Bronchial asthma clinical pharmacist hebatallah m abdallatif,bcps (1)

Pediatric Bronchial Asthma Hebatallah M Abdallatif,BCPS

Bronchial Asthma• Asthma is a heterogeneous disease

characterized by chronic airway inflammation.• Asthma is a common and potentially

serious chronic disease that can be controlled.• A chronic inflammatory disorder of the

airways that is caused by a variety of cell types (neutrophils, eosinophils, lymphocytes, mast cells) and cytokines)

Bronchial Asthma

Asthma Pathophysiology

Bronchial Asthma Pathophysiology

Airflow obstruction

Airway hyper-responsiveness

Inflammation

Signs & Symptoms• Wheezing• Cough• Shortness of breath• Chest tightness

Signs & Symptoms (Acute episode)• Breathless during rest• Not interested in feeding• Sit upright• Talk in words (not

sentences)• Usually agitated

Asthma in young children challenges

Wheezing occurs in many young children who do not

have asthma, making diagnosis of asthma difficult.

Lung function tests cannot be performed in this age group to help confirm the diagnosis.

Administering medication to young children may be challenging, and many medications for asthma are

poorly studied in very young children.

Gina 2015 updates

Asthma Predictive Index

• The 2007 National Heart, Lung and Blood Institute (NHLBI) Guidelines for the Diagnosis and Management of Asthma describes the Asthma Predictive Index (API), a guide to determining which small children will likely have asthma in later years

Asthma Predictive Index• High-risk children (under age three)• who have had four or more wheezing episodes in the past year that lasted more than one day that affected sleep, are much more likely to have persistent asthma after the age of five, if they have either of the following

Asthma Predictive Index

Diagnosis• Pulmonary

function test Essential to the

diagnosis and evaluation of asthma

Spirometry is the gold standard for the diagnosis and management of asthma

Diagnosis• Bronchodilator

response (BDR) Postbronchodilator

response criteria of 12% of FEV1 OR 200 ml

Asthma in Egypt• Asthma is the

commonest of all chronic diseases of childhood.• Pediatric asthma

prevalence within Egypt ranged between 7.7% in Nile Delta to 9.4% in Cairo.Egypt J Pediatr Allergy Immunol 2009;7(2):59-64.

Asthma in Egypt• Asthma is a common

cause of emergency room visits and hospital admissions

• Up to one in four children with asthma is unable to attend school regularly because of poor asthma control

Egypt J Pediatr Allergy Immunol 2009;7(2):59-64.

Barriers to Manage Asthma in Egypt

• lack of information• under-use of self management• Over-reliance on acute care• Cultural attitudes towards drugs and drug delivery systems

like for• example steroids and inhalers

Patient Barriers

Treatment GoalsControl asthma by reducing impairment through prevention of chronic and troublesome symptoms (eg, coughing or breathlessness in the daytime, in the night, or after exertion.Reduce the need for a short-acting beta2-agonist (SABA) for quick relief of symptoms (not including prevention of exercise-induced bronchospasm).

Maintain normal activity levels (including exercise and other physical activity and attendance at work or school).

How to treat Asthma

• Assessment and monitoring because asthma varies over time, follow-up every 2-6 weeks is initially necessary•  Education: Self-

management education should focus on teaching patients•  Control of

environmental factors and comorbid conditions• Pharmacologic

treatment

Guidelines from the National Asthma Education and Prevention Program emphasize the following components of asthma care

How to treat Asthma

Asthma classification at

diagnosis determines which treatment step is

initiated

Classification of asthma for those 0–4 years of age

Classification of Asthma in Those 5–11 Years of Age

Classification of Asthma in Those 12 Years of Age to Adult

Asthma TreatmentRelief Medications• short-acting

bronchodilators ipratropium

Controller Medications• Control agents include

inhaled corticosteroids, inhaled cromolyn or nedocromil, long-acting bronchodilators, theophylline, leukotriene modifiers.• More recent strategies

such as the use of anti-immunoglobulin E (IgE) antibodies (omalizumab). 

Reliever Medications

They are used for quick relief of asthma symptoms, such as wheezing, "feeling tight" when breathing, coughing and shortness of breath.

Short-acting beta agonists act within minutes to temporarily relieve these symptoms. They do this by relaxing the tightening (bronchospasm) of the muscle bands around the airways, and are very effective in opening the airways

They do not relieve the swelling or inflammation of the breathing tubes that occurs in individuals with asthma. If you need to use these short-acting beta agonists often, it means that the inflammation is not being controlled.

Reliever Medications

Quick relief medicines come in Metered dose inhalers and in a solution for nebulizers. An oral solution is also available, but is less effective and has more side effects. 

