#8: Mastering Outpatient Asthma

September 16, 2020 | By Justin Berk

How To Nail the Diagnosis, Assess Control, and Treat Like a Champ Using New GINA Strategies

Summary

 Join The Cribsiders as our guest Dr. David Stukus (@AllergyKidsDoc) to discuss “all that wheeze” as he takes us on an in-depth journey through the epidemiology, diagnosis, severity, and management of pediatric asthma. Learn everything from how to handle that wheezing kid in front of you, recommended treatment modalities before inhalers, and how to teach children proper inhaler technique. We also discuss the newest asthma GINA treatment strategies and what they mean for your practice.

Credits

• Written and produced by Edward Corty, MPH
• Infographic: Edward Corty, MPH, Cleo Rochat
• Cover Art: Chris Chiu, MD
• Hosts: Justin Berk, MD; Chris Chiu, MD
• Editor: Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): David Stukus, MD

Time Stamps 

• Asthma Advocacy 6:40
• A case from Kashlak Children’s 8:30
• Asthma Diagnosis 12:45
• Asthma Predictor Scores 14:10
• Asthma Triggers 16:10
• Severity vs. Control 20:14
• Assessing Control in Clinic 22:18
• Goals of asthma management 24:35
• Asthma Action Plan 26:30
• GINA Treatment Strategies 27:20
• Treatment Escalation 33:00
• Allergen Testing 38:40
• Oral steroids 41:55
• Use of peak flows 43:25
• Inhaler technique 45:00
• Future of Asthma 47:40

Asthma Pearls

1. The average mortality is six times higher in Black children with asthma as compared to Hispanic and white children. (Arroyo et al. 2017)
2. Posttussive emesis is highly associated with asthma; (OR 7.9, 95% CI 5.2-12), (Turbyville et. al, 2011)
3. One third of toddlers will wheeze at some point, but only 40% of those go on to develop asthma (van Aalderen, 2012)
4. There is no definition for reactive airway disease, so try not to use this term. Just call it what it is (i.e. “mild intermittent asthma”)
5. You can only assess severity of asthma in someone who is not on a daily controller.
6. Asthma is well controlled if the patient meets the rules of 2: 
   1. Using albuterol 2 or fewer times per week
   2. Waking at night with symptoms 2 or fewer times per month
   3. Needing oral corticosteroids treatment 2 or fewer times per year
7. Per 2020 GINA Treatment Strategies, Adults and adolescents 12+ should use ICS/LABA (i.e. budesonide/formoterol) as initial on-demand therapy
8. For asthma inhalers, use a spacer, get the aerosol into the lungs. Inhaled corticosteroids without a spacer and swallowed is the primary treatment for eosinophilic esophagitis!

SPONSORS:

VCU Health CE

We are excited to announce that the Cribsiders are now partnering with VCU Health Continuing Education to offer continuing education credits for physicians and other healthcare professionals. Check out cribsiders.vcuhealth.org and create your FREE account!

Asthma Notes 

Health Disparities: 

The average mortality is six times higher in Black children with asthma as compared to Hispanic and white children. (Arroyo et al. 2017)))))

Asthma Diagnosis

Questions to ask parents/kids

Asthma is recurrent episodes of respiratory symptoms over time.

It is vital to understand the chronicity of symptoms. It is very difficult to diagnose asthma with the first symptoms of cough or wheeze. Some questions to start with include: 

• Can you tell me about your (child’s) respiratory symptoms? 
• Is your child waking at night? 
• Is your child wheezing or having chest tightness?
• Do they ever cough so much that they vomit? *See Pearl 1*

Differential Diagnosis of a Wheeze

Not all that wheezes is asthma and lots of kids with asthma don’t wheeze at all!

(Producer’s note: our guest said 40% of toddlers wheeze and ⅓ go on to develop asthma but the actual statistic is flipped)  *See Pearl 2*

Some other common causes of a wheeze include: 

• Viral lower respiratory tract infections
• Foreign bodies 
• Anatomic obstructions

Making the Diagnosis

Age of Diagnosis

There is no specific age at which you can diagnose asthma, but you do need to have a pattern of symptoms, so it may be challenging at 6 months old, for example. *See Pearl 3*

Tempo of Diagnosis

Expert opinion: After 4 episodes of asthma-like symptoms you can make a diagnosis. Take this into consideration with the family history and allergic history of the child including food allergies, environmental allergies, and eczema: This is because asthma-related inflammation is associated with a broader Th2 inflammatory pathway.

What happens when they receive albuterol? If albuterol has never helped, it is probably not asthma. 

