Download Approach to the Wheezing Child - West Virginia Association

Approach to the Wheezing Child
Maple Landvoigt, MD
11/7/14
Disclosures
• I have no actual or potential conflict of
interest in relation to this
program/presentation.
• I have no financial relationships to disclose.
Objectives
• Summarize the current scientific understanding of
asthma.
• Recognize when to treat and when to refer the child for
further evaluation.
• Recall current treatments for asthma.
• Review best practice aerosol drug delivery devices and
methods.
• Identify other causes of wheezing including vocal cord
dysfunction, malacia, and other underlying
immunologic diseases.
• Enumerate clinical pearls for the care of children with
respiratory disease.
Wheezing
• Very common
– 25-30% of infants, at least 1 in 3 children by 3
years.
• Asthma
– Also common…
Scope of the Problem
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Over 25 million Americans have asthma.
Nearly 3,500 annual deaths attributed to asthma and over 150 in
children under the age of 15.
The annual health care costs of asthma is over 50 billion dollars.
It is one of the most common chronic disorders in childhood,
affecting over 7 million children or 1 in every 11 kids in the US.
More common in WV with a overall childhood lifetime asthma
prevalence of nearly 15%.
Asthma is the third leading cause of hospitalizations among
children under the age of 15.
It is one of the leading causes of school absenteeism accounting
for approximately 10.5 million lost school days.
The proportion of people with asthma in the United States has
grown by nearly 15% in the last decade.
From CDC National Asthma Control Program
What is Asthma?
“Asthma is a complex disorder characterized by
variable and recurring symptoms, airflow
obstruction, bronchial hyperresponsiveness,
and an underlying inflammation.”
– National Asthma Education and Prevention
Program Expert Panel Report 3 (2007)
http://www.nlm.nih.gov/medlineplus/magazine/issues/fall11/images/asthma-airways_lg.jpg
The Trouble with Being Small
Poiseuille's law R = 8nl/πr4
Overall Approach
Follow Up
National Asthma Education and Prevention Program Expert Panel Report 3
Diagnosis
National Asthma Education and Prevention
Program Expert Panel Report 3 (2007):
1. Episodic symptoms (history, physical exam)
2. Airflow obstruction that is at least partially
reversible (spirometry: ≥ 12% change in FEV1 from baseline
following short-acting beta agonist)
3. Alternative diagnoses are excluded
Common Asthma Symptoms
• Cough
– Particularly with activity
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•
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Wheezing
Dyspnea
Chest tightness
Exercise limitation
Goals of Treatment
• Reduce Impairment
– Prevent chronic symptoms.
– Decrease frequent need for short-acting beta2-agonist (SABA).
– Maintain near normal lung function and normal activity levels.
• Reduce Risk
– Prevent exacerbations.
– Minimize need for emergency care, hospitalization.
– Prevent loss of lung function (and for young children prevent
reduced lung growth).
– Minimize adverse effects of therapy.
No treatments proven to change the disease progression
(long term outcomes)
Treatment 2007 (NHLBI)
Reliever Medications
• Short acting, used for acute symptoms.
• Albuterol sulfate:
– Relaxes the smooth muscles of the bronchi
– Beta2-adrenergic agonist
• Proventil HFA
• Ventolin HFA
• ProAir HFA
• Levalbuterol:
– R isomer of albuterol
– Reportedly less tachycardia
• Xopenex
http://allergy.peds.arizona.edu/southwest/devices/inhalers-asthma/images/proventil1.jpg
http://www.proairhfa.com/healthcare-professionals/images/section-1/Proair-inhaler-difference.png
http://www.drug3k.com/img2/xopenex_11960_4_(big)_.jpg
Other Relievers
• Anticholinergic Agents
• Ipratropium bromide:
– Relaxes the smooth muscles of the bronchi
– Inhibits secretions from serous/mucous glands
– Typically used second line in Asthma
– Sometimes used for tracheomalacia,
bronchomalacia.
