Esteemed Faculty. Michael A. LeNoir MD, FAAP, FAAAI. Jointly sponsored by AKH Inc., Advancing Knowledge in Healthcare and Not One More Life, Inc.

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1 Esteemed Faculty Michael A. LeNoir MD, FAAP, FAAAI Joitly sposored by AKH Ic., Advacig Kowledge i Healthcare ad Not Oe More Life, Ic.

2 otoemorelife.org Allergy ad Asthma I Childre 70% o the post-test. A statemet of credit will be available for pritig upo successful completio. If you have questios about this CME/CE activity, please cotact AKH Ic. at service@akhealthcare.com FEES There are o fees to participate i this activity. PROGRAM OVERVIEW This module will focus o the liks betwee atopy, specifically allergic rhiitis ad childhood asthma. The goal is to ehace the ability of primary care providers (PCPs) to idetify patiets with allergic coditios that are associated with asthma. Origial Release Date: 10/01/2012 Review Date: 06/01/2014 Expiratio Date: 06/01/2016 TARGET AUDIENCE This activity is desiged for physicias ad urses who care for patiets with asthma. LEARNING OBJECTIVES Upo completio of the educatioal activity, participats should be able to: Describe the relatioship betwee upper airway ad lower airways i allergic rhiitis. Describe the role allergy plays i the developmet of asthma. Discuss commo wheezig pheotypes. METHOD OF PARTICIPATION/ CRITERIA FOR SUCCESS: To receive cotiuig educatio credit, participats should review all writte materials, complete ad submit a post-test ad evaluatio, ad score at least ESTEEMED FACULTY Michael A. LeNoir MD, FAAP, FAAAI Associate Cliical Professor i Pediatrics at the Uiversity of Califoria Presidet Elect, Natioal Medical Associatio CEO of the Ethic Health America Network Director of the Bay Area Multicultural Cliical Research ad Prevetio Ceter Presidet of the Ethic Health Istitute at Summit Medical Ceter Chair of the Allergy & Asthma iitiative Alta Bates Summit Medical Ceter Clear the Air Allergy ad Asthma Committee of the Natioal Medical Associatio FACULTY DISCLOSURES: Michael A. LeNoir MD, FAAP, FAAAI Speaker Bureau for Teva Pharmaceuticals ad GlaxoSmithKlie DISCLOSURE DECLARATION It is the policy of AKH Ic. to esure idepedece, balace, objectivity, scietific rigor, ad itegrity i all of its cotiuig educatio activities. The faculty must disclose to the participats ay sigificat relatioships with commercial iterests whose products or devices may be metioed i the activity or with the commercial supporter of this cotiuig educatio activity. Idetified coflict of iterest is resolved by AKH prior to accreditatio of the activity. AKH, CME Uiversity, The CHEST Foudatio, ad Not Oe More Life, Ic. plaers ad reviewers, outside of those listed, have o relevat fiacial relatioships to disclose. # 1

3 otoemorelife.org Allergy ad Asthma I Childre DISCLOSURE OF UNLABELED USE AND INVESTIGATIONAL PRODUCT This educatioal activity may iclude discussio of uses of agets that are ivestigatioal ad/or uapproved by the FDA. Please refer to the official prescribig iformatio for each product for discussio of approved idicatios, cotraidicatios, ad warigs. ACCREDITATION: Physicias: This activity has bee plaed ad implemeted i accordace with the Essetial Areas ad policies of the Accreditatio Coucil for Cotiuig Medical Educatio (ACCME) through the joit sposorship of AKH Ic., CME Uiversity Ic., The CHEST Foudatio, ad Not Oe More Life, Ic. AKH Ic. is accredited by the ACCME to provide cotiuig medical educatio for physicias. COMMERCIAL SUPPORT: There is o commercial support for this activity. PRIVACY AND CONFIDENTIALITY POLICY To review our privacy ad cofidetiality policy go to HARDWARE AND SOFTWARE REQUIREMENTS To access materials users will eed: A computer with a Iteret coectio. Iteret Explorer 7.x or higher, Firefox 3.x or higher, Safari 3.x or higher, or ay other W3C stadards compliat browser. Adobe Acrobat Reader or Apple Preveiw. Occasioally other additioal software may be required such as Adobe Flash Player ad/or a HTML5 capable browser for video or audio playback. AKH Ic., Advacig Kowledge i Healthcare desigates this edurig moograph for a maximum of 0.5 AMA PRA Category 1 Credit(s). Physicias should claim oly the credit commesurate with the extet of their participatio i the activity. Nurses: AKH Ic., Advacig Kowledge i Healthcare is accredited as a provider of cotiuig ursig educatio by the America Nurses Credetialig Ceter s Commissio o Accreditatio. This activity is awarded 0.5 cotact hour.. # 2

