Pediatric Asthma Management

Transcription

1 Pediatric Asthma Management APRN Conference February 2016 Cheryl Kerrigan, MSN, CPNP Aimee Tiller RN, AE-C The Plan Definition Pathophysiology review Triggers & Risk Factors Incidence and Prevalence Making the diagnosis Management and Medications Adherence Tactics Definition Asthma is a chronic inflammatory disease of the airways associated with: 1. airway hyper-responsiveness 2. airflow limitation (at least partially reversible) 3. respiratory symptoms (cough, wheeze, etc.) 1

2 Antibodies Inflammatory mediators 2/9/2016 Pathophysiology Two Main Issues: 1. Airway Inflammation 2. Smooth muscle constriction Pathophysiology best understood in allergic asthma Primarily IgE responding to an allergen Inflammatory Cells Eosinophils Mast Cells Lymphocytes All release inflammatory mediators Histamine Mast cell tryptase Prostaglandins Leukotrienes Cytokines Contribute to airway inflammation and bronchoconstriction Pathophysiology Airway inflammation contributes to: - acute bronchoconstriction - airway edema - mucus plug formation - lung hyperinflation Thickened bronchi with mucus plugs 2

3 Changes in Airway Morphology Airway lumen narrowing Mucous gland hypertrophy and hyperplasia Edema Mucus hypersecretion Thickening of basement membrane Epithelial damage Airway smoothmuscle hypertrophy, hyperplasia, and bronchoconstriction Inflammatory cell infiltration Vascular dilation Goblet cell hyperplasia Adapted from National Heart, Lung, and Blood Institute. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma NIH publication Asthma Triggers Viral illnesses Stress Allergies Reflux Animals Cigarette smoke Air pollution Weather changes Exercise Cold Air Allergens Strong emotions 3

4 Risk Factors Allergen exposure mold, cockroaches, dustmites, animals* Cigarette smoking active or passive Irritant exposure air pollution Gender - higher prevalence in males early in childhood, higher in females after age 13 Atopy personal or family history Family History of Asthma Obesity Prematurity Incidence and Prevalence Most common chronic disease of childhood million (9.3%) of children with asthma in million missed school days / year asthma deaths in 2006 in kids < 15 years - Costs are approx. $20.7 billon / year (hospital, clinic visits, meds, missed work) - Only 20% of kids with asthma are followed by a specialist Incidence and Prevalence Asthma affects 16% of African American children 10.7% of American Indian and Alaskan Native children 7.9% of Hispanic children (16.5 among Puerto Rican children) 8.2% Caucasian children 6.8 of Asian children 4

5 Incidence and Prevalence Racial Disparities African American children are twice as likely to have undiagnosed asthma compared to their white counterparts Minority children with asthma are less likely to receive regular care and recommended treatment, and more likely to be hospitalized for their condition. Non-Hispanic black children are twice as likely to be hospitalized and four times more likely to die because of asthma than non-hispanic white children. History most important Spirometry objective data, gold standard Chest x-rays nonspecific changes Impulse ossilometry measures airway resistance Exhaled nitric oxide (NO) inflammatory marker, not specific for asthma. Not widely used. Exam History Typical symptoms cough, wheeze, shortness of breath, chest pain, chest tightness Nocturnal cough? Symptoms with exercise? Seasonality? Long lasting URIs? Typical Triggers cold air, weather change, etc 5

6 History Previous Treatments what s worked, what hasn t Biggest clues come from quick(er) acting meds like: Bronchodilators albuterol (Ventolin, Proventil, Proair), Xopenex Oral steroids prednisone, Orapred History - Other clues: History of recurrent bronchitis or even recurrent pneumonia History of allergies (or family history of asthma and/or allergies) Family report of inactivity in a child with some history of respiratory symptoms likely not active because they can t breathe Spirometry Objective measurement of lung function Can be done in children 5 or 6 years and greater Should be ordered pre and post bronchodilator if considering asthma 6

7 Spirometry gives us a flow volume curve Flow (rate of air movement) Exhalation Inhalation Volume (amount of air) Spirometry Asthma is an obstructive airway disease causes more difficulty exhaling than inhaling, resulting in air trapping. Therefore when interpreting spirometry, we re more interested in the exhalation half of the curve 7