There are also scores to use that are particularly useful in ruling out persistent asthma in a wheezing child (based on other Th2 pathway comorbidities): 

• Asthma Predictive Index
• Pediatric Asthma Risk Score (PARS)

Asthma Triggers

Triggers can be both acute and chronic and can change over time.

By far, the most common trigger in children is viral URI (Johnston et. al, 1995) 

Other common triggers include: 

• Changes in weather patterns
• Cold air in the winter/hot air in the summer
• Any type of aerosolized products (even natural ones–ask about the home environment!)
• Any type of tobacco
• Indoor allergens–pet dander, dust mites, cockroaches, mice (this particularly affects health disparities in inner city populations)
• Seasonal pollens: tree pollen, grass, ragweed, mold, camp fires

Asthma Severity and Control

You can only assess severity in someone who is not on a daily controller, but you also need to assess control over time. “Asthma is a roller coaster–it is not a “set it and forget it” disease!” Assess control on every single visit. Assess control by looking at the previous 4 weeks and use a validated questionnaire like the Asthma Control Test.

Control Assessment

• Nocturnal awakenings: How often do they wake at night due to breathing difficulty?
• Rescue inhaler use: How often do they need to use their albuterol due to symptoms? (This does not count for exercise-induced asthma) 
• In well controlled asthma you are:
  • Using albuterol 2 or fewer times per week
  • Waking at night 2 or fewer times per month
  • Needing oral corticosteroids 2 or fewer times per year

Asthma Management

Goals should be individualized to every patient and family. The goals can vary widely, but in general should be to reduce symptoms/exacerbations, let kids sleep through the night, exercise without limitations. Asthma is the leading cause of missed school days. (Hsu et al. 2016)

You can use the Asthma Action Plan as the final take-home message for the family.

Some patients cannot perceive bronchoconstriction. These patients may benefit from a peak flow meter. But you need to teach them how to use it.

Therapy

2020 Global Initiative for Asthma (GINA) Treatment Strategies

The 2020 GINA treatment strategies made a major change:

• Adults and adolescents 12+ should use ICS/LABA (i.e. budesonide/formoterol) as initial on-demand therapy. Formoterol is the only rapid-acting LABA.
• Children 11 and under still use albuterol as initial on-demand therapy but can also use along with low-dose ICS

Expert opinion: Medicine is the last aspect of changing asthma therapy. Instead, the order of assessment should be: 

1. Assessment of adherence
   1. Review proper technique for inhalers with every asthma patient at every visit! You can even send them to useful videos about using inhalers with spacers and inhalers with a mask
2. Then environmental exposures (see triggers above)
3. Then comorbid conditions
4. THEN medication

Overarching rules of management (mini pearls):

• There is no reason to use high dose ICS as monotherapy
• Second-hand tobacco smoke can decrease your sensitivity to inhaled corticosteroids. (Podlecka et al. 2018).
• Seasonality affects asthma exacerbations: going back to school increases asthma exacerbations. (Cohen et al. 2014)
• It is reasonable to refer for allergy testing to look for triggers of asthma
• If you do go to oral steroids, it doesn’t necessarily need to be 7 days, 3 days may be sufficient
• Dexamethasone is associated with less emesis than prednisolone (Keeney et al. 2014)
• Montelukast can be useful–it is a tablet, but not effective for most. Montelukast is approved for exercise-induced asthma but does not replace the use of albuterol before exercise. It now has a FDA Boxed Warning for suicidal ideation so make the choice with the family.
• Many children with severe asthma cannot perceive bronchoconstriction (Baker et al. 2000) and these are patients that may benefit from regular peak flow monitoring

Links

Asthma and Allergy Foundation of America

https://www.aafa.org/

Book Recommendations 

The Martian by Andy Weir–Yes, it is also a book!

Bad Advice by Paul Offit–A vaccine guru talks about politics and misinformation.

The Checklist Manifesto by Atul Gawande–Put pride aside and use a checklist! 

Goal

Listeners will develop frameworks to recognize, treat, and follow children with asthma. 

Learning objectives

After listening to this episode listeners will…  

1. Discuss the differential diagnosis of a child with a wheeze.
2. List the major triggers of pediatric asthma.
3. Recognize family and environmental risk factors for pediatric asthma.
4. Recall the classifications of severity of pediatric asthma.
5. Summarize the management of pediatric asthma across classifications.
6. Recognize the most common concerns about pediatric asthma adherence and evidence-based ways to address them.
7. Have meaningful, individualized discussions with patients and parents/guardians about pediatric asthma to find solutions.

Disclosures

Dr. Stukus reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Stukus D, Corty EW, Chiu C, Berk J. “Step Up to Pediatric Asthma with David Stukus, MD (@AllergyKidsDoc).” The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/