Outpatient Management of Pediatric Asthma Ruth A. McConnell, MPH, MSN, RN, CPNP, AE-C

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1 Outpatient Management of Pediatric Asthma Ruth A. McConnell, MPH, MSN, RN, CPNP, AE-C Pediatric Nurse Practitioner, Certified Asthma Educator Department of Pediatrics, Pulmonology Section Texas Children's Hospital Instructor, Baylor College of Medicine

2 Outline Introduction Key Components of Asthma Care Asthma Care for Special Circumstances Managing Asthma Exacerbations Medications and Delivery Methods Basic Measures of Pulmonary Function Testing Summary

3 Introduction Asthma is a chronic inflammatory disorder of the airways. Asthma is a common chronic disorder of the airways that involves a complex interaction of airflow obstruction, bronchial hyperresponsiveness and underlying inflammation. This interaction can be highly variable among patients and within patients over time (EPR-Section 2, p 12.). EPR 3- Section 2, p xxx00.#####.ppt 4/6/18 9:55:28 AM

4 Introduction Characteristics of Asthma: Airway inflammation, bronchoconstriction, & increased mucus xxx00.#####.ppt 4/6/18 9:55:28 AM

5 T Asthma facts Asthma affects 25.7 million people, including 7.0 million children under 18. Asthma is a leading cause of school absenteeism. Every day in the US 30,000 people have an asthma attack 5,000 people visit the ED 1,000 people are admitted to the hospital 11 people die xxx00.#####.ppt 4/6/18 9:55:28 AM

6 Outline Introduction Key Components of Asthma Care Asthma Care for Special Circumstances Managing Asthma Exacerbations Medications and Delivery Methods Basic Measures of Pulmonary Function Testing Summary

7 Key Components of Asthma Care Clinical issue: Establish asthma diagnosis (1 st visit only) Make the diagnosis: Symptoms of recurrent episodes of airflow obstruction Airway obstruction is at least partially reversible (>5 yrs) Rule out alternate causes of obstruction xxx00.#####.ppt 4/6/18 9:55:28 AM

8 Assessment & Monitoring The goal of asthma therapy is asthma control. Asthma control focuses on two domains: Reducing impairment Reducing risk xxx00.#####.ppt 4/6/18 9:55:28 AM

9 Impairment domain Prevent chronic symptoms Require infrequent use of short-acting beta2-agonist (SABA) Maintain (near) normal lung function & activity levels xxx00.#####.ppt 4/6/18 9:55:28 AM

10 Risk domain Prevent exacerbations Minimize need for ED/hospital care Prevent loss of lung function, or for children, prevent reduced lung growth Have minimal or no adverse effects of therapy xxx00.#####.ppt 4/6/18 9:55:28 AM

11 Assessment & Monitoring Assess asthma severity to initiate therapy (initial visit) Use the severity classification chart, assessing both domains of impairment and risk, to determine initial treatment Assess asthma control to monitor and adjust therapy (follow up visits) Use the asthma control chart Expert Panel Report 3 Guidelines for the Diagnosis and Management of Asthma. NIH, NHLBI, xxx00.#####.ppt 4/6/18 9:55:28 AM

17 Principles of Stepwise Therapy The goal of asthma therapy is to maintain longterm control of asthma with the least amount of medication and hence minimal risk for adverse effects. EPR -3, Section 4, P xxx00.#####.ppt 4/6/18 9:55:29 AM

corticosteroids, or both Before increasing medication therapy, evaluate: Exposure to

18 Principles of step therapy to maintain control Step up medication dose if symptoms are not controlled If very poorly controlled, consider an increase by 2 steps, add oral corticosteroids, or both Before increasing medication therapy, evaluate: Exposure to environmental triggers Adherence to therapy For proper device technique Co-morbidities 17 xxx00.#####.ppt 4/6/18 9:55:29 AM

19 Outline Introduction Key Components of Asthma Care Asthma Care for Special Circumstances Managing Asthma Exacerbations Medications and Delivery Methods Basic Measures of Pulmonary Function Testing Summary

20 Exercise-Induced Bronchospam Exercise-Induced Bronchospasm Treatment strategies to prevent EIB Long-term control therapy Pretreatment before exercise (SABA, LTRA, cromolyn) Warm up Scarf /mask over mouth if cold-induced 19 xxx00.#####.ppt 4/6/18 9:55:29 AM

21 Outline Introduction Key Components of Asthma Care Asthma Care for Special Circumstances Managing Asthma Exacerbations Medications and Delivery Methods Basic Measures of Pulmonary Function Testing Summary

