Case One: Jose Sanchez is a 6 year old boy who presents to your clinic for a walk-in sick visit during a busy January afternoon. His mother reports that he wheezed “a lot” as a baby and that then he outgrew his asthma. He has had wheezing for 2 days and “always” wheezes during this time of the year. She adds that he usually has a great summer without any wheezing or respiratory problems. She states that he was seen in the ED last month, twice, and received a syrup for five days both at the beginning of the month and again at the end, which helped, along with his Albuterol. Since then he has continued to cough at night about 3 times/ week. When you ask her if he’s ever been admitted for asthma, she states “ he wheezes, I told you he outgrew his asthma”. She denies that he’s ever been admitted. She gave him Albuterol HFA 2 puffs this morning without a spacer which helped only a little bit. 1) What is Jose’s diagnosis? How do you classify his severity?
Asthma is the leading serious chronic illness among children and affects an estimated 6.5 million children in the U.S. African American children are affected 2:1 as compared to Caucasians in the US and their morbidity and mortality is higher. A diagnosis of asthma can be made when there have been symptoms of recurrent episodes of airflow obstruction which are reversible usually through the use of short acting beta-agonists or spontaneously. It is defined as a chronic inflammatory disorder of the airways which causes recurrent episodes of persistent cough, exercise intolerance, shortness of breath, or night time awakenings due to cough. The inflammation also causes an associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli. Aside from identifying symptoms to diagnose asthma, pulmonary function testing may be an additional tool to identify airway obstruction that is at least partially reversible and may aid in the diagnosis. These are usually recommended for children ages 5 and above.
Many parents will say that their child “outgrew” his/her asthma. Studies show that 60% of children who experience wheezing in the first 3 years of life will have complete resolution by school age. Allergy in a child’s history or family history, is a major predictor of symptoms beyond school age. Additionally, 60% of all children who have asthma have resolution of the condition by adulthood.
In 1991 and 1997 expert panels were convened by the National Asthma Education and Prevention Program (NAEPP) and the National Heart, Lung, and Blood Institute (NHLBI) to establish guidelines for the management and diagnosis of asthma. These were subsequently revised in 2007 focusing on the assessment of control which had been a challenging aspect of delivering care to children with asthma.
Jose has a history of repeated episodes of “wheezing” which are reversed by use of his short acting beta agonist and therefore he meets criteria for a diagnosis of asthma. The next step is to classify his asthma as either intermittent or persistent. The guidelines were revised to include classification of severity for children less than 4 years old, ages 5-11 and ages 12 and older. They include summary tables for each of these groups for classifying asthma severity and initiating treatment, assessing control and adjusting therapy and a “Stepwise” approach for managing asthma.
For Jose, who is 6 years old, you determine that he is moderate persistent due to his nighttime awakenings which are more than 1 per week, but less than nightly. This alone, places him in the moderate persistent category as children are classified based on this highest level of IMPAIRMENT in any of five areas (symptoms, nighttime awakenings, use of short-acting beta agonists, interference with normal activity, or lung function)or the highest level of risk. (SEE TABLES). After assessing impairment, one needs to consider RISK as an additional factor in determining severity. Jose has had 3 exacerbations in the past 2 months, 2 of which have required systemic steroids again reaffirming his persistent symptoms.
2) What medication would you recommend for Jose at this time?
Based on the 2007 National Guidelines, Jose should begin appropriate therapy at “Step 3” which is to start with a medium dose inhaled corticosteroid or a low dose ICS + LABA (long acting beta agonist) or a low dose ICS +leukotriene receptor antagonists or low dose ICS +theophylline. Inhaled corticosteroids continue to be the preferred long-term control therapy for all ages as they target the chronic inflammatory component of asthma. Several studies have supported the use of LABA with low dose ICS over higher doses of ICS alone. However, controversy exists as studies have also shown that there is a small, but significant risk of asthma related death in those patients using salmeterol, a common LABA. The risk was highest among African Americans. This study led the FDA to issue a black box warning for products with LABA and a recommendation against starting therapy for asthma with LABA and ICS combination therapy. This should be discussed with families and providers should not be prescribing LABA as single therapy under any circumstance.
