yet.
home severity monitoring may help keep kids out of the hospital
Home severity monitoring may help keep kids out of the hospital.
  • First, determine their “Personal Best”
  • Ask them to check PF a few times each day, for two weeks, when asthma in good control.
write out the pf color zones
Write out the PF Color Zones
  • PF <50% Red Zone
  • PF 50-80% Yellow Zone
  • PF> 80%: Green Zone
green zone pf 80 of personal best
Green Zone: PF > 80% of personal best.
  • No symptoms at all.
  • Good Control.
  • Continue taking regular medications.
yellow zone pf 50 80
Yellow Zone: PF 50%-80%
  • CAUTION! Need rescue meds:
  • Use short acting Beta-2 agonist (Albuterol MDI or nebulizer).
  • Consider increasing dose of medication.
  • Monitor PF more frequently.
red zone pf 50
Red Zone: PF < 50%
  • Use Short Acting beta-2 Agonist: Albuterol.
  • Call doctor’s office, or seek medical attention.
kids die of asthma

Kids die of Asthma.

Mortality rate increasing.

who is at risk of dying of asthma
Who is at risk of dying of asthma?
  • Severe disease: 1-2% of these kids will die of asthma.
  • Hx: prior hospitalization, steroid need.
  • Symptoms triggered by foods.
  • Self weaning, esp. off steroids.
  • Lack of parental care.
  • Poor, African-American, boys.
however in large study of asthma deaths
However…in large study of asthma deaths:
  • 33% had mild asthma.
  • 34% had no prior hospitalization.
  • A minority of patients (15-30%) die suddenly, within two hours of onset of dyspnea.
when assessing a sick asthmatic
When assessing a sick asthmatic:
  • If they are unable to lie down, the severity is moderate of great, and they will need more aggressive work up and treatment.