8 Spirometry FVC forced vital capacity total amount of air that can be exhaled forcefully FEV1 force expiratory volume in 1 second total amount of air exhaled in 1 second FEV1/FVC ratio of FEV1/FVC helps you decide if it s obstructive disease FEF forced expiratory flow during the mid portion of the exhalation PEF peak expiratory flow rate max flow rate during exhalation Spirometry: To be interpreted - needs to be acceptable and reproducible Acceptable: six second exhalation 3 attempts minimum no cough / or obstruction Reproducible: attempts need to be similar Predicted values are based on height, gender, and race Spirometry normal values FVC - >80% predicted FEV1 - >80% predicted FEV1/FVC ratio - >80% predicted (<12 yrs) >70% predicted (>12 yrs) FEF > 70% predicted PEF > 80% predicted 8

9 Spirometry To diagnosis asthma measure values before and after albuterol Ideally should be off albuterol x 4-6 hours and LABAs 12 hours prior to test Looking for 12-15% improvement in FEV1 and 25-30% improvement in FEF

10 Chest x-rays May show hyperinflation, peribronchial cuffing, possible atelectasis due to mucus plugging non specific for asthma Differential Diagnoses Gastroesophageal reflux Aspiration -? bottle in bed Sinusitis / allergies with post nasal drip Tracheo / bronchomalacia Tracheal compression vascular rings / slings Foreign body aspiration Cystic fibrosis Heart failure Viral bronchiolitis Vocal cord dysfunction Exam: Acute asthma: tachypnea, increased WOB, anxiety / mental status changes, can t find a comfortable position, speaking in short sentences, wheezing on exam, not wheezing on exam (silent chest much more concerning), decreased O2 sats Chronic asthma: likely normal exam, possibly prolonged exhalation, barrel chest (uncommon finding in children), possible signs of atopy (boggy turbinates, eczema) 10

11 New(ish) asthma guidelines 2007 Broken up in age groups Focus on severity, control, and assessment Goals focused on - reducing impairment (normal PFTs, symptom control, infrequent use of albuterol) - reducing risk (minimizing ER visits, preventing loss of lung function) - periodic assessment (every 1-6 months, determine if goals being met) Recommendations for follow up care: - Every 2-6 weeks for pts just starting therapy or who require step-up therapy - Every 1-6 months once control is achieved - Consider scheduling visits at 3 month intervals if step down therapy is anticipated Classification of Asthma Severity 12 years of age Components of Severity Persistent Intermittent Mild Moderate Severe 2 days/week >2 days/week but Daily Throughout the day Symptoms not daily Nighttime 2x/month 3 4x/month >1x/week but Often 7x/week awakenings not nightly Short-acting 2 days/week >2 days/week Daily Several times Impairment beta 2 -agonist use for but not daily, and per day symptom control (not not more than prevention of EIB) 1x on any day Normal FEV 1/FVC: Interference with None Minor limitation Some limitation Extremely limited 8 19 yr 85% normal activity yr 80% yr 75% Normal FEV 1 between yr 70% exacerbations Lung function FEV 1 >80% FEV 1 >80% FEV 1 >60% but FEV 1 <60% predicted predicted <80% predicted predicted Risk Exacerbations requiring oral systemic corticosteroids FEV 1 /FVC normal FEV 1 /FVC normal FEV 1 /FVC reduced FEV 1 /FVC 5% reduced >5% 0 1/year (see 2/year (see note) note) Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity category. Relative annual risk of exacerbations may be related to FEV 1. Step 3 Step 4 or 5 Recommended Step Step 1 Step 2 for Initiating Treatment and consider short course of oral systemic corticosteroids In 2 6 weeks, evaluate level of asthma control that is achieved and adjust therapy (See figure 4 5 for treatment steps.) accordingly. 11