22 Use of medications Managing exacerbations Recognize early warning signs Adjust medications Increase SABA Add oral corticosteroid when indicated Remove or withdraw from environmental factors Monitor response closely and seek emergency medical care if serous deterioration or lack of response to treatment 21 xxx00.#####.ppt 4/6/18 9:55:29 AM

23 Outline Introduction Key Components of Asthma Care Asthma Care for Special Circumstances Managing Asthma Exacerbations Medications and Delivery Methods Basic Measures of Pulmonary Function Testing Summary

24 Use of medications 23 xxx00.#####.ppt 4/6/18 9:55:29 AM

25 Use of medications Ø Select medication and delivery devices to meet patient s needs and circumstances Ø Use the stepwise approach to identify appropriate treatment options. Ø Inhaled corticosteroids (ICSs) are the most effective long-term control therapy. Ø When choosing among treatment options, consider: Ø Ø Ø Domain of relevance to the patient (impairment, risk, or both) History of response to the medication Patient s willingness and ability to use the medication 24 xxx00.#####.ppt 4/6/18 9:55:29 AM

26 Use of medications Ø General principles for all ages Ø Incorporate the 4 components of care Ø Initiate therapy based on asthma severity Ø Adjust therapy based on asthma control 25 xxx00.#####.ppt 4/6/18 9:55:29 AM

27 Use of medications ØFor ages 0-4 years Ø Consider daily long-term control therapy Ø Monitor response closely, and adjust treatment Ø If no clear benefit in 4-6 weeks consider alternate diagnosis. Ø If clear benefit for at least 3 months, consider step down to evaluate need for daily therapy. Children in this age group have high rates of spontaneous remission of symptoms 26 xxx00.#####.ppt 4/6/18 9:55:29 AM

28 Use of medications For ages >5 years Involve the child Concerns Preferences School schedules Promote physical activity Treat exercise induced symptoms Step up therapy for poor endurance or sx s during normal play Monitor for disease progression and loss of lung growth 27 xxx00.#####.ppt 4/6/18 9:55:29 AM

29 Two categories of medications Controller medications Taken every day to prevent swelling in the airways Reliever / rescue medications Taken only when needed to relieve symptoms To prevent exercise induced asthma from developing (taken before strenuous exercise) xxx00.#####.ppt 4/6/18 9:55:29 AM 28

Controller medications Keeps swelling and mucus from developing in the airways Must be taken EVERY day even when not having symptoms Inhaled

30 Controller medications Keeps swelling and mucus from developing in the airways Must be taken EVERY day even when not having symptoms Inhaled corticosteroids (ICS s) are the most common and effective way to control asthma Help prevent asthma exacerbations from developing! 29 xxx00.#####.ppt 4/6/18 9:55:29 AM

31 Use of medications Controllers ICSs Inhaled corticosteroids LABAs Long acting bronchodilators Combination (ICS + LABA) Mast cell stabilizers LTRAs Leukotriene receptor antagonists Methylxanthines Systemic corticosteroids 30 xxx00.#####.ppt 4/6/18 9:55:29 AM

32 Medications Controllers ICSs Inhaled corticosteroids Budesonide (Pulmicort): respules, flexhaler Beclomethasone diproprionate (Qvar): MDI Fluticasone (Flovent): diskus, MDI Mometasone furoate (Asmanex): twisthaler Ciclesonide (Alvesco): MDI 31 xxx00.#####.ppt 4/6/18 9:55:29 AM

33 Component 4 - Medications Controllers LABAs long acting bronchodilators Salmeterol (Serevent): diskus Formoterol fumarate (Foradil): aerolizer Combinations Fluticasone/salmeterol (Advair): MDI, diskus Mometasone furoate/formoterol fumate (Dulera): MDI Budesonide/formoterol fumate (Symbicort): MDI 32 xxx00.#####.ppt 4/6/18 9:55:29 AM

34 Medications Controllers Mast cell stabilizers Cromolyn: MDI, nebulizer Nedocromyl: MDI LTRAs Leukotriene receptor antagonists Montelukast (Singulair): 6mth+; oral Zafirlukast (Accolate): 5yr+; oral 33 xxx00.#####.ppt 4/6/18 9:55:29 AM

35 Medications Controllers Methylxanthines theophylline Systemic corticosteroids Prednisolone Methylprednisolone Prednisone 34 xxx00.#####.ppt 4/6/18 9:55:29 AM

