Pediatric Asthma Management

Transcription

1 Asthma Updates: Overview Pediatric Asthma Management An Evidence-based Update Shannon Thyne, MD June 1, 2007 Acute Management Medication delivery Systemic steroids Discharge planning Long Term Management Ongoing assessment Environmental controls Medication Updates Levalbuterol vs. Albuterol Combination controller medications Case Presentation Wheezie, a 6 yo girl, developed a URI a few days ago, and has been coughing and having trouble breathing since last night, despite using her albuterol every 4 hours PMH: Asthma since age 3, no hospitalizations; 2 ER visits in the past year; prescribed prednisone in past but always throws it up VS: Afebrile, HR 120, R 45, O2 sat 96%. Exam: Alert, tachypneic, increased work of breathing, poor air movement bilaterally, occasional wheeze Multiple Choice Question You give Wheezie 3 back-to-back doses of albuterol/atrovent. Meanwhile, you decide to give an anti-inflammatory agent, but wish to avoid oral prednisone. Which of the following is the BEST option at this point? A. Give a dose of inhaled budesonide (Pulmicort) B. Give solumedrol IM C. Place an IV and give solumedrol D. Give the IV form of decadron orally E. Give oral montelukast (Singulair) Questions for the Acute Asthma Visit How do we best deliver bronchodilators? How do we best deliver systemic steroids? Should a patient be started on a medicine at the acute visit? Medication Delivery: Bronchodilators Bottom line: Equivalent doses of albuterol by MDI/spacer are just as effective as nebulizer, even in the acute setting! Cost-effectiveness in ED Depends on availability of meds, equipment MDI preferred by parents 1

2 Medication Delivery: Recommendations Medication Delivery: Technique Use MDI/Spacer during acute visits whenever possible Reinforces use for the parent May be cost-effective 8 puffs from MDI = 2.5mg unit neb dose ALL patients should learn MDI/spacer technique!!! Spacers are great for all ages! (Yes, even adults) Good seal over nose AND mouth One puff at a time Count five breaths Systemic Steroids: Background Effective and safe in children Prevent hospitalization Reduce duration of symptoms Most effective when given early Oral and IV/IM routes equivalent efficacy Evidence from asthma, croup Problem: Oral prednisone poorly tolerated, compliance variable Systemic Steroids: Dexamethasone Longer half-life than prednisone (36-72 hours) Safety well-established The IV form (4mg/ml) can be given PO, very well-tolerated Efficacy in asthma? Two doses 24 hours apart shown better tolerated and equally effective as 5 days of prednisone in one RCT Multiple Choice Question You begin your patient on 3 back-to-back doses of albuterol/atrovent. Meanwhile, you decide to give an anti-inflammatory agent, but wish to avoid oral prednisone. Which of the following is the BEST option at this point? A. Give a dose of inhaled budesonide (Pulmicort) B. Give solumedrol IM C. Place an IV and give solumedrol D. Give the IV form of decadron orally E. Give oral montelukast (singulair) Case Continued Wheezie requires a 3 day hospital stay 2 weeks later, she returns to her PCP s office with a mild exacerbation, triggered by a rabbit at school She is evaluated by a pediatrician who is not the PCP and responds well to 2 albuterol treatments What can be done in the urgent care visit to improve her asthma control? 2

3 Moving Away from Traditional Asthma Care Stabilization in acute care setting, referral to PCP for long-term plan and education The traditional model is failing High risk children are also most likely to use the urgent care environment for episodic care Guidelines are not always followed Proposed role of emergency provider: Initiation of Long-Term Treatment Education Discharge Planning: Evidence Current NHLBI guidelines: Inhaled corticosteroids (ICS) are 1 st -line for persistent asthma in children Cochrane review of RCT s with adults and children: Initiating ICS at discharge reduces relapses and hospitalizations Benefit less significant when receiving systemic steroids Expert consensus: Supports initiation of ICS for children in the acute setting Discharge Planning: Recommendations Incorporate chronic asthma management into the acute asthma visit! Classify asthma severity Treat based on severity Give all patients an Action Plan Provide education Arrange follow-up Quick and Dirty Asthma Classification RULE OF TWO S: More than 2 daytime symptoms/week or More than 2 night symptoms/month or More than 2 ER visits/hospitalizations/yr = PERSISTENT ASTHMA So if we can initiate chronic asthma management in the acute setting, then what is the role of the primary care clinician??? 3

