Benjamin Tippets, DO, MPH

Asthma exacerbations continue to cause a significant number of emergency care visits and hospitalizations among children.

” (CONSULTANT FOR PEDIATRICIANS, May 2009, page 168), we reviewed the epidemiology, risk factors, and diagnosis of asthma in children. We also discussed how to make an initial assessment of asthma severity. In Part 2, we review the key components of treatment.

The goal of asthma management is to control the disease well enough that the child can lead a near-normal life.

 The Expert Panel Report 3 (EPR-3) guidelines suggest that the 4 aspects of care that are essential to achieving and maintaining control of asthma are:

•Providing education for a partnership in care.
•Controlling environmental factors and comorbid conditions that affect asthma.
•Prescribing medications that are appropriate.
•Assessing and monitoring asthma severity and asthma control.

Asthma can be a complex problem to understand. It has been shown that providing appropriate education to children and families improves outcomes.

 This can be done by forming a partnership with the child in selecting and maintaining a treatment plan. This includes identifying and addressing the concerns of the child and family, establishing open lines of communication by considering cultural and ethnic backgrounds, assessing health care knowledge and adjusting language and vocabulary accordingly, and allowing full participation of the child and family in decisions about treatment-to promote self-monitoring and management.

At each visit, outline and review a written asthma action plan that includes clear instructions on daily medications, with doses and intervals.

 Clearly define the signs and symptoms of exacerbations and provide instructions for acute management. Also include clear instructions on when to increase therapy and when it is appropriate to call or visit the health care provider.

In addition, an asthma education nurse or respiratory therapist should review the medications that have been prescribed and ensure proper technique in taking them. Skills that are important to review with the child and family include device use, spacer use and care, monitoring of symptoms and assessment of control, peak flowmeter monitoring, and recognition of the appropriate response to medications. Children should be instructed on how to reduce and control environmental factors that may exacerbate symptoms. Positive reinforcement from the care team when progress has been made has been shown to foster improved adherence and subsequent control of symptoms.

CONTROL OF ENVIRONMENTAL FACTORS AND COMORBID CONDITIONS

Many factors may precipitate an asthma exacerbation. One of the most common is exposure to irritants or allergens to which the child is sensitized.

 Reducing exposure to these factors may help reduce respiratory symptoms, underlying inflammation, and the need for long-term medications and acute rescue therapy.

 The most common allergens that patients are sensitive to include house dust mites, cockroaches, pet dander, molds, and indoor and outdoor plants and trees.

It is suggested that all children with persistent asthma have either skin testing or in vitro testing to assess their sensitivity to specific allergens.

 Subcutaneous allergen immunotherapy may be considered in children with a clear association between allergen exposure and asthma exacerbation.

It is important to educate families on a multifaceted approach to reducing exposure to specific allergens to which the child is sensitive.

 It is recommended that pets with fur be removed from the home or kept away from the child. Dust mite control is best attained by using an allergen-proof mattress and pillow covers, washing all bedding every 1 to 2 weeks in hot water, removing all stuffed toys from the bed, vacuuming and dusting regularly, and reducing indoor humidity.

Cockroach exposure can be reduced by combining extermination with vigorous cleaning and prompt disposal of food remains. Indoor mold allergens are minimized with thorough cleaning, reducing humidity levels, and keeping windows closed. Outdoor seasonal allergens are avoided by staying indoors with closed doors and windows, along with frequent washing of hands, face, and hair.

 Indoor air-cleaning devices are minimally helpful and are not a substitute for more effective dust mite and cockroach control.

It is important to advise children with severe persistent asthma, nasal polyps, or sensitization to aspirin or NSAIDs to avoid these drugs because of the risk of severe and even fatal exacerbations.

Another frequent cause of asthma exacerbation is viral respiratory infection. Rhinovirus has been reported to be the most frequent cause of viral-induced asthma exacerbations.

 It has been shown that the incidence of lower respiratory tract infections and recurrent wheezing is increased in children who are enrolled in day-care facilities or have siblings in day care.

 However, it should be noted that asthma is less likely to develop in children younger than 6 months who are exposed to day care.

 To reduce the risk of viral-induced exacerbations, it is recommended that all children with asthma receive the inactivated influenza vaccine.

