Tracking and treating asthma in young children

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1 PEDIATRIC ASTHMA UPDATE FOR PRIMARY CARE PROVIDERS SERIES EDITOR: KENAN HAVER, MD Tracking and treating asthma in young children ABSTRACT: The use of a signs-based diary can be a valuable tool for monitoring asthma in young children who cannot use peak flow meters. By keeping a record of their child s coughing, wheezing, retractions, and respiratory rate, parents can learn whether their child has persistent asthma, learn to identify triggers, and learn to identify the early signs of worsening asthma. Each asthma sign is scored on the basis of frequency or severity. The total score tells parents how severe the episode is and guides treatment. The results are classified into 1 of 4 color-coded asthma zones, each of which has a specific action plan. In the High Yellow Zone, the parent doubles the dosage of an inhaled corticosteroid and gives an inhaled ß 2 -agonist. Children in the Red Zone the danger zone should receive an inhaled ß 2 -agonist and prednisolone; if this does not get them out of the danger zone within 10 minutes, and if they do not stay out of that zone for 4 hours, they should go to the emergency department or to their doctor s office if the office is equipped for emergencies. (J Respir Dis Pediatrician. 2003; 5(2):67-72) THOMAS F. PLAUT, MD Copyright 2003 Pedipress, Inc. Children who are younger than 5 years are hospitalized for asthma more frequently than older children. There are several reasons for this for example, their airways are smaller, and they have more frequent upper respiratory tract infections, which are a major asthma trigger. However, it is also true that it is generally more difficult to monitor asthma in young children because they cannot use peak flow meters and often cannot describe their symptoms. This makes it more difficult for parents to assess the severity of an asthma episode. This problem can be overcome if parents use a diary based on 4 common signs of asthma. In this article, I will describe an asthma diary for children younger than 5 years. I will also discuss action plans for young children based on these common signs. MAKING THE DIAGNOSIS In 1988, I studied hospitalizations of children with lower respiratory tract diseases in 6 HMOs that had developed protocols for managing Dr Plaut directs Asthma Consultants in Amherst, Massachusetts. He is the author of several books on asthma, including One Minute Asthma: What You Need to Know, and Dr. Tom Plaut s Asthma Guide for People of All Ages. 67