• Atrovent
http://www.atrovent.com/images/dosing-inhaler-mobile.png
Controller Medications
• Leukotriene receptor antagonists:
– Non-steroid immunomodulator
– Inhibits leukotrienes
– Mild potency
– Significant behavioral side effects have been noted
• Montelukast (Singulair)
• Zafirlukast (Accolate)
Controller Medications
• Inhaled corticosteroids:
– Steroids are the most effective drugs for asthma control
– Inhaled forms are topically active, poorly absorbed, and
least likely to cause adverse effects
– Reduce asthma mortality, hospital visits, and exacerbations
– Higher doses may lead to steroid side effects
– Cochrane review on growth effects:
• Daily treatment lead to an approximately 0.5 centimeter decrease
in linear growth during the first year of treatment
• Effect is less pronounced in subsequent years
• “This effect seems minor compared with the known benefit of
these medications for asthma control”
Cochrane Database Syst Rev. 2014 Jul 17. Inhaled corticosteroids in children with persistent asthma: effects on growth. Zhang, L.
Controller Medications
• Inhaled corticosteroids:
• Fluticasone (Flovent)
• beclomethasone dipropionate (QVAR)
• Combination long acting beta agonist and
inhaled corticosteroids:
– Long acting beta agonists carry a black box
warning
• Fluticasone/salmeterol (Advair)
• Budesonide/formoterol (Symbicort)
• Mometasone/formoterol (Dulera)
http://www.asthmasymptoms86.com/images/Flovent-inhaler1.jpg
http://allergy.peds.arizona.edu/southwest/devices/inhalers-asthma/images/qvar.h4.jpg
http://allergy.peds.arizona.edu/southwest/devices/inhalers-asthma/advair3.jpg
http://www.multivu.com/assets/60910/photos/60910-457-Inhaler-F-4C-HR-original.jpg?1366812083
Devices and Drug Delivery
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Nebulizers:
– Commonly available
– Slow – typically 15-20 minutes
– Young children need to wear mask, blow-by decreases drug delivery to lower airways
•
MDIs without spacers:
– Fast 1-2 minutes, portable
– May improve adherence
– Most of the medication is deposited in the mouth and GI tract
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MDIs with spacers:
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Significantly increases drug delivery to the lower airways
Proper technique requires slow deep breaths
Younger children or children with cognitive delay should use a spacer with mask
Equally effective as nebulized medication when used properly
Dry powder inhalers:
– Fast, portable
– Proper technique requires fast deep breaths
– Not appropriate for pre-school and younger children.
http://www.healthcare.philips.com/pwc_hc/main/shared/Assets/Images/Homehealthcare/Respironics/275s/optichamberDiamondInUse_275.jpg
http://www.frx.com/pi/AeroChamberPlusFlow-VuSmall-Medium_PI.pdf
http://images.rxlist.com/images/rxlist/flovent-diskus6.gif
http://www.asmanex.com/static/images/bottle220_tcm682-19861.png
How much is too much?
• When do children need to see a specialist?
Stepwise Approach for managing asthma in children 5-11 years of age
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult asthma specialist if step 4 care or higher is required.
Consider consultation at step 3
Step 5
Step 2
Preferred
Step 1
Low dose
ICS
Preferred
Alternative
SABA
PRN
LTRA,
Cromolyn
Nedocromil or
Theophylline
Step 4
Preferred
Step 3
Preferred
Preferred
Medium
Dose ICS +
LABA
High Dose
ICS + LABA
Either
Low Dose
ICS + LABA,
LTRA, or
Theophylline
OR
Medium
Dose ICS
Alternative
Medium dose
ICS + either
LTRA, or
Theophylline
Step 6
Preferred
High Dose ICS
+ LABA
+ oral
corticosteroid
Alternative
Alternative
High dose ICS
+ either LTRA,
or
Theophylline
High dose ICS +
either LTRA, or
Theophylline
+ oral
corticosteroid
Patient Education and Environmental Control at Each Step
Quick-relief medication for ALL patients
SABA as needed for symptoms.
Short course of oral corticosteroids maybe needed.