Leukotriene receptor antagonists (LTRA) interfere with the pathway of leukotriene mediators, the most common of which is montelukast. They are an alternative therapy for patients with mild persistent asthma who require Step 2 care but ICS remains the preferred medication of choice. LTRAs can be used as adjunctive therapy to ICS in moderate and severe persistent children with asthma but again LABA remain the preferred adjunctive therapy. Some studies have shown that LTRA do have long term protective lung remodeling effects when compared to ICS which appear to only protect the lungs when the medication is being taken.
In this case, Jose should be followed anywhere from 2-6 weeks, to evaluate the level of asthma control that is achieved and adjustments to therapy may need to be made.
3) You decide, with mom to prescribe a medium dose ICS and suddenly she tells you that you misunderstood and that he only has symptoms during the winter, and that he does not have chronic asthma- did you misunderstand? This scenario is quite common as providers, patients and caretakers struggle with understanding that asthma is a chronic illness and that despite symptoms only during particular times of the year there is strong undisputed scientific evidence that asthma is a chronic inflammatory disease of the airways. Patient education is a critical piece in the successful management of asthma and parents need to receive education repeatedly on the chronicity of the disease and the implications of this on its management and control. Education should occur at the time of diagnosis and subsequently at follow up visits. It should be integrated in all points of care ( regular check up, sick visit, ED visit, pharmacies, schools and homes) and should involve all team members including physicians, nurses, pharmacists, and asthma educators.
This scenario is quite common as providers, patients and caretakers struggle with understanding that asthma is a chronic illness and that despite symptoms only during particular times of the year there is strong undisputed scientific evidence that asthma is a chronic inflammatory disease of the airways. Patient education is a critical piece in the successful management of asthma and parents need to receive education repeatedly on the chronicity of the disease and the implications of this on its management and control. Education should occur at the time of diagnosis and subsequently at follow up visits. It should be integrated in all points of care ( regular check up, sick visit, ED visit, pharmacies, schools and homes) and should involve all team members including physicians, nurses, pharmacists, and asthma educators. For Jose’s mother, like so many caregivers, it is very difficult to give their child a daily medication when he is “fine”. Adherence will be increased with a deeper understanding of the underlying disease process and also with exploration of the fears and health beliefs which families have.
4) After you explain to Jose’s mother that the medium dose ICS will prevent further exacerbations during the winter, you ask her if she still has any concerns. After a long pause, she tells you “People say that once he is on this medicine he will become addicted and stop growing”. What do you respond? Many families in our area hold the belief that inhalers are addictive and that once they are on them they can never come off of them. It is important to explain to families that the diagnosis of asthma is a chronic one but that the current treatment regimen you have recommended will likely change and hopefully with good control, medications will be “stepped down”. Specifically, in Jose’s case he may need less control during the summer months as compared to the winter months but you along with his mother, will make those decisions with appropriate follow up and communication. It is important to address and explore these concerns as they are major contributors to decreased adherence.
Many families in our area hold the belief that inhalers are addictive and that once they are on them they can never come off of them. It is important to explain to families that the diagnosis of asthma is a chronic one but that the current treatment regimen you have recommended will likely change and hopefully with good control, medications will be “stepped down”. Specifically, in Jose’s case he may need less control during the summer months as compared to the winter months but you along with his mother, will make those decisions with appropriate follow up and communication. It is important to address and explore these concerns as they are major contributors to decreased adherence. The benefits of ICSs outweigh any concerns about the potential risks of a small, nonprogressive reduction in growth velocity. Studies using second-generation ICS (fluticasone and budesonide) revealed mild growth suppression during the first year of therapy but none after four years. As with all medications, they should be titrated to as low a dose as possible to maintain appropriate control. There is strong evidence of the effectiveness of ICS in children ages 5-11 and improved control when compared to other long-term control medications. They are recommended as the standard of care in persistent asthma. Utilizing a spacer appropriately and rinsing the mouth after each use should reduce systemic absorption and needs to be reinforced.
A final point of ICS, as the guidelines point out there is no data that during the early stages of an exacerbation doubling the dose of ICS is effective in younger children. In older children and adults increasing the dose (closer to 4 times the regular dose) in these early stages can reduce the risk of exacerbations.