2 Tracking and treating asthma in young children asthma. 1 When I compared their data covering 983,000 enrollee years with US data, I found that the HMO children were hospitalized for bronchitis/bronchiolitis (ICDM 466) and pneumonia (ICDM ) at less than 33% of the national rate. I interpreted this to mean that many of the children hospitalized for bronchitis/bronchiolitis and pneumonia actually had asthma. My experience is that physicians who understand that children do not normally have bronchitis or pneumonia more than once in a year diagnose asthma more frequently than their counterparts. Once their asthma is properly diagnosed and treated, these children are hospitalized far less often. If the child s asthma is not diagnosed, it obviously can not be adequately controlled. In my view, the simplest way to diagnose asthma in young children with respiratory symptoms is to give them an inhaled ß-agonist. You can do this in the office by compressor-driven nebulizer or by metered-dose inhaler (MDI) using a holding chamber with mask. If the child improves after receiving the ß-agonist, the diagnosis of asthma is likely. If every child hospitalized for bronchitis or pneumonia received such a therapeutic trial, those children with asthma would receive proper treatment and be discharged earlier. Once parents know that their child has asthma, they can learn about this disease and intervene early if you have given them a specific plan. I tell parents, Your child has a lower respiratory tract illness. He improved with asthma medicine. If this happens again, we are going to call it asthma. He may outgrow the problem by age 6; a lot of children do. But you ought to know how to take care of it so that you can avoid the need for emergency care and hospitalization. The classification of asthma is based primarily on the frequency of signs of the disease. Children who have signs 2 or fewer days a week have intermittent asthma and can ordinarily be treated as needed. Children who have signs more than 2 days a week need to take a controller medicine daily to reduce the frequency and severity of episodes. About 70% of children with asthma fall into this category. THE ASTHMA SIGNS DIARY To monitor asthma, I measure peak flow in all of my patients who are older than 4 years and track their status using the Asthma Peak Flow Diary. Since peak flow monitoring is not feasible in younger children, I developed a diary based on the signs of asthma. Parents and clinicians use this to guide their assessment and treatment of young children with asthma. There are more than 20 signs and symptoms of asthma. I decided Table Steps in filling out an asthma signs diary Set up the daily columns Score each of the 4 signs of asthma, record each score, and calculate the total score of asthma signs Plot the total score of asthma signs to determine the asthma treatment zone Connect the daily sign scores to detect the pattern Check off asthma medications taken each day Record triggers, events, and other important comments Score activity and sleep to base my diary on signs, which are objective, rather than symptoms, which rely on a child s report. Because I wanted parents to be able to score these signs in terms of severity or frequency, I chose signs that are common, are easy to score, appear early, and worsen as an episode progresses. By using common signs, I was able to create a system that worked well for almost all patients. By using signs that appear early, I was able to teach parents to intervene in a timely fashion. By using signs that worsen as the episode progresses, I was able to devise a scoring system that offered a stepwise guide to treatment. The 4 major signs The diary tracks 4 major signs of asthma: cough, wheeze, retractions, and increased respiratory rate. The steps in filling out the asthma signs diary are shown in the Table. Cough: The most common sign of asthma is cough. It is much more common than wheeze. It is scored on a scale of 0 to 3, based on its frequency per minute. A cough occurring less than once a minute scores 1, between 1 and 4 times a minute scores 2, and more than 4 times a minute scores 3. Wheeze: This can be tricky, because it is not the loudness of the wheeze that counts but the timing in the expiratory cycle. A wheeze heard only at the end of expiration is the earliest type of wheeze and scores 1. A wheeze heard throughout expiration scores 3, and a wheeze heard during both inspiration and expiration scores 5. Parents do not use a stethoscope in this scoring system but may put their ear on the child s bare chest. In some critically ill children, they may not hear a wheeze, since no air can flow through airways that are 68