Treatment, including selection of an appropriate medication regimen, is based on the level of severity or control of the child’s asthma. The EPR-3 has created a stepwise approach that easily allows the clinician to choose the appropriate treatment to achieve and maintain control (

 For a review of how to make an initial assessment of the severity of a child’s asthma and select medications based on that severity, see the Table in “Managing Asthma in Children, Part 1” (CONSULTANT FOR PEDIATRICIANS, May 2009).

Asthma medications can be categorized into quick-relief medications and long-acting controller medications. The regimen chosen should take into account underlying pathology, severity of disease, delivery devices, and safety.

Long-term controller medications are used to target the underlying pathology of the airways. They are designed to be used daily by patients who have persistent asthma. Because of their anti-inflammatory mechanism, inhaled corticosteroids (ICSs) are the preferred medication for all children with persistent asthma.

 They have also been shown to reduce airway hyperresponsiveness, inhibit inflammatory cell migration and activation, blunt the late-phase reaction to allergens, and reduce the risk of exacerbations.

 Although ICSs control symptoms, they do not appear to alter or slow the progression of the underlying disease.

Oral corticosteroids are used in short courses to gain prompt control of symptoms when exacerbations occur and as controller medications in children requiring step 6 care (severe persistent asthma).

 Although corticosteroids are not free of adverse effects, they have been shown to be relatively safe in children, and regular use of low-dose ICSs is associated with a reduced risk of death from asthma.

Long-acting β-agonists (LABAs) are long-term controlling medications that have been shown to reduce symptoms, improve lung function, and reduce the risk of exacerbation when added to an ICS.

 Their onset of action is 10 to 15 minutes, and the effects last for 12 to 18 hours. They cause long-acting bronchodilation but do not have any anti-inflammatory effect.

LABAs are indicated for use in combination with ICSs in children older than 5 years who require step 3 care or higher (step 4 care in children 0 to 4 years of age).

 They are not indicated as monotherapy, and it has been shown that if an ICS is withdrawn after an LABA is started, there is an increase in asthma symptoms. 

 All formulations containing LABAs have a black box warning from the FDA because of reports of an increased risk of severe asthma exacerbations associated with LABA use.

Other controlling medications include cromolyn, nedocromil, leukotriene modifiers, and methylxanthines. Cromolyn and nedocromil are mast-cell stabilizers and are used as alternative medications in children who require step 2 care (mild persistent asthma).

 Leukotriene modifiers, which include leukotriene receptor antagonists (LTRAs) and 5-lipoxygenase inhibitors, interfere with a component of the inflammatory cascade-the leukotriene mediator pathway-and potentially block bronchoconstriction and mucus secretion.

LTRAs are used as an alternative medication in patients requiring step 2 care and as add-on therapy with ICSs in children older than 12 years.

 5-Lipoxygenase inhibitors are indicated for adults only. Methylxanthines are mild bronchodilators that are used as an alternative (not preferred) therapy for step 2 care and as add-on therapy with an ICS for children older than 5 years.

Short-acting or quick-relief medications are used to treat acute symptoms of asthma. Short-acting β-agonists (SABAs) are the most frequently used agents. These bronchodilators target the smooth muscles of the airway. Their onset of action is approximately 5 minutes, and their effects last about 4 hours. SABAs are the drug of choice for relief of acute symptoms and exercise-induced bronchospasm.

 SABAs are not designed to be used on a scheduled daily basis.

Anticholinergics are another short-acting medication used to treat asthma. They inhibit muscarinic cholinergic receptors and reduce the vagal tone of the airway. Anticholinergics are used in conjunction with SABAs for moderate to severe exacerbations in the acute setting. Also, they can be used as an alternative in children who do not tolerate SABAs.

ASSESSMENT OF CONTROL AND ADJUSTMENT OF TREATMENT

After a treatment plan is in place, proper follow-up is crucial to ensure that control has been accomplished. Once the initial plan is instituted, a visit should be scheduled within 2 to 6 weeks to assess control and make adjustments to the plan. Once control is attained, return visits can be scheduled 1 to 6 months apart on the basis of clinical judgment. 

 Each time a decision to adjust therapy is made, more frequent visits are warranted.

Control of asthma can be defined as the degree to which symptoms are alleviated by intervention and the degree to which the goals of therapy are met. The degree of control can be categorized as well controlled, not well controlled, or very poorly controlled (see 

Changes to the intervention plan are dictated by the child’s current level of control.

