1. Asthma in Children
October 29, 2002
Swedish Family Medicine
Jorge Garcia, MD

3. 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.

4. 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.

5. According to the above
information:
How would you classify this
patient's severity?
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent

6. Diagnosis of Asthma Severity
Diagnosis Days w/Sx Nights 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

7. What makes you think this is
ASTHMA?

8. 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%)

9. What is your differential?

10. Wheezing can be caused by:
 URIs
 Rhinitis
 Sinusitis
 CF
 Cardiac disease
 GERD
 Foreign body aspiration...

11. Workup?

12. New Asthma Dx:
 Confirm with PFT
 Consider Allergy testing if the child also
has significant allergic rhinitis.

13. With the diagnosis of Asthma
What are the findings on PFT?

14. 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.

15. 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.

16. 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.

17. What more would you want to
know about your patient?

18. Obtain a history to rule out
triggers
 What are some possible triggers of
RAD?

19. Obtain a history to rule out
triggers.
 What are some possible triggers of
RAD?

20. 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.

21. What is the best way to treat her
today?
 ?

22. “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.”

23. Moderate Persistent Asthma
(Step 3)
 High dose corticosteroid inhaler daily.
 Long acting daily bronchodilators.
 Short acting bronchodilator for
symptoms.

24. Asthma treatment by severity:
 Step 1; mild, intermittent
 days with symptoms: <2 times per week
 nights with symptoms <2 per month
 PEF>80% predicted.

25. 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.

26. Step one:
One inhaler...

27. 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%.

28. 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)]

29. Asthma treatment by severity:
Step 2; mild, persistent
 Short-acting bronchodilator as needed
for symptoms. Intensity of treatment
depends on severity of exacerbation:
 Inhaled short-acting beta2 agonist by
nebulizer or spacer/holding chamber
and face mask
or Oral beta2 agonist.

30. Step two:
Two inhalers...

31. 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%

32. Treatment of Asthma by severity:
Moderate Persistent Asthma
(Step 3)
 High dose corticosteroid inhaler daily.
 Long acting daily bronchodilators.
 Short acting bronchodilator for
symptoms.

33. Step 3:
Rx with…?

34. Step 3:
3 inhalers...

35. 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.

36. Long acting daily bronchodilators.
 Salmeterol (Serevent MDI) $42.00
(Serevent Diskus DPI) $43.50
 Short acting bronchodilators for rescue
only: Albuterol.

37. Step 4: Severe and persistent Sx
 Days with symptoms: Continual
 nights with symptoms: Frequent
 PEF <60% predicted.

39. Usually add oral pred to Step 3
medications.
Treatment can be variable in step 4.

40. Step 4; severe, persistent
 Daily anti-inflammatory medications:
High-dose inhaled corticosteroid with
spacer/ holding chamber and face
mask
and
If needed, add systemic
corticosteroids (0.25 to 2 mg per kg
per day) and reduce to lowest daily or
alternate-day dosage that stabilizes
symptoms.

41. 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

42. 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.

43. 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.

44. Write out the PF Color Zones
 PF <50% Red Zone
 PF 50-80% Yellow Zone
 PF> 80%: Green Zone

45. Green Zone: PF > 80% of
personal best.
 No symptoms at all.
 Good Control.
 Continue taking regular medications.

46. 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.

47. Red Zone: PF < 50%
 Use Short Acting beta-2 Agonist:
Albuterol.
 Call doctor’s office, or seek medical
attention.

48. Kids die of Asthma.
Mortality rate increasing.

49. 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.

50. 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.

51. 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.

53. The end.