3 totally obstructed. Such children will show one of the emergency signs of asthma, such as cyanosis, inability to speak sentences, or breathing hunched over. Retractions: Intercostal, substernal, and supraclavicular retractions score 1 if they are barely noticeable, 3 if they are obvious, and 5 if they are severe. Please note that a slim child may show retractions in the absence of respiratory distress, whereas a chubby child will be late to exhibit them. It is easy to demonstrate retractions to parents if the child is having labored breathing. If the child is well, you can show them an illustration. Increased respiratory rate: The fourth sign breathing faster is based on the child s normal respiratory rate. This is scored in increments of 5. If the child is breathing up to 5 breaths faster than normal, it scores 1; 6 to 10 breaths more, 2; and more than 10 breaths, 3. You can use 24 as the normal respiratory rate until you establish the child s actual rate. In this case, score 1 if the child takes 25 to 29 breaths per minute, score 2 if breathing 30 to 34, and score 3 if breathing more than 35 times a minute. Interestingly, an increase in respiration may be the first sign of an asthma problem in an infant. Keeping score The scores are totaled and plotted on a 3-color graph of asthma care zones: Green, High Yellow, Low Yellow, and Red (see Asthma Diary ). Parents use these zones to guide their child s treatment. The Green Zone: This is the okay zone. The child has no cough, wheezing, retractions, or increased respiratory rate, so the score is 0. The High Yellow Zone: A score ranging from 1 to 4 indicates that a mild episode is in progress, and the child needs a change in treatment. The score ranges from 1 to 4. The Low Yellow Zone: A score ranging from 5 to 8 indicates that a moderate episode is in progress and that the child needs more aggressive treatment. The Red Zone: A score of 9 or higher indicates a need to visit the doctor or emergency department. Dividing the Yellow Zone into High and Low allows parents to be much more specific in their treatment. The ideal therapy for someone with a very mild episode is not appropriate for a child who is practically a candidate for emergency care. A 4-zone plan encourages parents to take mild signs of asthma seriously. If parents intervene immediately when their child enters the High Yellow Zone, they will often be able to prevent an episode from worsening. Asthma diaries can be used by parents to: Collect accurate and detailed information about their child. Communicate clearly and concisely on the telephone. Identify triggers that provoke an episode. Identify asthma action zones. Determine whether an episode is worsening or improving. Determine the lowest effective dose of an inhaled corticosteroid. Asthma Action Plan An example of the Asthma Action Plan is shown on page 71. The Green Zone plan: This plan guides treatment for children with persistent asthma who are having no symptoms. It involves the daily use of a controller medication, usually an inhaled corticosteroid. The inhaled corticosteroid can be given by MDI using a holding chamber with mask or by compressor-driven nebulizer. I prescribe inhaled corticosteroids by MDI in a strength that requires no more than 2 puffs once a day. Keeping dosing to a minimum increases compliance. The High Yellow Zone plan: At this point, you have to reduce inflammation and dilate the airways. You double the dose of the inhaled corticosteroid or, if the child has not been taking one, you add an inhaled corticosteroid at a moderate dose. Also, you give an inhaled ß 2 - agonist, such as albuterol. If they are using a holding chamber with mask, most of my patients will take about 6 puffs a day, with a range of 3 to 24. The Low Yellow Zone plan: For the child in this zone, you must add an oral corticosteroid. My patients have prednisolone at home, and they usually take it without checking with me, since we discuss and review the indications for giving it at each visit. About a quarter of them used prednisolone once last year, and very few used it twice. This is because they double their dose of inhaled corticosteroids as soon as they enter the High Yellow Zone or at the first sign of a respiratory infection. To make sure that their child is really stuck in the Low Yellow Zone, parents give them 4 puffs of albuterol by MDI via holding chamber with mask, or they give albuterol by compressor-driven nebulizer. If the child escapes the Yellow Zone within 10 minutes and stays out of that zone for 4 hours, the parents continue the High Yellow Zone treatment plan. If not, they increase the dose or frequency of albuterol and add prednisolone. The Red Zone plan: After giving albuterol by MDI or compressor-driven nebulizer, the parents give a dose of an oral corticosteroid to jump-start treatment in case a visit to the emergency department is needed. If the child cannot escape the Red Zone within 10 minutes and does not stay out of that zone 69

4 0303JRDPPLAUT2.Lay 4/1/03 3:05 PM Page 70 Tracking and treating asthma in young children for 4 hours, he or she has to go to the emergency department or the doctor s office if the office is equipped for emergencies. Other uses of the diary The diary provides space to record possible triggers and comments each day, such as a visit to the zoo, a birthday party, an upper respiratory tract infection, or the beginning of pollen season. After recording a possible trigger, parents monitor their child s signs over the next 2 days. An increase in the signs score indicates that contact with a trigger occurred. If the signs score does not change, it is unlikely that 70 the contact is a trigger. Many parents and many doctors do not realize that the effects of asthma triggers are long-lasting and additive. An upper respiratory tract infection can cause bronchial hyperresponsiveness lasting several weeks.2 Even after the symptoms disappear, that child will be much more sensitive on contact with another trigger. Other information entered in the diary includes medicines by name, dose, and frequency and changes in activity and sleep. Unlike other diaries, the Asthma Signs Diary summarizes the child s status in a graphic form that the parent or physician can analyze at a glance. Since signs, triggers, comments, and medicines are all entered in a single column, the parents and physician can see how these factors interact. Parents find that the diary is an excellent tool for learning about their child s asthma. In the office, I can scan a patient s diary sheet in about a minute or two. After asking some clarifying questions, I can spend my time discussing environmental controls and treatment options. Parents of my patients keep a diary while they are learning about asthma the medicines, signs, symptoms, and triggers. Once their

