Pediatrics asthma

Pediatric Asthma
what's new in GINA 2018

1. Pediatric Asthma W hat is New?? Dr. nazleen shakir

2. Objectives are to answer these questions When to diagnose asthma in a child?? Are there tests to aid in diagnosis?? What is Asthma Predictive Index API?? What are the goals of asthma management?? And how to achieve them?? What are the new guidelines for asthma management in children??

3. Pediatric Asthma T he most commonly encountered childhood chronic disease O ccurring in approximately 13.5% of children Due to the interplay between patient , family physician (the managing physician here), and the environment, asthma often proves challenging to control

4. Definition?? Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation It is defined by the history of respiratory symptoms such as wheezes, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitations.

5. Case Scenario A three years old boy presents to your office with complain of cough and wheeze for 3 weeks duration. He has history of eczema and two other episodes of wheeze during the last year W ould you diagnose asthma in this child??

6. Asthma-like symptoms?? Reactive airway disease?? Recurrent wheeze?? Recurrent wheeze occurs in large proportion of children 5 years and younger, typically with viral upper respiratory tract infections Deciding when this is the initial presentation of asthma is DIFFICULT Asthma in under 5 years Euphemisms with uncertain clinical usefulness

7. When to Diagnose asthma in under 5?? Asthma is likely in young children with history of wheeze when they have: Wheezing or coughing that occurs with exercise, laughing or crying in the absence of an apparent respiratory infection History of other allergic disease (eczema or allergic rhinitis) or asthma in the first degree relatives Clinical improvement during 2-3 months of controller treatment, and worsening after cessation

8. Are there tests to aid in diagnosis?? No tests diagnose asthma with certainty in under 5 years A therapeutic trial for at least 2-3 months with SABA and regular low dose ICS Tests for atopy ; skin prick test or allergen specific immunoglobulins (absence of atopy does not rule out asthma) Chest X-ray to exclude structural abnormalities when expected Lung function tests ?? Difficult in 4 years and younger FeNO (Fractional concentration of Exhaled Nitric Oxide); it is becoming popular In pre-school children with recurrent cough and wheeze, elevated FeNO >4 weeks from any URTI, predicted physician-diagnosed asthma at school age

9. What about the Asthma Predictive Index ?? Children ≤3 years who have ≥4 wheezing episodes that lasted one day or more PLUS either of the following will likely have persistent asthma after 5 years age Asthma in parents Physician-diagnosed atopic dermatitis (eczema) Positive skin test to aero-allergens Two Minor Criteria Eosinophilia (≥4%) Wheezing unrelated to cold Allergic sensitization to food One Major Criteria OR

10. Goals of asthma management?? Achieve asthma control (control of symptoms) Reduce the need for rescue inhalers Maintain near-normal pulmonary function and minimize impaired lung development and drug side effects Maintain normal activity levels (including exercise and other physical activity and attendance at school) Step-down therapy; minimum possible medication to maintain control Satisfy parents ' expectations for asthma care

11. Stepwise approach – pharmacotherapy ( children ≤5 years ) GINA Update 2018 GINA 2018 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 beta 2 -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

12. GINA 2018 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 beta 2 -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) GINA Update 2018

13. What was known???

14. What is NEW in GINA 2018?? Step 2 (initial controller treatment) for children with frequent viral-induced wheezing and with interval asthma symptoms A trial of regular low-dose ICS should be undertaken first As-needed (prn) or episodic ICS may be considered The reduction in exacerbations seems similar for regular and high dose episodic ICS (Kaiser Pediatr 2015) LTRA is another controller option

15. What is NEW in GINA 2018?? Step 3 (additional controller treatment) First check diagnosis, exposures, inhaler technique, adherence Preferred option is medium dose ICS L ow-dose ICS + LTRA is another controller option Blood eosinophils and atopy predict greater short-term response to moderate dose ICS than to LTRA (Fitzpatrick JACI 2016) Relative cost of different treatment options in some countries may be relevant to controller choices

16. Assessing severity and initiating therapy in children who are not currently on long term control medications Well controlled No well controlled

17. Children aged ≤5 years – key changes Home management of intermittent viral-triggered wheezing Pre-emptive episodic high-dose ICS may reduce progression to exacerbation (Kaiser Pediatr 2016) However , this has a high potential for side-effects, especially if continued inappropriately or is given frequently Family-administered high dose ICS should be considered only if the health care provider is confident that the medications will be used appropriately, and the child closely monitored for side-effects Emergency department management of worsening asthma Reduced risk of hospitalization when OCS are given in the emergency department, but no clear benefit in risk of hospitalization when given in the outpatient setting (Castro-Rodriguez Pediatr Pulm 2016) What’s new in GINA 2018?