Short-acting beta agonists have few severe side effects when used in the recommended dose.

The possible side effects of short-acting inhaled beta agonists include a fast heartbeat, nervousness and shakiness, which usually pass quickly when the medicine is inhaled

Controller Medications

Controller medications work over a period of time to reduce airway inflammation and help prevent asthma symptoms from occurring.Prevent asthma symptoms from occurring and reduce and/or prevent,Inflammation and scarring inside the airways

Do not show immediate results, but work slowly over time• Should be taken daily, even when you are not having symptoms.

Controller Medications

Long-term controller medications may act by providing long-acting bronchodilation .These medications are used together with anti-inflammatory medications for better control of chronic asthma. 

Leukotriene modifiers: Leukotriene modifiers, such as zafirlukast and montelukast (Singulair®), affect only one portion of the inflammatory process .

Methylxanthines are theophyllines often used in conjunction with anti-inflammatory medications to provide continuous relief from asthmatic symptoms.

Medications(SABAs)

Mechanism Adverse effects Dosage formsBinds to β2-receptors on airway smooth muscle

i. Agitationii. Irritabilityiii. Tachycardiaiv. Tremorv. Hypokalemiavi. Hyperglycemia

Salbutamol •Nebulization solution (1.25 mg/3 mL; 2.5 mg/3 mL; 5 mg/1 mL)• Metered dose inhaler (MDI) 90 mcg/puff

Medications(Inhaled corticosteroids (ICS)

Mechanism of action

Adverse effects Drugs and dosage forms

Anti-inflammatory activity

Linear growth velocity was reduced by around 1 cm in the first year of treatment for low- to medium-dose ICS; however, the patients caught up later.ii. Adverse effects are generally low because systemic absorption is low.Thrush

Budesonide – Typically dosed twice daily(a)Nebulizer

solution (0.25 mg/2 mL; 0.5 mg/2 mL; 1 mg/2 mL)

Fluticasone – Doses divided twice daily(b)MDI: 44

mcg/puff, 110 mcg/puff, 220 mcg/puff

DPI: 50 mcg/inhalation, 100 mcg/inhalation, 250 mcg/inhalation

ICS plus a long-acting β-agonist (LABA)

Drugs and dosage formsFluticasone/salmeterol (Advair)(a) MDI (dosing 2 puffs twice daily): 45/21 mcg, 115/21 mcg/puff, 230/21 mcg/puff(b) DPI (dosing 1 puff twice daily): 100/50 mcg/inhalation, 250/50 mcg/inhalation, 500/50 mcg/inhalation Budesonide/formoterol (Symbicort): MDI (dosing 2 puffs twice daily): 80/4.5 mcg/puff, 160/4.5 mcg/puffiii. Mometasone/formoterol (Dulera): MDI (dosing 2 puffs twice daily): 100/5 mcg/puff, 200/5 mcg/puff

ICS Doses

Leukotriene antagonists

Mechanism of action

Adverse effects Drugs

Block leukotrienes, which are part of the inflammatory pathway

Usually well tolerated Sedation

Montelukast(a) 6 months – 5 years: 4 mg orally daily(b) 6–14 years: 5 mg orally daily(c) 15 years and older: 10 mg orally dailyii. Zafirlukast(a) 5–11 years: 10 mg orally twice daily(b) 12 years and older: 20 mg orally twice daily

Asthma Treatment

A stepwise approach to pharmacologic therapy

is recommended to gain and maintain control of asthma. 

The type, amount, and scheduling of medication is dictated by asthma severity (for initiating therapy) and the level of asthma control (for adjusting

therapy).

Asthma Treatment Steps(0-4 age)

Treatment Steps: 5–11 Years of Age

Treatment Steps:12 Years to Adult

Devices Metered Dose Inhaler• MDIs can be used in a patient at any age with the

use of a spacer.• Children aged four years or younger will generally

require a metered dose inhaler (MDI) via a spacer with a mask

• Children should progress to using a spacer and mouthpiece without mask as soon as they are able.

Dry Powder Inhaler DPIChildren aged over seven years may prefer a dry powder inhaler, such as a Turbuhaler or Accuhaler, as they are less conspicuous than a MDI with a spacer, which may increase compliance.

Spacers• Spacers are

devices that help you get the best from your medicine if you use a metered dose inhaler (MDI).

Spacers with facemask• Can be used with

babies or with younger children who find it hard to use an ordinary spacer with a mouthpiece.

Nebulizers

used to deliver inhaled medications to infants and young children who are unable to use a metered dose inhaler (MDI) and/or to children with severe, symptomatic asthma.

