Download PRACTALL CONSENSUS REPORT

DIAGNOSIS AND TREATMENT
OF ASTHMA IN CHILDHOOD:
A PRACTALL CONSENSUS REPORT
L. B. Bacharier, A. Boner, K.-H. Carlsen, P. A. Eigenmann, T. Frischer, M. Gçtz,
P. J. Helms, J. Hunt, A. Liu, N. Papadopoulos, T. Platts-Mills, P. Pohunek,
F. E. R. Simons, E. Valovirta, U. Wahn, J. Wildhaber –
The European Pediatric Asthma Group Allergy 2008; 63: 5
The PRACTALL consensus report describes asthma in
children as “repeated attacks of airway obstruction
and intermittent symptoms of increased airway
responsiveness to triggering factors, such as exercise,
allergen exposure and viral infections”.
DIAGNOSIS AND TREATMENT
OF ASTHMA IN CHILDHOOD:
A PRACTALL CONSENSUS REPORT
L. B. Bacharier, A. Boner, K.-H. Carlsen, P. A. Eigenmann, T. Frischer, M. Gçtz,
P. J. Helms, J. Hunt, A. Liu, N. Papadopoulos, T. Platts-Mills, P. Pohunek,
F. E. R. Simons, E. Valovirta, U. Wahn, J. Wildhaber –
The This
European
Pediatric Asthma
Group more
Allergydifficult
2008; 63: 5
definition
becomes
to apply confidently in infants and
children of preschool age who present
The PRACTALL consensus report describes asthma in
with recurrent episodes of coughing
children as “repeated
attacks
of airway obstruction
and/or
wheezing.
and intermittent symptoms of increased airway
responsiveness to triggering factors, such as exercise,
allergen exposure and viral infections”.
PRACTALL CONSENSUS REPORT:
INCIDENCE AND PREVALENCE OF PEDIATRIC ASTHMA
Incidence of pediatric wheezing
18 16 –
Incidence (in %)
14 -
12 10 8 6 4 2 0
1
2
3
4
5
6
7
8
Age (years)
9
10
11
12
13
PRACTALL CONSENSUS REPORT:
INCIDENCE AND PREVALENCE OF PEDIATRIC ASTHMA
Incidence of pediatric wheezing
18 16 –
According to prospective birth cohort
studies, up to 50% of all infants and
children younger than 3 years will have
at least 1 episode of wheezing.
However, 60% of children with infantile
wheeze will be healthy at school age.
Incidence (in %)
14 -
12 10 8 6 4 2 0
1
2
3
4
5
6
7
8
Age (years)
9
10
11
12
13
PRACTALL CONSENSUS REPORT:
INCIDENCE AND PREVALENCE OF PEDIATRIC ASTHMA
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A COMMUNITY-BASED STUDY OF EPIDEMIOLOGY OF ASTHMA
Yunginger ARRD 1992, 146: 888
%
females
4000 –
males
3000 –
 From Jan 1, 1964
through Dec 31, 1983
 Population-based
computer-linked
medical diagnosis
2000 –
1000 –
0
yrs
<1
1-4
5-9
10-14 15-29
30-49
>50
A COMMUNITY-BASED STUDY OF EPIDEMIOLOGY OF ASTHMA
Yunginger ARRD 1992, 146: 888
%
females
4000 –
males
 From Jan 1, 1964
Asthma shows its peak
of incidence
through
Dec 31, 1983
in the first 1-4years
of life
Population-based
and 80% of asthmacomputer-linked
has its onset
medical
diagnosis
before the age of
4 years.
3000 –
2000 –
1000 –
0
yrs
<1
1-4
5-9
10-14 15-29
30-49
>50
PRACTALL CONSENSUS REPORT:
WHEEZING PATTERNS
Hypothetical peak prevalence for 3 different wheezing phenotypes
PRACTALL CONSENSUS REPORT:
WHEEZING PATTERNS
1.Transient (early) wheezing
2.Nonatopic wheezing
3.Persistent asthma
4.Severe intermittent wheezing
PRACTALL CONSENSUS REPORT:
ASTHMA PHENOTYPES
No
PRACTALL CONSENSUS REPORT:
AGE AND ASTHMA PHENOTYPES
 Preschool children (ages 3 to 5 years)
Virus-induced asthma > allergen-induced asthma >
exercise induced asthma
 School children (ages 6 to 12 years)
Allergen-induced asthma > virus-induced asthma >
exercise induced asthma
 Adolescents (older than 12 years)
Allergen-induced asthma > virus-induced asthma >
exercise induced asthma
PRACTALL CONSENSUS REPORT:
ASTHMA PHENOTYPES
1) According to the PRACTALL consensus report,
age and triggers can be used to define different
phenotypes of disease.