4 otoemorelife.org Allergy ad Asthma I Childre INTRODUCTION Asthma, affectig over seve millio childre i the Uited States, is the most commo chroic disease of childhood 1 ad is associated with cosiderable morbidity ad icreasig frequecy over time. The upredictable ature of asthma expressios makes the diagosis of asthma i childre complex ad variable betwee stages of childhood. Bacterial rhiosiusitis (allergic rhiitis), viral upper respiratory ifectios (URI) ad asal polyposis is ofte preset i childre with asthma ad may add to the complexity of the diagosis ad treatmet. This activity will focus o the lik allergic rhiitis ad other atopic coditios have with childhood asthma. ALLERGIC RHINITIS It has bee estimated that 40 percet of childre suffer from allergic rhiitis. Parets ad care givers ofte uderestimate the physical, emotioal ad ecoomic impact of both allergic- ad o-allergic rhiitis. A commo disease i childre, rhiitis may have a major impact o the affected child s quality of life ad may require substatial health care resources. Diagosis of this coditio is ofte difficult due to ospecific idicators ad the youg child s iability to describe their symptoms. A child with allergies may report with symptoms of rhiorrhea, asal cogestio, seezig, ad asal itchig. I additio, these childre may be tired from disrupted sleep. Chroic allergic rhiitis ca lead to a physical symptom of discoloratio uder the eyes. I extreme cases this ca maifest as blue/grey to purple circles uder the eyes. The child may also iadvertetly demostrate the allergic salute which is pushig the tip of the ose up with the had due to the itchig. Upo physical examiatio, they exhibit edematous ad pale asal mucosa. ALLERGIC RHINITIS AND ASTHMA Rhiitis is a major idepedet risk factor for asthma. Cross-sectioal ad logitudial studies have suggested a relatioship betwee rhiitis ad asthma as beig oe sydrome that maifests i two parts of the respiratory tract. This theory maitais that rhiitis occurs i the upper airways ad airway obstructio/asthma occurs i the lower airways. Whether this is true or ot, there are similar allergic compoets to bith rhiitis ad asthma ad to maage allergic rhiitis effectively requires a itegrated view of both the upper ad lower airways. 2 Allergic rhiitis has a varyig spectrum of severity that rages from: Ivolvemet of the asal airways oly (rhiitis without airway hyperresposiveess /asthma) Rhiitis with evidece of lower airway hyperresposiveess (ot cliical asthma) Rhiitis ad coexistet asthma 3 Several studies idicate that patiets at the low ed of the spectrum, or rhiitis without asthma, are ot free of disease of the lower airways. Patiets with rhiitis should be evaluated for lower airway chages as a part of their routie care, ad should be maaged aggressively. Patiets with asthma should also have their asal airways evaluated for allergic rhiitis as a stadard part of their cliical assessmet ad follow-up. 4 3