5 0303JRDPPLAUT2.Lay 4/1/03 3:05 PM Page 71 71

6 Tracking and treating asthma in young children Practical help for you Clinical Consultation Do you have a question about a particularly troublesome diagnostic or therapeutic problem involving one of your respiratory patients? As a service to our readers, we endeavor to find qualified consultants to answer your clinical questions. Simply submit a brief description of the case and your query to The Journal of Respiratory Diseases for Pediatricians. The most interesting and broadly applicable questions and replies will be published in future issues. (Your name will be withheld on request.) Follow-up questions The experts who write articles for The Journal of Respiratory Diseases for Pediatricians stand ready to answer follow-up questions from readers. We also welcome letters discussing specific articles that have appeared in the journal or respiratory diseases in general. And we invite your suggestions for topics to consider in future issues. Address correspondence to: Editor The Journal of Respiratory Diseases for Pediatricians 330 Boston Post Road Box 4027 Darien, CT child s asthma is well controlled that is, they have signs of asthma less than 2 days a week they can stop keeping the diary every day. At this point, I suggest they resume recording whenever they make a change in their medication routine, if there are any signs of asthma, or if they anticipate a problem for example, if they expect to encounter a trigger. Many parents like to keep a diary during vacation as an indicator that their child s asthma needs attention. I ask parents to keep the diary for 1 week before they see me. Review of this diary plus the sheets they have accumulated since the last visit streamlines the history taking. I am able to spend my time analyzing data, rather than working with the parent to recall it. This leads to a more effective visit and increased patient satisfaction. I also use the diary to convince parents that their child has persistent asthma and needs a controller medicine daily. Although most parents can recognize a full-scale asthma episode, many simply are not aware that their child has a frequent mild cough. After explaining how to detect and score the 4 signs of asthma, I ask parents to record them in the diary. When the parents return a month later, the diary usually contains a record of signs that they have missed in the past. I let them know that although a mild cough does not seem like a problem, it does indicate that the airways are not clear and will overreact to a minor trigger. Parents whose child has a sign of asthma more than 2 days a week are usually willing to give a trial of inhaled corticosteroids for a month to learn whether this treatment will reduce the severity and frequency of their child s signs and episodes. Another important use of the Asthma Signs Diary is that it helps the doctor determine the lowest effective dose of an inhaled corticosteroid. You are supposed to start inhaled corticosteroids at a high level, and then lower the dosage after the child s asthma is under control. Parents who keep an asthma diary will see a recurrence in the signs of asthma when the inhaled corticosteroid dose is too low. Once a child has signs of asthma less than 2 days a week for a period of 2 months, you can reduce the dose by 25%. If no signs develop, you can keep them at that level for 2 months, and then lower the dosage again. If signs recur, you increase the dose to the previous step. Parents who understand this system appreciate the fact that you are serious about prescribing the minimum dose of corticosteroids needed to control their child s asthma. SUMMARY The Asthma Signs Diary is an excellent tool for learning about and tracking asthma in young children. An Asthma Action Plan based on the 4-zone diary gives parents a way to respond appropriately to every asthma scenario. REFERENCES 1. Plaut TF. Childhood asthma: a missed diagnosis. HMO Practice. 1991;5: Empey DW. Mechanisms of bronchial hyperreactivity in normal subjects after upper respiratory tract infection. Am Rev Respir Dis. 1976;113: SUGGESTED READINGS Plaut TF. One Minute Asthma: What You Need to Know. 5th ed. Amherst, Mass: Pedipress, Inc; Available at: com. Plaut TF. Dr. Tom Plaut s Asthma Guide for People of All Ages. Amherst, Mass: Pedipress, Inc; Available at: 72

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