2) These phenotypes are likely to be useful because
they recognize the heterogeneity of childhood
asthma.
3) Asthma phenotypes do not represent separate
diseases, but are part of the
“asthma syndrome”.
PRACTALL CONSENSUS REPORT:
ASTHMA PHENOTYPES
Allergen-induced asthma
1) Allergen-induced asthma is more common in
school-age children than in children of
preschool age.
2) If a clinically relevant association between
exposure and symptom occurrence is suspected,
allergen-induced asthma is the likely diagnosis.
3) The risk of acquiring atopy and allergic asthma
continues during adolescence.
PRACTALL CONSENSUS REPORT:
ASTHMA PHENOTYPES
1)
2)
3)
4)
Exercise-induced asthma
Exercise-induced asthma can be a unique phenotype
in children aged 3 to 5 years.
It may be the primary clinical manifestation in
patients with mild intermittent disease
(ie, isolated exercise-induced asthma).
Patients with isolated exercise-induced asthma
are free of symptoms for extended periods in
the absence of triggers.
Asthma symptoms in isolated EIA are frequently
reported in association with viral infections of
the upper respiratory tract, though.
PREVALENCE OF EXERCISE-INDUCED
ASTHMA IN CHILDREN
In
the general population is between 6% and 13%.
Among
adolescent athletes EIA estimates reach 12%.
EIA
is found in up to 90% of asthmatics and in
up to 40% of patients with allergic rhinitis.
EIA
is usually more prevalent in children than
in adults, most likely because children are
physically more active.
PREVALENCE OF EXERCISE-INDUCED
ASTHMA IN CHILDREN
In
the general population is between 6% and 13%.
Among
adolescent athletes EIA estimates reach 12%.
It is very likely that EIA
go
EIA is found inmay
up tofrequently
90% of asthmatics
and in
undiagnosed.
up to 40% of patients
with allergic rhinitis.
EIA
is usually more prevalent in children than
in adults, most likely because children are
physically more active.
DETERMINANTS OF AND RISK FACTORS
FOR EXERCISE-INDUCED ASTHMA
1) It is estimated that 91% of individuals with EIA
have a history of asthma or allergy, making it
the premier risk factor for EIA.
2) A child’s response to exercise may change
markedly from day to day.
3) Response depends on the mode of exercise
(eg, treadmill running, biking on ergometer,
swimming), environmental conditions, and the
child’s airway responsiveness that in turn may
be affected by viral infections, exposure to
allergens, and the current use of medications.
DETERMINANTS OF AND RISK FACTORS
FOR EXERCISE-INDUCED ASTHMA
4) The severity of bronchospasm in EIA is believed
to be related to the level of ventilation, to heat
and water loss from the respiratory tree, and
the rate of airway rewarming and rehydration
after exercise.
5) Reduction of the temperature and humidity of
the inspired air enhances bronchoconstriction
caused by isocapnic hyperventilation.
PRACTALL CONSENSUS REPORT:
ASTHMA PHENOTYPES
Virus-induced asthma
1) Viral infections are the most common trigger of
wheezing in preschool children and are still very
frequent among school-age children.
2) If symptoms are usually preceded by a cold, are
transient and disappear completely between
episodes, virus-induced asthma is the most likely
diagnosis according to the consensus report.
PRACTALL CONSENSUS REPORT:
PATHOPHYSIOLOGY
Interactions between airway tissue damage in early life caused by viral
infections and inhalant allergens in asthma etiology.
PRACTALL CONSENSUS REPORT:
PATHOPHYSIOLOGY
Interactions between airway tissue damage in early life caused by viral
infections and inhalant allergens in asthma etiology.
Low TH1 competence during
infancy is associated with
increased risk for respiratory
infection and respiratory allergy.
PRACTALL CONSENSUS REPORT:
DIAGNOSIS
1.Asthma should be suspected in any infant with
recurrent wheezing and coughing episodes.
2.Diagnosis is often only possible through
long-term follow-up, observations of the
child´s response to bronchodilator and/or
anti-inflammatory treatment and consideration
of the extensive differential diagnoses.