Key Points: Safety of ICS s ICS s are the most effective long-term therapy available, are well tolerated & safe at recommended doses The potential but small risk of adverse events from the use of ICS

36 Key Points: Safety of ICS s ICS s are the most effective long-term therapy available, are well tolerated & safe at recommended doses The potential but small risk of adverse events from the use of ICS treatment is well balanced by their efficacy The dose-response curve for ICS treatment begins to flatten at low to medium doses Most benefit is achieved with relatively low doses, whereas the risk of adverse effects increases with dose 35 xxx00.#####.ppt 4/6/18 9:55:29 AM

37 Key Points: Safety of Long-Acting Beta 2 - Agonists (LABA s) Adding a LABA to the tx of patients whose asthma is not well controlled on lowor medium-dose ICS improves lung function, decreases symptoms, and reduces exacerbations and use of SABA for quick relief in most patients The FDA determined that a Black Box warning was warranted on all preparations containing a LABA For patients who have asthma not sufficiently controlled with ICS alone, the option to increase the ICS dose should be given equal weight to the option of the addition of a LABA to ICS It is not currently recommended that LABA be used for treatment of acute symptoms or exacerbations LABAs are not to be used as monotherapy for long-term control 36 xxx00.#####.ppt 4/6/18 9:55:29 AM

38 FDA Recommendations for LABA s February 2010 Are contraindicated without the use of an asthma controller medication such as an ICS Single-ingredient LABAs should only be used in combination with an asthma controller medication; they should not be used alone Should only be used long-term in patients whose asthma cannot be adequately controlled on asthma controller medications xxx00.#####.ppt 4/6/18 9:55:29 AM 37

39 FDA Recommendations for LABA s Cont. Should be used for the shortest duration of time required to achieve control of asthma symptoms and discontinued, if possible, once asthma control is achieved Patients should then be maintained on an asthma controller medication Pediatric and adolescent patients who require the addition of a LABA to an ICS should use a combination product containing both an ICS and a LABA, to ensure compliance with both medications xxx00.#####.ppt 4/6/18 9:55:29 AM 38

40 Key Points: Reducing Potential Adverse Effects Ø Spacers or valved holding chambers (VHCs) used with non-breath-activated MDIs reduce local side effects There is little or no data on use of spacers with hydrofluoroalkane (HFA) MDIs Ø Patients should rinse their mouths (rinse and spit) after (ICS) inhalation Ø Use the lowest dose of ICS that maintains asthma control: Evaluate patient adherence and inhaler technique as well as environmental factors before increasing the dose of ICS Ø To achieve or maintain control of asthma, add a LABA to a low or medium dose of ICS rather than using a higher dose of ICS Ø Monitor linear growth in children xxx00.#####.ppt 4/6/18 9:55:29 AM 39

41 Use of medications Rescue SABAs Short acting beta2 agonists Anticholinergics Systemic corticosteroids 40 xxx00.#####.ppt 4/6/18 9:55:29 AM

42 Rescue / reliever medications Rescue inhalers are typically Albuterol and Xopenex (levalbuterol) products Are taken when asthma symptoms are appearing (asthma episode) Work by relaxing the muscles surrounding the airways Are taken minutes before strenuous exercise/activity by people with EIA Do NOT reduce or prevent swelling from developing in the lungs May be carried in school by a student only if approved by the doctor, school nurse and parent 41 xxx00.#####.ppt 4/6/18 9:55:29 AM

Key Points: Safety of Short -Acting Beta 2 -Agonists (SABA s) SABAs are the most effective medication for relieving acute bronchospasm Increasing use of SABA treatment or using SABA >2 days

43 Key Points: Safety of Short -Acting Beta 2 -Agonists (SABA s) SABAs are the most effective medication for relieving acute bronchospasm Increasing use of SABA treatment or using SABA >2 days a week for symptom relief (not prevention of EIB) indicates inadequate control of asthma Regularly scheduled, daily, chronic use of SABA is not recommended xxx00.#####.ppt 4/6/18 9:55:29 AM 42

44 Delivery methods Both control and rescue medications come in MDI (metered dose inhalers) and nebulized forms Control medications are also available in dry powder discs, breath actuated inhalers and pill form 43 xxx00.#####.ppt 4/6/18 9:55:30 AM

45 xxx00.#####.ppt 4/6/18 9:55:30 AM

46 Typical Spacers/Holding Chambers xxx00.#####.ppt 4/6/18 9:55:30 AM 45

Spacers or holding chambers Most MDI s (metered dose inhalers) should be used with a spacer or holding chamber This device attaches to the MDI and allows the user to breathe in more medication