12 Normal FEV 1 2/9/2016 Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3. Step 6 Step up if Step 5 needed High-dose (first, check Step 4 High-dose ICS + LABA + oral adherence, ICS + LABA corticosteroid Step 3 environmental AND AND control, and Medium-dose ICS + LABA comorbid Step 2 Low-dose ICS + LABA Consider Consider conditions) OR Alternative: Omalizumab for Omalizumab for Low-dose ICS Step 1 Medium-dose ICS patients who have patients who have Medium-dose ICS Alternative: allergies allergies Assess Alternative: + either LTRA, Cromolyn, LTRA, Low-dose ICS + Theophylline, or control Nedocromil, or SABA PRN either LTRA, Zileuton Theophylline Theophylline, or Zileuton Step down if possible (and asthma is Each step: Patient education, environmental control, and management of comorbidities. well controlled Steps 2 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes). at least 3 months) Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed. Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment. Components of Control Classification of Asthma Control ( 12 years of age) Not Very Poorly Well Controlled Well Controlled Controlled Symptoms 2 days/week >2 days/week Throughout the day Nighttime awakenings 2x/month 1 3x/week 4x/week Interference with normal activity None Some limitation Extremely limited Short-acting beta 2 -agonist use for 2 days/week symptom control (not prevention of EIB) Impairment FEV 1 or peak flow >80% predicted/ personal best Validated questionnaires >2 days/week 60 80% predicted/ personal best Several times per day <60% predicted/ personal best ATAQ ACQ ACT * N/A 15 Risk Exacerbations requiring oral systemic corticosteroids Progressive loss of lung function Treatment-related adverse effects 0 1/year 2/year (see note) Consider severity and interval since last exacerbation Evaluation requires long-term followup care Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. Recommended Action for Treatment (see figure 4 5 for treatment steps) Maintain current step. Step up 1 step and Consider short course of Regular followups Reevaluate in oral systemic every 1 6 months to 2 6 weeks. corticosteroids, maintain control. For side effects, Step up 1 2 steps, and Consider step down if consider alternative Reevaluate in 2 weeks. well controlled for at treatment options. For side effects, least 3 months. consider alternative treatment options. Classification of Asthma Severity Components of (5 11 years of age) Severity Persistent Intermittent Mild Moderate Severe 2 days/week >2 days/week but Daily Throughout Symptoms not daily the day Nighttime >1x/week but 2x/month 3 4x/month Often 7x/week awakenings not nightly Short-acting beta 2-agonist use for >2 days/week Several times 2 days/week Daily symptom control (not but not daily per day prevention of EIB) Impairment Interference with None Minor limitation Some limitation Extremely limited normal activity Lung function between exacerbations FEV 1 >80% predicted FEV 1 = >80% predicted FEV 1 = 60 80% predicted FEV 1 <60% predicted FEV 1 /FVC >85% FEV 1 /FVC >80% FEV 1 /FVC = 75 80% FEV 1 /FVC <75% Risk Exacerbations requiring oral systemic corticosteroids 0 1/year (see note) 2/year (see note) Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity category. Relative annual risk of exacerbations may be related to FEV 1. Recommended Step for Initiating Therapy (See figure 4 1b for treatment steps.) Step 3, mediumdose ICS option ICS option, or step 4 Step 3, medium-dose Step 1 Step 2 and consider short course of oral systemic corticosteroids In 2 6 weeks, evaluate level of asthma control that is achieved, and adjust therapy accordingly. 12

13 Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3. Step 6 Step 5 Step 4 High-dose ICS + High-dose ICS Step 3 LABA + LABA + oral systemic Medium-dose Step 2 Alternative: corticosteroid ICS + LABA EITHER: High-dose ICS + Alternative: Alternative: either LTRA or Low-dose ICS + Low-dose ICS Theophylline High-dose ICS + either LABA, Step 1 Medium-dose either LTRA or LTRA, or Alternative: ICS + either Theophylline + Theophylline LTRA or oral systemic Cromolyn, LTRA, OR Theophylline corticosteroid SABA PRN Nedocromil, or Theophylline Medium-dose ICS Each step: Patient education, environmental control, and management of comorbidities. Steps 2 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes). Step up if needed (first, check adherence, inhaler technique, environmental control, and comorbid conditions) Assess control Step down if possible (and asthma is well controlled at least 3 months) Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed. Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment. Classification of Asthma Control (5 11 years of age) Components of Control Well Not Well Very Poorly Controlled Controlled Controlled 2 days/week but not >2 days/week or Symptoms more than once on each multiple times on Throughout the day day 2 days/week Nighttime 1x/month 2x/month 2x/week awakenings Interference with normal None Some limitation Extremely limited activity Impairment Short-acting beta 2 -agonist use 2 days/week >2 days/week Several times per day for symptom control (not prevention of EIB) Lung function FEV 1 or peak flow >80% predicted/ 60 80% predicted/ <60% predicted/ personal best personal best personal best FEV 1 /FVC >80% 75 80% <75% Exacerbations requiring 0 1/year 2/year (see note) oral systemic corticosteroids Consider severity and interval since last exacerbation Reduction in Risk Evaluation requires long-term followup. lung growth Medication side effects can vary in intensity from none to very troublesome and worrisome. Treatment-related The level of intensity does not correlate to specific levels of control but should be adverse effects considered in the overall assessment of risk. Maintain current step. Step up at least Consider short course of oral Recommended Action Regular followup 1 step and systemic corticosteroids, for Treatment every 1 6 months. Reevaluate in Step up 1 2 steps, and Consider step down if 2 6 weeks. Reevaluate in 2 weeks. (See figure 4 1b for well controlled for at For side effects: For side effects, consider least 3 months. consider alternative alternative treatment options. treatment steps.) treatment options. Classification of Asthma Severity Components of (0 4 years of age) Severity Persistent Intermittent Mild Moderate Severe >2 days/week Throughout Symptoms 2 days/week Daily but not daily the day Nighttime 0 1 2x/month 3 4x/month >1x/week awakenings Impairment Short-acting beta 2-agonist use >2 days/week Several times for symptom 2 days/week Daily but not daily per day control (not prevention of EIB) Interference with None Minor limitation Some limitation Extremely limited normal activity 2 exacerbations in 6 months requiring oral systemic 0 1/year corticosteroids, or 4 wheezing episodes/1 year lasting Exacerbations >1 day AND risk factors for persistent asthma Risk requiring oral systemic Consider severity and interval since last exacerbation. corticosteroids Frequency and severity may fluctuate over time. Exacerbations of any severity may occur in patients in any severity category. Recommended Step for Initiating Therapy (See figure 4 1a for treatment steps.) Step 3 and consider short course of Step 1 Step 2 oral systemic corticosteroids In 2 6 weeks, depending on severity, evaluate level of asthma control that is achieved. If no clear benefit is observed in 4 6 weeks, consider adjusting therapy or alternative diagnoses. 13