TO DIAGNOSE ASTHMA IN INFANTS
THINK OF THE “3R”
Reactivity
Reversibility
Recurrence
 There should be an identifiable
trigger usually a viral infection
 Airways obstruction is reversible
with bronchodilators
 Usually more than 3 episodes
Finder Curr. Probl. Pediatr. 1999; 29: 65
PRACTALL CONSENSUS REPORT:
CASE HISTORY
In all children, ask about:
Wheezing and/or coughing.
Specific triggers, such as exposure to passive smoke
or cold air, pets, humidity, mold and dampness,
respiratory infections, exercise/activity, coughing
after laughing or crying.
Altered sleep patterns (ie, awakening, night cough,
sleep apnea).
Number of exacerbations in the past year.
Nasal symptoms, including runny nose, itching,
sneezing, and blocking.
PRACTALL CONSENSUS REPORT:
CASE HISTORY
In infants (younger than 2 yrs), ask about:
Noisy breathing or vomiting associated with cough.
Retractions of the chest.
Difficulty with feeding
(eg, grunting sounds, poor sucking.
Changes in respiratory rate.
PRACTALL CONSENSUS REPORT:
CASE HISTORY
In children (older than 2 yrs), ask about:
 Shortness of breath (day or night).
 Fatigue (eg, decrease in play activity compared with peers,
increased irritability.
 Avoidance of other activities, such as sleep out or visit to
friends with pets.
 Complaints about not feeling well.
 Poor school performance or school absences.
 Reduced frequency or intensity of physical activity
(eg, in sports or gym classes).
 Specific triggers (eg, sports, exercise/activity.)
PRACTALL CONSENSUS REPORT:
CASE HISTORY
In children (older than 2 yrs), ask about:
 Shortness of breath (day or night).
 Fatigue (eg, decrease in play activity compared with peers,
increased irritability.
 Avoidance of other activities, such as sleep out or visit to
should also be asked if
friendsAdolescents
with pets.
they well.
smoke.
 Complaints about not feeling
 Poor school performance or school absences.
 Reduced frequency or intensity of physical activity
(eg, in sports or gym classes).
 Specific triggers (eg, sports, exercise/activity.)
PHYSICAL EXAMINATION
Listening to
forced expiration and a nasal examination
Key
..
clinical signs suggesting an atopic phenotype
include:
atopic eczema or dermatitis
dry skin
dark rings under the eyes (allergic shiners)
irritated conjunctivae
persistent edema of the nasal mucosa, nasal
discharge,
allergic salut and allergic crease on the bridge of
the nose.
ASSESSING LUNG FUNCTION
FEV1
FEV1/FVC
FEF25-75
ASSESSING LUNG FUNCTION
FEV1
An increase in (FEV1) of
FEV1/FVC
>12%suggests
a significant
bronchodilation.
FEF25-75
OTHER TESTS
a) Exercise testing
b) Exhaled nitric oxide
c) Eosinophil counting
d) Measures of bronchial hyperresponsiveness
e) Skin Prick Tests
f) Serum specific IgE
OTHER TESTS
a) Exercise testing
b) Exhaled nitric oxide
In vitro testing for allergen-specific
IgE doescounting
not provide more accurate
c) Eosinophil
results than skin prick testing but
d) Measures
bronchial
hyperresponsiveness
may beof
useful
if skin
prick testing
cannot be performed.
e) Skin Prick Tests
f) Serum specific IgE
DIFFERENTIAL DIAGNOSIS AND COMORBIDITIES
Aspiration of a foreign body.
Cystic fibrosis.
Structural abnormalities.
Aggravating factors, such as gastroesophageal
reflux and rhinitis, must be excluded.
PRACTALL CONSENSUS REPORT: PHARMACOLOGIC
MANAGEMENT OF PEDIATRIC ASTHMA
Goals of pharmacotherapy
Control of symptoms.
Prevention of exacerbations.
To allow the child to maintain normal
activities.
Without producing possible adverse medication
side effects.
DEFINING AND EVALUATING ASTHMA CONTROL
Asthma is well controlled when all of the following
are achieved and maintained:
Daytime symptoms twice or less per week
No limitations of activities because of asthma.
Night-time symptoms 0 to 1 per month
(0-2 per month if child is 12 years or older).
Reliever/rescue medication use is twice or less
per week.
Normal lung function (if able to measure).
0 to 1 exacerbations in the last year.
