Patient Presentation
An 11-year-old known-asthmatic male came to clinic for his health supervision visit. He was doing well in school, but his mother was concerned because he seemed to need his albuterol inhaler more and was coughing more at night. During the fall he had been playing soccer and although he took his inhaler before practices and games, he seemed to need the inhaler again during practices and games most days. Usually he also had no problems at night but his coughing was now waking the mother up at night at least 2-3 times per week. She had started giving him his inhaler before school on some days also. None of the symptoms improved as the fall frosts occurred. He said he had problems keeping up with the kids on the playground and had several episodes where his chest got tight at school.
The past medical history showed seasonal allergic rhinitis that was usually well controlled with cetirizine. He had never been hospitalized for asthma, and took oral steroids ~ 2 times a year for acute exacerbations. The family history was positive for asthma and allergies in multiple family members. The pertinent physical exam showed a healthy appearing male with normal vital signs and growth parameters. HEENT showed slightly pale mucous membranes and allergic shiners. Lungs were clear but after exercise in the room, he had some mild end expiratory wheezing. The rest of his examination was normal.
The diagnosis of uncontrolled asthma was made. An office peak flow meter reading was diminished from previous results. The resident seeing the child knew that he should probably start on an inhaled corticosteroid for better management, but he asked if one steroid was better than another. The staff pediatrician said that she didn’t think so because professional guidelines offered many different options plus the local pulmonologist seemed to use 2-3 different ones usually. “I’ll have to look at the guidelines again but I think if we use what the pulmonologist uses, he should get better,” she said. At follow-up in 4 weeks, the mother said that he was not coughing at night and he was using less albuterol although she could not quantify it. The physician did re-teaching about how to use the spacer and inhaler properly and had the mother start a symptom diary. The mother would contact the office with the amount of albuterol use over the next two weeks.
Discussion
Asthma is a chronic obstructive lung disease that affects many children and adults. There is a wide range of symptoms that people experience from occurring relatively rarely (ie intermittent asthma) to patients having daily symptoms of such intensity that they are life-threatening (ie chronic severe asthma). The goals of asthma management include patient education and medication management so patients have no or minimal symptoms, prevent exacerbations, have no activity restrictions, have normal pulmonary function tests, have no or minimal medication side effects and meet patient and family expectations. Well controlled asthma should have:
- Asthma symptoms twice a week or less
- Rescue bronchodilator use twice a week or less
- No nighttime or early morning awakening
- Daily, school and work activities should not be limited
- Patient, family and physician believe asthma is well-controlled.
- Normal pulmonary function tests
Assessment of asthma should occur routinely and especially if the patient’s symptoms are not well controlled.
This includes:
- Frequency of
- Symptoms
- Night and morning symptoms
- Rescue inhaler use
- Activities, school or work limitations
- Overall patient assessment
- Pulmonary function tests
- Assess
- Psychosocial status
- Adherence/compliance
- Potential reasons for non-adherence
- Tobacco smoke
- Allergen avoidance and control measures including dust, cockroaches, animal dander etc.
- Weight reduction for obesity
- Mental illness
- Poverty and social stressors
- Poor technique of inhaler use
- Poor understanding of disease or management
- Medication side effects
- Triggers
- Asthma action plan knowledge
- Reconfirm the asthma diagnosis – is there more than 1 diagnosis
A step-wise approach for asthma has been advocated, where patients who are not well-controlled at a particular step, are given medication at the next higher step (ie “stepped-up”) until they are controlled.
Likewise, patients who are well-controlled may be candidates to “step-down” to a lower step in order to minimize the potential medication side effects.
Guidelines for treatment of asthma include:
- Step 1 Short acting beta-agonist prn
- Step 2 Low-dose inhaled corticosteroids (ICS), leukotriene modifiers, theophylline, cromolyn or nedocromil
- Step 3 Medium-dose ICS, Low-dose ICS plus long-acting beta-agonist or a leukotriene modifier or theophylline
- Step 4 Medium-dose ICS and long-acting beta-agonist, or medium- dose ICS plus a leukotriene modifier or theophylline
- Step 5 High-dose ICS and long-acting beta-agonist
- Step 6 High-dose ICS and long-acting beta-agonist plus systemic corticosteroids
Patients at Step 3 or higher should consult with an asthma specialist.
Learning Point
Professional societies do not recommend a particular inhaled corticosteroid (ICS) for asthma.
Different medications have different pharmcological profiles. Equivalency tables are available to assist clinicians at
AAAAI- Table 4-4b. and Scottish Intercollegiate Guidelines Network (SIGN).
The overall efficacy is affected by:
- Steroid type itself
- The type of spacer or chamber used. A one-way valve is preferred.
- Technique of the inhaler use
- Personal factors and other considerations (i.e. tobacco smoker, African-American, etc.)
The total ICS systemic concentration equals the total amount delivered to the lungs, plus the oral amount that is not deactivated by the liver. Overall, about 10-50% of the ICS is delivered to the lungs. Almost 100% of the ICS dose in the lung is bioavailable and will enter the circulation. Without a spacer or valved holding chamber, about 50-80% of the ICS medication is swallowed. Much of this will be deactivated by the liver, but some will enter the circulation. The overall oral ICS bioavailability (of the swallowed portion of the dose) has been reported as:
- Flunisolide = 21%
- Beclomethasone dipropionate = 20%
- Triamcinolone acetonide = 10.6%
- Budesonide = 11%
- Fluticasone propionate = 1%
- Mometasone = <1%
Questions for Further Discussion
1. How does asthma itself and treatments potentially affect children’s growth?
2. What are other potential side effects of pharmacological treatment of asthma?
Related Cases
- Disease: Asthma | Asthma in Children
- Symptom/Presentation: Cough | Shortness of Breath | Wheezing
- Specialty: Allergy / Pulmonary Diseases
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Asthma and Asthma in Children.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
National Heart, Lung and Blood Institute. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma – Summary Report 2007.
Available from the Internet at http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf (rev. 2007, cited 11/18/14).
Rachelefsky G. Inhaled Corticosteroids and Asthma Control in Children: Assessing Impairment and Risk. Pediatrics. 2009;123(1):353-366.
Scottish Intercollegiate Guidelines Network (SIGN), British Thoracic Society. British guideline on the management of asthma. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2011 May.
Available from the Internet at Scottish Intercollegiate Guidelines Network (SIGN)(cited 11/18/14).
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 