5 otoemorelife.org Allergy ad Asthma I Childre THE PATHOPHYSIOLOGY OF AN ALLERGIC REACTIONS AND ASTHMA Upper airway allergic reactios are caused whe a idividual respods to a allerge exposure by producig allerge-specific immuoglobuli E (IgE) atibodies. The atibodies bid to IgE receptors o mast cells i the respiratory mucosa, leadig to mast cell activatio with subsequet exposures to the same allerge. The mast cell release of chemical mediators causes the stimulatio of blood vessels, erves ad glads which produces the symptoms of allergic rhiitis (seezig, rhiorrhea, itchig). Elevated total IgE levels idicate the presece of allergic sesitizatio. Because the ose ad the brochi share a similar histological structure, the mucosal cellular ifiltrate characterizig allergic rhiitis is similar to that i asthma with the same pro-iflammatory mediators (histamie, leukotriee s). Patiets with allergic rhiitis commoly experiece airway hyperresposiveess ad data have show that serum levels of IgE also correlate with airway hyperresposiveess. 4 ATOPY AND ASTHMA Atopy is defied as the geetic tedecy to develop allergic diseases. The Third Natioal Health ad Nutritio Examiatio Survey (NHANES) reported that 56.3%of the asthma cases i the Uited States were attributable to atopy. 5 Specifically, atopic dermatitis, a chroic iflammatory ski coditio, has bee liked to asthma. WHEEZING PHENOTYPES Studies have show that approximately 50% of childre report wheezig i the first year of life. 6 While commo, ot all wheezig is a symptom of asthma. To assist with the idetificatio wheezig symptoms, researchers have attempted to defie the pheotypes associatio with wheezig. Oe method of defiig these pheotypes is based o the temporal patter of the wheeze ad ca be applied prospectively. For example, the Europea Respiratory Society has described the followig pheotypes: Episodic wheeze which occurs at ospecific time periods ad is usually associated with viral respiratory ifectios Multi-trigger wheeze which occurs durig exacerbatios ad betwee episodes ad is ofte triggered by viruses, allerges, exercise ad cigarette smoke exposure. 7 Other researchers have attempted to classify wheezig pheotypes by assessig the relatioship betwee atopy ad asthma. These classificatios iclude: No-atopic persistet wheezig which begis i the first year of life ad becomes less frequet by early adolescece. 8,9 IgE-associated/atopic persistet wheezig which begis after the first year of life ad persists ito later adolescece. 7 Classificatio systems have also bee developed that assess the child s risk of developig asthma. The Tucso classificatio which has bee developed from the Tucso Childre s Respiratory Study (TCRS) ad icludes four pheotypes: 7 Never wheezers Early, trasiet wheezers (begiig before age 3 years ad resolvig by age 6) 4

6 otoemorelife.org Allergy ad Asthma I Childre Persistet wheezers (begiig before age 3 ad still preset at age 6) Note: these patiets are at icreased risk for persistet asthma-like symptoms ito adolescece ad adulthood 10 Late-oset wheezers (begiig betwee age 3 ad age 6). These patiets are at icreased risk for persistet asthma-like symptoms ito adolescece ad adulthood. 9 The Avo Classificatio Study of Parets ad Childre (ALSPAC) further refied ad added two pheotypes to the Tucso classificatio. 11 Late-oset wheeze (Ifrequet from 6-42 moths of age but commo after 42 moths). These patiets are at icreased risk for persistet asthma-like symptoms ito adolescece ad adulthood. Persistet wheeze (commo after 6 moths of age). These patiets are at icreased risk for persistet asthma-like symptoms ito adolescece ad adulthood. SUMMARY May childre experiece wheezig durig childhood; however, childre with episodic wheezig may or may ot have true asthma. Practitioers must assess the child thoroughly ad evaluate the iterrelatioships with allergic rhiitis ad atopy that may be occurrig i order to provide optimum care for these patiets. 5