Step up if
needed
(first check
adherence,
environmen
tal control,
and
comorbid
conditions)
Assess
control
Step down
if possible
(and asthma
is well
controlled at
least 3
months)
Not All That Wheezes Is Asthma
http://1.bp.blogspot.com/_-Uzu0xg5lh0/R6XkBDkhs6I/AAAAAAAAAIc/BbMW0MemCLM/s1600/DDX_of_Asthma-Children.jpg
Types of Wheezing
Polyphonic:
• Multiple tones
• Sounds musical
• Associated with more distal airway disease
• Classic asthma wheezing
Types of Wheezing
Monophonic:
• Single tone
• Repeated same sound
• Associated with central airway disease
• Concerning for underlying structural airway
disease
Structural Airway Disease
• Tracheobronchomalacia:
– Associated with coarse, monophonic wheezing.
– Symptoms may persist past age 2, but typically do not
persist past school age.
– Causes impairment of mucous clearance and can lead
to recurrent pneumonias.
– Beta-agonists may worsen.
– Can be associated with other anatomic anomalies.
Structural Airway Disease
• Stenosis can be either congenital or acquired in nature.
– Associated with monophonic wheezing.
– Risk factors:
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prolonged intubation
aspiration
prolonged or severe infections
previous airway surgery
• Compression is typically vascular in nature.
– Consider vascular rings or slings.
• Both stenosis/compression impair mucous clearance
(can lead to recurrent pneumonias).
Foreign Body Aspiration
• Classically occurs in mobile toddlers, but can occur at any
age including infants (particularly with toddler sibs) and
older patients (especially those with developmental
delays).
• Concerning historical points include:
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Any witnessed choking event
Persistent cough or wheeze
Poor response to beta-agonist
Persistent respiratory infections
• Key respiratory findings include:
– Focal monophonic wheeze
• X ray or direct airway endoscopy may be need to confirm
the diagnosis.
Chronic Aspiration Syndromes
• Unrecognized or untreated can lead to bronchiectasis
and severe lung disease.
• Risk factors include:
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Neurologic disease or developmental delay
Vocal paralysis or paresis
Swallowing dysfunction
Reflux or upper GI anatomic abnormalities
Increased work of breathing.
• Concerning historical points include:
– Coughing, choking, or gagging with oral intake
– Recurrent respiratory infections
– Pooling of oral secretions
Occult Immunodeficiency
• Can lead to bronchiectasis and severe lung disease.
• Concerning historical points include:
– Persistent cough or wheeze
– Productive cough
– Recurrent respiratory and unusual non-respiratory
infections.
• Key respiratory findings include:
– Coarse crackles
– Monophonic and/or polyphonic wheezing
– Associated findings of chronic inflammation (i.e. digital
clubbing).
Digital Clubbing
http://medlibes.com/uploads/Screen%20shot%202010-07-19%20at%205.51.24%20PM.png
Vocal Cord Dysfunction
• Partial closure of the vocal cords during inspiration.
• Can occur in combination with other pulmonary processes.
• In children, often can persist after an initial triggering
irritant (reflux, post-nasal drip) or can be related to anxiety.
• Concerning historical points include:
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Difficulty getting air “in” vs. “out”
Throat tightness or pain
Extreme sensitivity to smells (perfume, etc)
Inspiratory stridor in the older child, particularly during exercise
Poor response to controller medications
• Spirometry can be diagnostic when showing intermittent
inspiratory obstruction.
Summary
• Asthma is characterized by respiratory symptoms and
airflow obstruction that is reversible or variable in nature.
• The diagnosis is typically confirmed by thorough history
and physical as well as spirometry.
• Current standard of care treatment involves initiation of
inhaled corticosteroid controller for frequent symptoms as
well as beta-agonist rescue therapy with frequent
monitoring to step up or step down therapy as needed.
• Common barriers to optimal asthma control include incorrect
inhaler technique and poor adherence.
• Use of a spacer device improves drug delivery to the lower airways.
• Proper evaluation of uncontrolled or severe asthma often requires
detailed examination by an asthma specialist and testing to rule out
other underlying respiratory disease.
The End