MDI vs NebulizersDouble-blind, randomized, placebo-controlled clinical trialIn Pediatric emergency department inchildren aged 2 to 24 months, 85 patients were enrolled in the nebulizer group and 83 in the spacer group.

Data suggest that metered-dose inhalers with spacers may be as efficacious as nebulizers for the emergency department treatment of wheezing in children aged 2 years or younger.

Delgado A1, Chou KJ, Silver EJ, Crain EF, Arch Pediatr Adolesc Med.

 2003 Jan;157(1):76-80

Assessment & Monitoring

Follow-up every 2-6 weeks is initially necessary (when gaining control of the disease) and then every 1-6 months thereafter.

spirometry should be measured every 1-2 years, or more frequently for uncontrolled asthma.

Assessment & Monitoring (0-4 of Age)

Assessment & Monitoring (5-11 of Age)

Asthma Control Test

Reviewing response and adjusting treatment

How often should

asthma be reviewed?

•1-3 months after treatment started, then every 3-12 months•After an exacerbation, within 1 week

Reviewing response and adjusting treatment

Stepping up asthma

treatment

•Sustained step-up, for at least 2-3 months if asthma poorly controlled•Important: first check for common causes (symptoms not due to asthma, incorrect inhaler technique, poor adherence)

Reviewing response and adjusting treatment

Stepping up asthma

treatment

•Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen•May be initiated by patient with written asthma action plan

•Day-to-day adjustment•For patients prescribed low-dose ICS/formoterol maintenance and reliever regimen*

Reviewing response and adjusting treatment

Stepping down asthma

treatment

•Consider step-down after good control maintained for 3 months•Find each patient’s minimum effective dose, that controls both symptoms and exacerbations

Prepare for step-down

Aim •To find the lowest dose that controls symptoms and exacerbations, and minimizes the risk of side-effects

When •When symptoms have been well controlled and lung function stable for ≥3 months

Prepare •Record the level of symptom control and consider risk factors•Make sure the patient has a written asthma action plan•Book a follow-up visit in 1-3 months•Stepping down ICS doses by 25–50% at 3 month intervals is feasible and safe for most patients

EducationPatient education continues to be

important in all areas of medicine and is

particularly important in asthma

Self-management education should focus on teaching

patients the importance of recognizing their own their level of control and signs of

progressively worsening asthma symptoms

Education Strategies

Environmental control avoidance

strategies Medication use and adherence

Providing written asthma action

plans in partnership with

the patient

Patient Education

cdc.gov

Asthma triggers • An asthma trigger is a thing, activity or

condition that makes asthma worse. • When you encounter a trigger it can

cause a sudden worsening of symptoms, often called an asthma attack, episode or flare-up.

Asthma triggers

Avoidance triggers educational tool

Correct inhaler techniques and use of other devices)

Medication Use in Children

Inhaler technique should be assessed at appointments to ensure adequate

delivery.

Asthma Devices Checklist

Asthma Action Plan•A written care plan for asthma treatment personalized for the patient.

•Asthma triggers should be documented so that the patient can try to avoid them.

•It is important to share the asthma action plan with the school or day care.

Asthma Action Plan model

Asthma Action Plan

Status asthmaticus

an acute asthma exacerbation in which bronchial obstruction is severe and

continues to worsen or not improve

despite the institution of a

adequate standard therapy

PATHOPHYSIOLOGY

Inflammation and edema of bronchial

mucosa,increased mucusproduction with

airway plugging, and bronchospam.

Increased airway resistance, leading to

increase work of breathing, inspiration

starts before termination of the previous expiration

air trapping and hyperinflation.,H

ypoxemia

Dexamethasone vs Predisnolone

A meta-analysis concluded that, in comparing a one- or two-dose dexamethasone regimen with a 5-day prednisolone regimen

There was no difference in relapse rate but patient vomiting was less in those with asthma exacerbations discharged from the ED.

Dexamethasone 0.6 mg/kg/dose (max dose 18 mg) every 24 hours times one or two doses is an option for status asthmaticus treatment in the ED.

Grant E. Keeney, Matthew P. Gray, Andrea K. Morrison, Michael N. Levas, Elizabeth A. Kessler, Garick D. Hill, Marc H. Gorelick, Jeffrey L. Jackson, PediatricsFebruary 2014

Follow-up after an exacerbation

•Follow up all patients regularly after an exacerbation, until symptoms and lung function return to normal•Patients are at increased risk during recovery from an exacerbation.

•Exacerbations often represent failures in chronic asthma care and they provide opportunities to review the patient’s asthma management.

At follow-up visits (Check)

The patient’s understanding of the cause of the flare-up

Adherence with medications, and understanding of their

purpose

Inhaler technique skills

Written asthma action plan