4 Case Continued After the rabbit incident, Wheezie was given a refill for her bronchodilator to use as needed and a low dose ICS which she has been using twice daily for 2 weeks. She returns to your office today and is completely symptom free. Question What is the best course of action? A. Stop the controller since she is now feeling better B. Continue the controller until she has been controlled for 1-3 months C. Continue the controller until she has been controlled for 6-12 months What other interventions can supplement her current regimen? Long Term Management: Ongoing Assessment The NHLBI guidelines recommend a stepwise approach to asthma Recommendations: After a step-up in therapy such as addition of inhaled corticosteroid, reassess after 1 month After a step-down in therapy, reassess after 3 months All patients with asthma should be evaluated 2x annually, even if stable, to review medications and to reinforce prevention Question What is the best course of action? A. Stop the inhaled steroid and go back to prn albuterol only B. Continue the inhaled steroid until she has been well controlled for 1-3 months C. Continue the inhaled steroid for 6-12 months What other interventions can supplement her current regimen? Long Term Management: Environmental Controls Long Term Management: Environmental Controls Recent evidence supports the aggressive institution of environmental controls in the management of childhood asthma Inner City Asthma Study Decreased tobacco exposure and allergen exposure Symptom reduction effect size SIMILAR to that of inhaled corticosteroids! Skin testing and/or comprehensive allergy history for all children with asthma Use of mattress and pillow covers for those with evidence of atopic asthma Consider antihistamine for patients with atopic asthma Tobacco and other irritant avoidance Instruction in allergen reduction 4

5 Case continued You decide to continue Wheezie s inhaled steroid for a little longer and skin testing reveals allergy to dust mites, grass, and cats. You recommend bedcovers and minimized exposure to cats and grass, review the action plan, and send Weezie on her way. Over the next few months you are able to get her off the inhaled steroids and she is back on prn albuterol, needing this less than once per month. Nice work Several years later Wheezie has been symptom free for a long time, but as she enters junior high school, she has poor control, especially during soccer season. Her mother asks whether she can get Wheezie started on the fancy albuterol and maybe even that disc thing because she s heard that it works well for kids with exercise-induced asthma. Medication Updates: Levalbuterol (Xopenex) vs. Albuterol Both improve clinical status Evidence does not support the use of one medication over the other in terms of bronchodilatory effects or side effect profile at equivalent dosing Cost Depends on how dosed Availability Different insurance plans now covering either Albuterol HFA or Levalbuterol as mainstay of bronchodilator therapy Dosing Med Levalbuterol Albuterol Nebulized 0.63 mg 2.5 mg MDI 1-2 puffs q 4-6 hr 2 puffs q 4 hr Medication Updates: Inhaled Corticosteroids + Long Acting Beta Agonist Combinations (Advair) 2005 Black Box warning issued Evidence of increased asthma deaths, respiratory-related deaths and life- threatening events among patients on salmeterol (SMART Study) 2006 Meta-analysis Additional evidence that these risks exist in children and in those also using inhaled corticosteroids in conjunction the LABAs Medication Updates: ICS/Long Acting Beta Agonist Combos ICS/LABA combination medications should not routinely be used in asthma management! Consider these medications only when patients are not sufficiently controlled using low or moderate dose inhaled corticosteroids Inform patients/families of risks Wean as soon as control is achieved So what should you prescribe for Wheezie now? Choose bronchodilator based on insurance coverage Consider using ICS/LABA if she remains symptomatic after treatment with low and moderate doses of ICS over a 1-2 month period If started on ICS/LABA, reassess every 1-2 months and decrease as soon as possible 5

6 The good news Wheezie responds well to treatment with low dose ICS, makes it through soccer season with only occasional albuterol use She later gets a scholarship to play soccer at a very fancy university on the east coast and no one even knows she has asthma because she is so well controlled! Thank you! 6