7 otoemorelife.org Allergy ad Asthma I Childre REFERENCES 1 Natioal Health Iterview Survey (NHIS 2005), Natioal Ceter for Health Statistics (NCHS), Ceters for Disease Cotrol ad Prevetio. Hyattsville, MD Accessed o Jue 11, Navarro A, Valero A, Julia B, Quirce S. Coexistece of asthma ad allergic rhiitis i adult patiets attedig allergy Cliics ONEAIR Study. J Allergy Cli Immuol. 2003;111: Togias A. Rhiitis ad asthma: Evidece for respiratory system itegratio. J Allergy ad Cli Immuology. 2003;111:37A. 4 Arshad SH, Kurukulaaretchy RJ, Fe M, et al. Rhiitis i 10-year-old childre ad early life risk factors for its developmet. Acta Paediatr. 2002;91: Arbes SJ Jr, Gerge PJ, Vaugh B, Zeldi DC. Asthma cases attributable to atopy: results from the Third Natioal Health ad Nutritio Examiatio Survey. J Allergy Cli Immuol. 2007;120(5): Martiez FD, Wright AL, Taussig LM, et al. Asthma ad wheezig i the first six years of life. The Group Health N Egl J Med. 1995;332: Brad PL, Baraldi E, Bisgaard H, et al.defiitio, assessmet ad treatmet of wheezig disorders i preschool childre: a evidece-based approach. Eur Respir J. 2008;32: Stei RT, Sherrill D, Morga WJ, et al. Respiratory sycytial virus i early life ad risk of wheeze ad allergy by age 13 years. Lacet. 1999;354: Brad PL, Baraldi E, Bisgaard H, eta l. Defiitio, assessmet ad treatmet of wheezig disorders i preschool childre: a evidece-based approach. Eur Respir J. 2008;32: Ster DA, Morga WJ, Haloe M, et al. Wheezig ad brochial hyperresposiveess i early childhood as predictors of ewly diagosed asthma i early adulthood: a logitudial birth-cohort study. Lacet. 2008;372: Hederso J, Graell R, Hero J, et al. Associatios of wheezig pheotypes i the first 6 years of life with atopy, lug fuctio ad airway resposiveess i mid-childhood. Thorax. 2008;63:974. 6

8 otoemorelife.org Allergy ad Asthma I Childre EXAMINATION REVIEW This page is provided for review oly. To receive CE/CME credits you must successfully complete the olie program post-exam ad evaluatio. To complete the olie exam ad evaluatio proceed to ad follow these easy steps to ear credit. 1. Sig-I or Register (at select the Professioal Eductio sectio). 2. Select the course from the Olie Programs listig (you must complete the olie course selectio process i its etirety i order to access the olie exam). 3. Course title will be added to your User Record page. 4. Select the Take Exam lik ad aswer all the questios. Whe ready submit the olie Exam. A immediate grade report will be displayed. Upo successful completio of the post-exam with a score of 70% or higher click cotiue ad complete the program evaluatio. 5. Certificate lik will be provided withi the User Record page directly across from the course title. Click to view or prit your statemet of credit. Importat Credit Note: Credit may ot be claimed if completed after the course expiratio date. 1. Asthma affects more tha seve millio childre i the Uited States. Which of the followig coditios is usually ot see cocurretly i childre with asthma? A. Bacterial rhio siusitis B. Nasal septum deviatio C. Viral upper respiratory ifectios D. Nasal polyposis 2. What percetage of childre i the US suffers from allergic rhiitis? A. 10% B. 20% C. 30% D. 40% 3. Upper airway allergic reactios occur whe a idividual respods to a allerge exposure by producig : A. Iterleuki 5 (IL-5 ) B. Type 2 T-Helper Cells C. Allerge-specific immuoglobuli E (IgE) atibodies D. Graulocyte-macrophage coloy-stimulatig factor (GM-CSF) 7

9 otoemorelife.org Allergy ad Asthma I Childre 4. Accordig to the Europea Respiratory Society pheotype defiitios, episodic wheezig which occurs at ospecific time periods is usually associated with: A. Viral respiratory ifectios B. Elevated eosiophilia C. Bacterial respiratory ifectios D. Seasoal allergies 5. Childre i whom wheezig begis betwee the age of 3 years ad 6 years are classified as late wheezers ad are at icreased risk for persistet asthma-like symptoms ito adolescece ad adulthood. A. True B. False 8