47 Spacers or holding chambers Most MDI s (metered dose inhalers) should be used with a spacer or holding chamber This device attaches to the MDI and allows the user to breathe in more medication effectively The clinician must write an order for a chamber when prescribing your MDI medication Both controller and reliever medications are in MDI dispensers Dry powder inhalers do NOT require spacers xxx00.#####.ppt 4/6/18 9:55:30 AM 46

48 Patient education for self management 47 xxx00.#####.ppt 4/6/18 9:55:30 AM

49 48 Picture courtesy of American Lung Association of the Inland Counties CA 2004

50 xxx00.#####.ppt 4/6/18 9:55:30 AM

51 Patient education for self management ØProvide self management education ØDevelop a written asthma action plan in partnership with the patient. ØIntegrate education into all points of care where health professionals interact with patients EPR 3, Section 3, Pg. 93 xxx00.#####.ppt 4/6/18 9:55:30 AM 50

Patient education for self management Provide self management education Teach and reinforce Self-monitoring to assess level of asthma control and signs of worsening asthma (sx s / peak flows) Using a

52 Patient education for self management Provide self management education Teach and reinforce Self-monitoring to assess level of asthma control and signs of worsening asthma (sx s / peak flows) Using a written asthma action plan (differences between long term control and quick-relief medication) Taking medication correctly (inhaler technique and use of devices). Avoiding environmental triggers. Tailor education to literacy level Appreciate the potential role of a poatient s cultural beliefs and practices EPR 3, Section 3, Pg. 93 xxx00.#####.ppt 4/6/18 9:55:30 AM 51

53 Patient education for self management Develop a written asthma action plan in partnership with the patient. Agree on treatment goals Address patient concerns Provide instructions for Daily management (long term control medication & environment) Managing worsening asthma (how to adjust medication when to seek medical care) EPR 3, Section 3, Pg xxx00.#####.ppt 4/6/18 9:55:30 AM

54 Patient education for self management Integrate education into all points of care where health professionals interact with patients Involve all members of the health care team in providing/reinforcing education, including physicians, nurses, pharmacists, respiratory therapists, and asthma educators. Encourage education at all points of care: Clinics ED/hospitals Pharmacies Schools & other community settings Patients homes Use a variety of education strategies EPR 3, Section 3, Pg xxx00.#####.ppt 4/6/18 9:55:30 AM

55 Asthma Action Plan Zones Green Zone: All Clear/Breathing Good/Go No asthma symptoms and/or Peak flow % Yellow Zone: Caution/Slow Down Some asthma symptoms and/or Peak flow 50-80% Red Zone: Medical Alert/Stop Severe asthma symptoms and/or Peak flow < 50% 54 xxx00.#####.ppt 4/6/18 9:55:30 AM

56 Control of environmental factor and comorbid conditions xxx00.#####.ppt 4/6/18 9:55:30 AM 55

57 Control environmental factors and comorbid conditions ØRecommend measures to control exposures to allergens and pollutants or irritants that make asthma worse ØTreat comorbid conditions EPR 3 xxx00.#####.ppt 4/6/18 9:55:30 AM 56

Triggers and Irritants Copyright 2004, 3M

59 Common Allergens (Triggers) Seasonal pollens Animal dander /saliva/urine Dust mites Cockroaches/mice/rat droppings and urine Mold Some foods or food additives xxx00.#####.ppt 4/6/18 9:55:30 AM 58

Common Irritants (Triggers) Exercise/sports Cold air Chalk dust Viral/upper respiratory infections Air pollution Tobacco smoke or secondhand smoke

60 Common Irritants (Triggers) Exercise/sports Cold air Chalk dust Viral/upper respiratory infections Air pollution Tobacco smoke or secondhand smoke Chemical irritants and strong smells Diesel fumes Cleaning supplies Other Strong emotions, weather changes, some medications 59 xxx00.#####.ppt 4/6/18 9:55:30 AM

61 Control environmental factors and comorbid conditions Recommend measures to control exposures to allergens and pollutants or irritants that make asthma worse Determine exposures Determine sensitivities Advise on ways to reduce exposure to those allergens, pollutants, and/or irritants to which the patient is sensitive. Consider allergen immunotherapy for patient with persistent for whom there is a clear relationship between symptoms and exposure. EPR 3 xxx00.#####.ppt 4/6/18 9:55:30 AM 60

62 Control environmental factors and comorbid conditions Treat comorbid conditions this may improve asthma control ABPA GERD Obesity Osa Rhinitis Sinusitis Stress depression EPR 3 61 xxx00.#####.ppt 4/6/18 9:55:30 AM