RELIEVER MEDICATIONS
The consensus report stresses that reliever
medications are taken as needed for immediate
relief of acute symptoms and before exercise
to prevent exercise-induced bronchospasm.
a) Short-acting ß-2 agonists
b) Ipratropium bromide
CONTROLLER MEDICATIONS:
(Inhaled corticosteroids - Leukotriene receptor antagonists
Long-acting beta-agonists)
According to the consensus report, controller
medications decrease the swelling and
inflammation in the airways and may reduce
mucous buildup.
Medications for long-term control
should be taken
daily to help maintain control of asthma and
prevent exacerbations.
The
main goal of regular controller therapy is
to reduce bronchial inflammation.
ALGORITHM OF PREVENTIVE PHARMACOLOGIC TREATMENT
FOR ASTHMA IN CHILDREN >2 YEARS OF AGE (PRACTALL GUIDELINES)
Bacharier Allergy 2008; 63: 5
ASTHMA TREATMENT IN CHILDREN AGED 0 TO 2 YEARS
A
diagnosis of asthma should be considered if
more than 3 episodes of reversible bronchial
obstruction have been documented within the
previous 6 months.
Intermittent
Leukotriene
ß2 agonists are the first choice.
Receptor Antagonists (LTRAs)
have been shown to reduce asthmatic episodes
in children aged 2 to 5 years, and
there is some evidence that they may be
beneficial in children 2 years and younger.
ASTHMA TREATMENT IN CHILDREN AGED 0 TO 2 YEARS
A
daily controller therapy with LTRAs for
viral-induced asthma (long- or short-term
treatment) should be considered.
Nebulized
or inhaled (metered-dose inhaler
[MDI] and spacer) corticosteroids can be
used as daily controller therapy for persistent
asthma, especially if severe or requiring
frequent oral corticosteroid therapy.
ASTHMA TREATMENT IN CHILDREN AGED 0 TO 2 YEARS
Evidence
of atopy/allergy lowers the threshold
for use of ICS and they may be used as
first-line treatment in such cases.
Use
of oral corticosteroids (eg, 1-2 mg/kg
prednisone) for 3 to 5 days during acute and
frequently recurrent obstructive episodes is
considered.
MANAGEMENT OF ACUTE ASTHMA EPISODES
Inhaled
short-acting ß2 agonists (spacer):
Two to four puffs (200 µg salbutamol equivalent)
every 10 to 20 minutes for up to 1 hour.
Children who have not improved should be
referred to a hospital.
Nebulized ß2 agonists: 2.5 to 5 mg salbutamol
equivalent can be repeated every 20 to 30
minutes.
Ipratropium bromide: This should be mixed with
a nebulized ß2 agonist solution at 250 µg/dose
and given every 20 to 30 minutes.
MANAGEMENT OF ACUTE ASTHMA EPISODES
High-flow
O2 (if available) to ensure normal
oxygenation.
Oral
and IV glucocorticosteroids are of similar
efficacy. Steroid tablets are preferable to
inhaled steroids. A dose of 1 or 2 mg/kg
prednisone or prednisolone should be given;
treatment for up to 3 days is usually sufficient.
LISTS COMMON ALLERGENS AND POTENTIAL
AVOIDANCE STRATEGIES
Allergen
Avoidance measure
Comments
Pets
Remove pet and
clean home,
especially carpets
and upholstered
surfaces.
Encourage schools
to ban pets
Allergen levels will
typically take up to
6 months after removal
of the pet from the
household to fall enough
to reduce asthmatic
reactions. However,
there is very little
evidence that not having
a pet will decrease the
risk of sensitization.
LISTS COMMON ALLERGENS AND POTENTIAL
AVOIDANCE STRATEGIES
Dust
mites
Avoidance measure
Wash
bedding and clothing in hot
water every 1–2 weeks at >56°C.
Freeze stuffed toys once per
week.
Encase mattress, pillows and
quilts in impermeable covers.
Use dehumidifying device and
ventilate room regularly.
LISTS COMMON ALLERGENS AND POTENTIAL
AVOIDANCE STRATEGIES
Cockroaches
Avoidance measure
Clean home.
Use professional
Encase mattress
pest control.
and pillows
in impermeable covers.
LISTS COMMON ALLERGENS AND POTENTIAL
AVOIDANCE STRATEGIES
Mold
Avoidance measure
Wash
moldy surfaces with weak
bleach solution.
Use dehumidifying equipment.
Fix leaks.
Remove carpets.
Use High Efficiency Particle
Arrestor filtration.