18. Inhalers OR Nebulizers??? MDI are as effective as Nebulizers for asthma exacerbations

19. Choosing an inhaler for children under 5 years 0-3 years Preferred device: pMDI + Spacer with face mask Alternatives: Nebulizer with face mask 4-5 years Preferred device: pMDI + Spacer with mouth piece Alternatives: pMDI + Spacer with face mask or Nebulizer with mouth piece or face mask

20. ‘Low dose’ inhaled corticosteroids (mcg/day) for children ≤5 years – updated 2018 This is not a table of equivalence A low daily dose is defined as the lowest approved dose for which safety and effectiveness have been adequately studied in this age group Inhaled corticosteroid Low daily dose, mcg (with lower limit of age-group studied) Beclometasone dipropionate (HFA) 100 (ages ≥5 years) Budesonide (nebulized) 500 (ages ≥1 year) Fluticasone propionate (HFA) 100 (ages ≥4 years) Mometasone furoate 110 (ages ≥4 years) Budesonide ( pMDI + spacer) Not sufficiently studied in this age group Ciclesonide Not sufficiently studied in this age group Triamcinolone acetonide Not sufficiently studied in this age group

21. TREATMENT of acute exacerbations In young children (0-3 years), SABAs delivered by MDI with a spacer were more effective in reducing admission rates than nebulizers In older children (3-18 years), SABAs delivered via spacer reduced ED length of stay , but did not significantly affect hospitalization rates. Additionally, SABAs administered with anticholinergics such as ipratropium bromide were more effective than SABAs alone in reducing admissions Dexamethasone and prednisone are the 2 most commonly used systemic steroids , and studies haven't indicated superiority of either. There is no difference in efficacy between oral and intravenous steroids Recent clinical trial found a 2-day course of dexamethasone (0.6 mg/kg) had similar efficacy with fewer adverse effects when compared to a 5-day course of prednisone ( 1-2 mg/kg/day ) GINA 2018?

22. What are Non-pharmacological strategies for asthma management??? Education of parent/ carer and the child (depending on child’s age) Skill training for effective use of inhaler devices and encouragement of good adherence Monitoring of symptoms by parent/carer A written asthma action plan

23. ENVIRONMENTAL measures??? Removal of pets from home and most specifically from child’s bedroom Seal or filter air ducts that lead to child’s bedroom Maintain relative humidity below 50% Encase mattress and possibly pillows in mite allergen impermeable covers Launder bed linens in hot water (55◦ C) Remove carpeting if possible or vacuum weekly Stay indoor with windows closed during peak season especially in the afternoon Parents should stop smoking or smoke outside If smoking outside, wear a “smoking jacket” Don’t smoke in the car

24. Other changes Primary prevention of asthma A systematic review of randomized controlled trials on maternal dietary intake of fish or long-chain polyunsaturated fatty acids during pregnancy showed no consistent effects on the risk of wheeze, asthma or atopy in the child  (Best Am J Clin Nutr 2016) One recent study demonstrated decreased wheeze/asthma in pre-school children at high risk for asthma when mothers were given a high dose fish oil supplement in the third trimester ( Bisgard NEJM 2016) ; but ‘ fish oil’ is not well defined, and the optimal dosing regimen has not been established What’s new in GINA 2018?

25. Reducing the burden of asthma A voiding tobacco smoke exposure L essening maternal obesity Decreasing maternal antibiotic and acetaminophen use, and curtailing stress Evidence suggests that after birth , breastfeeding and reducing childhood obesity can help lower the risk of asthma Atopic disease, in general, can be reduced by breastfeeding until at least 4 months, as well as encouraging a varied diet that does not restrict potential allergens during pregnancy or lactation, and introducing foods ( including potential allergens) after the age of 4 months

26. Finally Key recommendations are Reassure parents that metered-dose inhalers are as effective as nebulizers for asthma exacerbations. A Use a 2-day course of systemic steroids for asthma exacerbations rather than extended regimens. B Develop an asthma action plan for every patient with asthma to decrease acute care visits. B Guidelines emphasize stepwise treatment, based on symptom severity, to maximize quality of life while minimizing morbidity Consider de-escalating care when symptoms are controlled to minimize adverse effects Inhaled SABA are the mainstay of treatment for intermittent asthma, as well as asthma exacerbations Self-management strategies reduces asthma morbidity in both adults and children. A Good communication by the health care providers is essential as the basis for good outcomes. B

27. References Global Initiative for Asthma (GINA 2018) National Heart, Lung, Blood Institute (NHLBI), EPR 3 National Asthma Education and Prevention Program (NAEPP )