63 Outline Introduction Key Components of Asthma Care Asthma Care for Special Circumstances Managing Asthma Exacerbations Medications and Delivery Methods Basic Measures of Pulmonary Function Testing Summary

64 Spirometry interpretation Spirometry is often used to diagnose asthma and for assessing the risk of future adverse events. The FVC (forced vital capacity) is the maximal amount of air that the patient can forcibly exhale after taking a maximal inhalation The FEV1 (forced expiratory volume in 1 second) is the most reproducible flow parameter and is especially useful in diagnosing and monitoring patients with obstructive pulmonary disorders (eg, asthma, COPD) xxx00.#####.ppt 4/6/18 9:55:30 AM

65 Outline Introduction Key Components of Asthma Care Asthma Care for Special Circumstances Managing Asthma Exacerbations Medications and Delivery Methods Basic Measures of Pulmonary Function Testing Summary (activity time permitting)

66 T Summary Make the diagnosis Goal of therapy is control Manage asthma Assessment and monitoring Education Controlling environmental triggers & comorbid conditions Medications xxx00.#####.ppt 4/6/18 9:55:30 AM

67 xxx00.#####.ppt 4/6/18 9:55:30 AM

68 Wisdom is the reward you get for a lifetime of listening when you'd rather have been talking. Aristotle

69 Resources American Sign Language Video - 'Information About Asthma' Information About Asthma This American Sign Language (ASL) film, produced by the CDC and the Deaf Wellness Center at the University of Rochester Medical Center, discusses how to manage asthma to help prevent attacks or decrease the overall health effects of this disease. Listen to/watch this Video (15:26) Español xxx00.#####.ppt 4/6/18 9:55:30 AM

70 T Asthma resources (EPA) Help In My Community American Lung Association, , Allergy & Asthma Network Mothers of Asthmatics, , Asthma and Allergy Foundation of America, , Learn More About Asthma U.S. Environmental Protection Agency, Centers for Disease Control and Prevention, CDC-info, xxx00.#####.ppt 4/6/18 9:55:31 AM

71 References "Airflow, Lung Volumes, and Flow-Volume Loop: Tests of Pulmonary Function (PFT)." Merck Manual Professional. N.p., n.d. Web. 28 Jan Brusasco, V., R. Carpo, and G. Viegi, et al. "Series ATS/ERS Task Force: Standardisation of Lung Function Testing", Interpretative Strategies for Lung Function Tests." European Respiratory Journal 5 th ser. 26 (2005): Castro, Mario, and Monica Kraft. Clinical Asthma. Philadelphia: Mosby / Elsevier, Cherniack, Reuben M. Pulmonary Function Testing. 2nd ed. Philadelphia: Saunders, Dozor, A.J (Ed) (2001). Primary Pediatric Pulmonology. Armonk: Futura Publishing Company. Godfrey, Simon, and Kenneth D. Fitch. "Exercise Induced Bronchoconstriction: Celebrating 50 Years." Immunol Allergy Clin N Am 33 (2013): xxx00.#####.ppt 4/6/18 9:55:31 AM

72 References Grippi, M.A. (Ed) (1995). Pulmonary Pathophysiology. Philadelphia: J.P. Lippincott Company. Miller, M. R., R. Carpo, and J. Hankinson, eds. "Series "ATS/ERS Task Force: Standardisation of Lung Function Testing", General Considerations for Lung Function." European Respiratory Journal 1st ser. 26 (2005): National Asthma Education and Prevention Program (National Heart, Lung, and Blood Institute). Third Expert Panel on the Management of Asthma. Expert Panel Report 3 Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: U.S. Dept. of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Breathing Easier. N.p.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Asthma_508_compliant_1. CDC, 28 Jan Web. 03 Feb Witek, Theodore J., and E. Neil Schachter. Pharmacology and Therapeutics in Respiratory Care. Philadelphia: W.B. Saunders, 1994 xxx00.#####.ppt 4/6/18 9:55:31 AM

73 References Witek, Theodore J., and E. Neil Schachter. Pharmacology and Therapeutics in Respiratory Care. Philadelphia: W.B. Saunders, 1994 xxx00.#####.ppt 4/6/18 9:55:31 AM

Clinical Practice Guideline: Asthma

Clinical Practice Guideline: Asthma INTRODUCTION A critical aspect of the diagnosis and management of asthma is the precise and periodic measurement of lung function both before and after bronchodilator