14 Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if step 3 care or higher is required. Consider consultation at step 2. Step 6 Step 5 Step 4 High-dose ICS + High-dose ICS + either Step 3 either LABA or LABA or Montelukast Medium-dose Montelukast Step 2 ICS + either Oral systemic Medium-dose LABA or corticosteroids ICS Montelukast Step 1 Low-dose ICS Alternative: SABA PRN Cromolyn or Montelukast Patient Education and Environmental Control at Each Step Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms. With viral respiratory infection: SABA q 4 6 hours up to 24 hours (longer with physician consult). Consider short course of oral systemic corticosteroids if exacerbation is severe or patient has history of previous severe exacerbations. Caution: Frequent use of SABA may indicate the need to step up treatment. See text for recommendations on initiating daily long-term-control therapy. Step up if needed (first, check adherence, inhaler technique, and environmental control) Assess control Step down if possible (and asthma is well controlled at least 3 months) Components of Control Classification of Asthma Control (0 4 years of age) Well Not Well Very Poorly Controlled Controlled Controlled Symptoms 2 days/week >2 days/week Throughout the day Nighttime awakenings 1x/month >1x/month >1x/week Interference with None Some limitation Extremely limited Impairment normal activity Short-acting beta 2-agonist use 2 days/week >2 days/week Several times per day for symptom control (not prevention of EIB) Exacerbations requiring oral systemic 0 1/year 2 3/year >3/year corticosteroids Risk Medication side effects can vary in intensity from none to very troublesome and Treatment-related worrisome. The level of intensity does not correlate to specific levels of control adverse effects but should be considered in the overall assessment of risk. Maintain current Step up (1 step) and Consider short course of treatment. Reevaluate in oral systemic Regular followup 2 6 weeks. corticosteroids, every 1 6 If no clear benefit in Step up (1 2 steps), and Recommended Action months. for Treatment 4 6 weeks, consider Reevaluate in 2 weeks. Consider step alternative diagnoses If no clear benefit in 4 6 down if well or adjusting therapy. weeks, consider alternative (See figure 4 1a for controlled for at For side effects, diagnoses or adjusting treatment steps.) least 3 months. consider alternative therapy. treatment options. For side effects, consider alternative treatment options. 14

15 Short acting beta agonists (SABAs) - quick relief - relieves acute bronchospasm - fast onset 5-15 minutes Examples: Albuterol (Proventil, Ventolin, ProAir), Levalbuterol (Xopenex), Pirbuterol (Maxair) Inhaled Corticosteroids Gold standard in chronic asthma management Inhibits late phase response Treats inflammatory component of asthma Low systemic bioavailability Most common side effects thrush, hoarseness can be avoided by rinsing mouth Examples: Flovent, Pulmicort, Asmanex, QVAR, Aerospan, Alvesco Long acting beta agonists (LABAs) Intended for use in pts with moderate to severe asthma uncontrolled on a medium dose ICS Caution is recommended in prescribed these products and use in children (as a single agent) is strongly discouraged Examples: Serevent, Foradil 15