5) It is now four weeks later and you are about to see Jose for follow up, how will you assess how he is doing since the last encounter?
On re-evaluation, control is assessed based on the same 5 areas of IMPAIRMENT(symptoms, nighttime awakenings, use of short-acting beta agonists, interference with normal activity, or lung function) based on the caretaker’s recall over the last 2-4 weeks. SEE TABLES Patients should also be evaluated for RISK which involves asking about interim exacerbations requiring oral systemic corticosteroids, reduction in lung growth(not easily measured by general practicioners) and possible treatment related adverse effects. Once impairment and risk are assessed, control is determined as “well controlled”, “not well controlled” or “very poorly controlled”. Using a stepwise approach, patients who are well controlled should have regular follow up 1-6 months and consider step-down therapy after 3 months of good control. If patients are not well controlled, you should step up 1 step and reevaluate in 2-6 weeks. If they are very poorly controlled, consider a short course of oral systemic corticosteroids, step up 1-2 steps, and reevaluate in 2 weeks.
Prior to stepping up in any case, providers should review adherence of medications, inhaler technique, environmental control and comorbid conditions. 6) His mother reports that he is still coughing about 1 time per week at night and using his short acting beta agonist 2 days/week despite using his medium dose ICS appropriately with his spacer. What are the next steps in his care? Based on self-report, Jose is not well controlled given his symptoms at night. Keep in mind that 2 days/ week of SABA use classifies him as well controlled but he is classified based on his most impaired marker, in this case nighttime awakenings. A thorough examination of triggers at home should be discussed including exposure to cigarette smoke, dust mites, pollutants, and other indoor allergens. Advise patients on means of reducing exposure to such allergens. In patients with persistent asthma, consider skin or in vitro testing to assess sensitivity to perennial indoor allergens. Encourage the use of mattress and pillow covers, eliminating stuffed animals, carpeting and heavy draperies. Refer smokers to smoking cessation programs such as Fax-to-Quit.
Based on self-report, Jose is not well controlled given his symptoms at night. Keep in mind that 2 days/ week of SABA use classifies him as well controlled but he is classified based on his most impaired marker, in this case nighttime awakenings. A thorough examination of triggers at home should be discussed including exposure to cigarette smoke, dust mites, pollutants, and other indoor allergens. Advise patients on means of reducing exposure to such allergens. In patients with persistent asthma, consider skin or in vitro testing to assess sensitivity to perennial indoor allergens. Encourage the use of mattress and pillow covers, eliminating stuffed animals, carpeting and heavy draperies. Refer smokers to smoking cessation programs such as Fax-to-Quit. Additionally, one should consider the treatment of co-morbid conditions. Common ones include allergic rhinitis, gastroesophageal reflux, obesity, obstructive sleep apnea, and depression. Recognizing these and addressing them may improve asthma control.
In Jose’s case, one should Step up his therapy to “Step 4” in addition to considering environmental triggers and the treatment of any co-morbid conditions. The preferred Step 4 involves a medium-dose ICS in combination with a long-acting beta agonist. As an alternative, one can recommend a medium-dose ICS with either a leukotriene receptor antagonist or theophylline. He should be re-evaluated once again in 2 weeks for control assessment.
7) Jose’s mother tells you that sometimes she gets confused on when to give which medication, what can you do to help her with this? It is recommended that caretakers and patients with asthma be given a written asthma plan. This allows them to reference their medications and the indications for each of them both during stable, healthy days and during acute exacerbations. These should be at appropriate literacy levels, simple and clear and should be revised as management plans change. The goal is to review the differences between long-term controllers and quick-relief medications and to empower families to manage asthma and feel comfortable doing so.
It is recommended that caretakers and patients with asthma be given a written asthma plan. This allows them to reference their medications and the indications for each of them both during stable, healthy days and during acute exacerbations. These should be at appropriate literacy levels, simple and clear and should be revised as management plans change. The goal is to review the differences between long-term controllers and quick-relief medications and to empower families to manage asthma and feel comfortable doing so. Additionally, it is important to recommend that families bring their medications and spacers to each and every visit to assess proper use and delivery of medications.