 The same stepwise approach that was used in the initial assessment of severity is used on subsequent visits to evaluate whether therapy should be decreased or increased. If the child’s asthma has been well controlled for at least 3 months, the recommendation by EPR-3 is either to step down therapy or to not change treatment. If the asthma is categorized as “not well controlled,” therapy should be increased 1 step, with a return visit scheduled in 2 to 6 weeks. If the asthma is “very poorly controlled,” therapy should be increased 1 to 2 steps and a short course of oral corticosteroids should be considered.

In addition, once control is attained, severity can be reassessed. In these assessments-as distinct from the initial assessment-the definition of severity is based on the amount of medication necessary to maintain adequate control.

 At each follow-up visit, the categories of impairment and risk should be assessed.

The decision to change therapy can be difficult. However, if after initiating a treatment plan, there is no clear response, the medication should be stopped and other therapies or diagnoses considered (assuming that the technique and adherence to the medication regimen are adequate). In addition, it is appropriate to refer the child to an asthma specialist if control has been difficult to attain, if the child has required more than 2 courses of corticosteroids, if the child has had an exacerbation requiring hospitalization, or if the treatment plan has entailed step 4 or higher therapy (or step 3 care for children 4 years or younger) in the past year.

Spirometry should be used at follow-up visits to obtain an objective measure of lung function. It is indicated routinely every 1 to 2 years in patients with well-controlled asthma. Also, spirometry can be of assistance during exacerbations or during a prolonged period of poor control.

Recent evidence-based guidelines have standardized the care of asthma to help clinicians manage asthma in the most effective way. These guidelines take into account the current severity of the underlying disease and the present level of control. They also consider the current impairment that the child is experiencing and the risk of exacerbations. While initial treatment is based on the severity of the disease, further alterations to the plan depend on the level of control that the child has achieved.

The importance of educating the child and family on the underlying pathology, proper use of medications, and appropriate times to contact their clinician cannot be overemphasized. In addition, routine follow-up visits are essential to allow the clinician to adequately assess the level of control and make appropriate changes to the plan. With careful monitoring and appropriate treatment, the clinician can help the child reach the goal of controlling asthma rather than having asthma control the child’s life.

 Akinbami L; CDC National Center for Health Statistics. The state of childhood asthma, United States, 1980-2005. 

National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma-Full Report 2007. Washington, DC: US Dept of Health and Human Services. 

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

. Published August 28, 2007. Accessed April 16, 2009.
  

 Cicutto L, Murphy S, Coutts D, et al. Breaking the access barrier: evaluating an asthma center’s efforts to provide education to children with asthma in schools. 

 Guilbert TW, Morgan WJ, Zeiger RS, et al. Atopic characteristics of children with recurrent wheezing at high risk for the development of childhood asthma.

 Abramson MJ, Puy RM, Weiner JM. Allergen immunotherapy for asthma. 

 Diette GB, McCormack MC, Hansel NN, et al. Environmental issues in managing asthma.

 Jenkins C, Costello J, Hodge L. Systematic review of prevalence of aspirin induced asthma and its implications for clinical practice. 

 Heymann PW, Carper HT, Murphy DD, et al. Viral infections in relation to age, atopy, and season of admission among children hospitalized for wheezing. 

 Rusconi F, Galassi C, Corbo GM, et al. Risk factors for early, persistent, and late-onset wheezing in young children. SIDRIA Collaborative Group. 

 Ball TM, Castro-Rodriguez JA, Griffith KA, et al. Siblings, day-care attendance, and the risk of asthma and wheezing during childhood. 

 Becker A, Watson W, Ferguson A, et al. The Canadian asthma primary prevention study: outcomes at 2 years of age. 

 Guilbert TW, Morgan WJ, Zeiger RS, et al. Long-term inhaled corticosteroids in preschool children at high risk for asthma.

 The Childhood Asthma Management Program Research Group. Long-term effects of budesonide or nedocromil in children with asthma. 

 Bisgaard H, Hermansen MN, Loland L, et al. Intermittent inhaled corticosteroids in infants with episodic wheezing. 

Articles

Asthma exacerbations continue to cause a significant number of emergency care visits and hospitalizations among children.1 In “Managing Asthma in Children, Part 1” (CONSULTANT FOR PEDIATRICIANS, May 2009, page 168), we reviewed the epidemiology, risk factors, and diagnosis of asthma in children. We also discussed how to make an initial assessment of asthma severity. In Part 2, we review the key components of treatment.

Benjamin Tippets, DO, MPH

Articles

Managing Asthma in Children, Part 2: Achieving and Maintaining Control