16 Combination Products ICS + LABA Useful in moderate to severe asthma Useful in those with exercise intolerance Helpful in kids who need both products convenient for pt, providers don t need to worry that child is only taking the LABA Examples Advair, Symbicort, Dulera Leukotriene Modifiers: Stops inflammatory cascade ICS still first line treatment, though can consider monotherapy in those with mild symptoms May be helpful in those with associated allergy symptoms Examples Singulair, Zyflo Methylzanthines Long acting bronchodilators Requires close monitoring of drug levels Can cause toxicity with permanent CNS damage Recheck levels if symptoms of toxicity, continued asthma symptoms, or with viral illnesses Rarely used in pediatrics because of these issues Examples: Theophylline 16

17 Mast cell stabilizers: Anti-inflammatories Not as effective as ICS Often require TID QID dosing Rarely used in because of the above Examples: Cromolyn, Nedocromil (Tilade) Acute asthma management beyond albuterol Oral corticosteroids potent anti-inflammatories Anticholinergics (Atrovent) another type of bronchodilator Magnesium Sulfate smooth muscle relaxant Heliox mixture of helium and oxygen used to drive albuterol treatment. Its lower gas density results in decreased flow resistance and increased lung penetration Medications are available in several delivery forms: Metered dose inhalers should be used with a spacer in most populations Dry powder inhalers Nebulized medications Oral tablet / liquid Goal is to pick the best route of delivery for each patient 17

18 Special Considerations Nebulized medications especially budesonide must be delivered with a face mask in young children no blow by! Flovent, QVAR, Symbicort, Dulera, Advair must be BID dosing when weaning, wean dose, not frequency Pulmicort and Asmanex may be given once daily Spacers are recommended in all age groups. Most kids need one with a mask until 5-6 years of age. Age considerations Flovent - 44mcg approved ages & 220 approved 11 + QVAR approved for 5+ Pulmicort Respules approved 12 months + Singulair approved 6 months + Symbicort & Dulera 12+ Advair diskus 4+ Advair HFA 12+ Education is key Critical families know asthma triggers, symptoms, acute management, and difference between controller and rescue meds Stress that controller medications need to be refilled every month Show patient and family how to use the device chosen check technique at every visit Give written asthma action plans 18

19 Asthma Action Plan Peak flow meters Home device where patients blow as hard as they can into device to get reading Norms are based on height Usually results divided into green zone (>80% predicted), yellow zone 60-80% predicted) or red zone (< 60% predicted) Peak flow meters Choose candidates wisely adds one more thing Helpful in those who are poor perceivers or for parents who are unsure if this is asthma Can be done daily, or prn after establishing child s norm 19

20 Trouble shooting and adherence issues: Trouble shooting Considerations if not getting better - They aren t taking their medication (check a refill history) - They aren t taking their medication correctly (check technique) - Not the right medication for that patient - Not the right delivery method for that patient - Co-morbid condition GERD, allergies, sinusitis - Environmental factors smoke, allergens - It s not asthma VCD, CF, airway anomaly 20

21 Adherence - A HUGE ISSUE with asthma A 2005 study showed that: An ICS is filled an average of 2.29 x / yr. Advair diskus filled an average of 3.98 x / yr. Singulair is filled an average of 4.33 x / yr. Another study showed that: Parental report of adherence is 85% Actual adherence was 25% (using an electrically monitored device) Assessing adherence Ask how many doses they think they miss a week Ask where the controller inhaler is located Ask who is responsible for remembering the medication Ask parent if they personally observe each dose Ask parent if they check the dose counter 21

22 Improving adherence Acknowledge that it s a difficult thing Assess barriers finances, transportation, etc. - consider options such as mail order pharmacies, auto-refills w/ text reminders Suggest the inhaler not be kept in the child s bedroom or even bathroom Ask parents not just to remind the child, but to personally observe each dose good time to bring up developmental considerations Remind patients that most inhalers do have counters, and if they don t most inhalers have exactly enough for 30 days then the medicine is gone, even if the inhaler doesn t feel empty Improving adherence Have parents or teens set a reminder on their phone Use sticker calendars to help remember doses Consider med choices carefully do they really need every they re on, can something be QD vs. BID, etc Get the school involved Encourage positive reinforcement Frequent follow up monthly if needed School and Daycare issues Educate caregivers on s/s of asthma and how to relieve symptoms Every child should have a rescue medication available at school and staff should be trained to administer it check expiration dates Provide school with written asthma action plan and emergency phone numbers Encourage participation in physical activity recess, PE, sports activities 22

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