IMMUNOTHERAPY
A.Subcutaneous immunotherapy has been shown to
be effective in allergic asthma.
B.Efficacy in young children younger than 5 years
is less well documented for sublingual
immunotherapy.
C.Anti-IgE antibodies. Omalizumab licensed for
children 12 years and older with severe, allergic
asthma and proven IgE-mediated sensitivity to
inhaled allergens is administered via subcutaneous
injection every 2 to 4 weeks, depending on
patient weight and total serum IgE level.
NON-PHARMACOLOGICAL MANAGEMENT
OF ALLERGEN-INDUCED ASTHM
Prevention
Primary
prevention: Elimination of any risk or
etiological factor before it causes sensitization.
Secondary
prevention: Diagnosis and therapy at
the earliest point in disease development.
Tertiary
prevention: Limitation of disease effect
NON-PHARMACOLOGICAL MANAGEMENT
OF ALLERGEN-INDUCED ASTHM
Avoidance of allergens
Exposure
Typical
-
to allergens leads to sensitization.
avoidable allergens include:
pets,
dust mites,
mold,
cockroaches,and
foods.
NON-PHARMACOLOGICAL MANAGEMENT
OF ALLERGEN-INDUCED ASTHMA
Avoidance of triggers
Avoidance
of triggers should be part of the general
strategy for asthma management.
Key avoidable triggers are tobacco smoke, other
irritants, and some allergens.
Tobacco smoke should be eliminated from the
environment of all children.
Infections and stress should be avoided.
Physical exercise, although a possible trigger itself,
should be encouraged when appropriate.
PHARMACOLOGIC MANAGEMENT
OF ALLERGEN-INDUCED ASTHMA
 Controller
Therapy: Inhaled corticosteroids
 A first-line treatment for persistent asthma.
 Should be introduced as initial maintenance treatment
when
asthma control is inadequate.
 Atopy and poor lung function can predict favorable response.
 If control is inadequate on low dose, identify reasons.
 If indicated, an increased ICS dose or additional therapy
with LTRAs or LABAs should be considered.
 Effect in older children disappears as soon as treatment is
discontinued.
 New evidence does not support a disease-modifying role
after cessation of treatment in preschool children.
PHARMACOLOGIC MANAGEMENT
OF ALLERGEN-INDUCED ASTHMA
 Controller Therapy: Leukotriene receptor antagonists
 Alternative first-line treatment for persistent asthma.
 Evidence supports LTRA as initial controller therapy for
mild asthma in children with allergic asthma.
 Younger age (younger than 10 years) and high levels of
urinary leukotrienes can predict favorable response.
 Therapy for patients who cannot or will not use ICS.
 Useful also as add-on therapy to ICS: Different and
complementary mechanisms of action.
 Suggested for viral-induced asthma in young children.
 Benefit shown in children as young as 6 months.
 May be particularly useful if the patient has concomitant
rhinitis.
PHARMACOLOGIC MANAGEMENT
OF ALLERGEN-INDUCED ASTHMA
Controller
Add-on
therapy: Long-acting ß-agonists
to ICS for partially controlled/uncontrolled
asthma.
Efficacy not as well documented in children.
Use should be restricted to add-on therapy to
ICS, when indicated.
Combination LABA/ICS therapies may be licensed
for use in children older than 4 or 5 years.
IMMUNOTHERAPY
Combination
of immunotherapy with other therapies
allows a broad therapeutic approach that addresses
the pathophysiologic mechanism of allergy.
Early intervention with immunotherapy may prevent
the progression from monosensitization to
polysensitization.
Subcutaneous immunotherapy has been shown to be
effective in allergic asthma in some patients.
Effective sublingual immunotherapy may be an
attractive alternative to injection.
Injection immunotherapy should only be performed
in a proper environment.
ANTI IGE ANTIBODIES
Benefit-to-risk
ratio of this relatively new
agent is being defined.
Licensed
for children 12 years of age and
older with severe, allergic asthma and proven
IgE-mediated sensitivity to inhaled allergens
PRACTALL CONSENSUS REPORT:
EDUCATION
Asthma education is an integral part
of asthma management:
Identification
and avoidance of triggers.
Understanding
the uses of prescribed
medications, and the importance of
compliance and monitoring.
Proper
use of inhalation devices.
PRACTALL CONSENSUS REPORT:
MONITORING
Physical
examination should include regular
assessment of the child´s height and weight,
along with respiratory signs and symptoms.
Lung
function measurement.
The
nasal airway should also be assessed.