- Email: [email protected]
Asthma management across the life span: the child with asthma
Nurs Clin N Am 38 (2003) 635–652
Asthma management across the life span: the child with asthma H. Lorrie Yoos, PhD, CPNPa,b,*, Elaine Philipson, MS, PNPa, Ann McMullen, MS, CPNPa,b a
Department of Pediatrics, University of Rochester Medical Center, 601 Elmwood Avenue, Box 667, Rochester, NY 14642, USA b University of Rochester School of Nursing, 601 Elmwood Avenue, Box SON, Rochester, NY 14642, USA
Incidence and impact of childhood asthma Asthma is a leading cause of morbidity in childhood, affecting about 5 million children in the United States [1–3]. Childhood asthma has an adverse impact on children, families, health care institutions, health care finances, educational institutions, industry, and the economy. While asthma treatment overall cost an estimated $6 billion in 1990 in direct and indirect expenditures, that cost had more than doubled to $12.7 billion by the year 2000 [4,5]. Loss of school days alone (more than 10 million/year) caused decreased productivity among parents and caregivers at an estimated cost of $1 billion [4]. Asthma kills 5000 Americans each year, and among children aged 5 to 14 years the asthma death rate has nearly doubled since the 1980s [6]. The numbers alone do not, however, portray the real story of childhood asthma. Behind each of the statistics is a child who has difficulty breathing and a parent who has worried and sacrificed [7]. Disproportionate rates of death, hospitalization, emergency room use, and disability from asthma occur in specific age, gender, socioeconomic, and ethnic groups. Inner-city, poor, and black children have the highest prevalence and morbidity rates [1,8–10]. The reasons for these differences are not completely understood, but there is a growing body of research indicating that factors such as biological/genetic characteristics, environmental
* Corresponding author. Department of Pediatrics, University of Rochester Medical Center, 601 Elmwood Avenue, Box SON, Rochester, NY 14642. E-mail address: [email protected] (H.L. Yoos). 0029-6465/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0029-6465(03)00113-0
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exposures, socioeconomic status, differences in health care access, quality, and use, and cultural beliefs and practices of parents interact to produce these asthma disparities in different populations [11–15].
Unique challenges in childhood asthma Although the means are now available to control virtually all asthma with safe and convenient treatments, asthma management nevertheless presents a significant challenge to patients and families [16]. It is estimated that only about 20% of children who have persistent asthma (who should all be on daily anti-inflammatory medication) receive appropriate therapy [17]. Special complexities related to diagnosis, ongoing symptom monitoring, and management arise when the patient is a child. Initial diagnosis Establishing the diagnosis of asthma often occurs over time and might be difficult in young children. Presentation is highly variable, ranging from children whose only symptom is cough to children who have persistent wheezing and airway compromise [18,19]. Recognition of asthma patterns can be further complicated by comorbid conditions that confuse the clinical picture. Conditions such as gastroesophageal reflux disease (GERD), tracheobronchial malacia, obstructive sleep apnea, postnasal drip, cystic fibrosis, vocal cord dysfunction, and habit cough are among the many diagnoses that mimic or aggravate the symptoms of asthma [19–21]. The insidious nature of a slow loss in lung function secondary to lung inflammation combined with difficulties related to testing infants and young children for changes in lung function result in a dependence on the physical examination for clinical data; however, the episodic nature of the bronchospasm is likely to result in an apparently normal physical examination, even when inflammation and airway obstruction exist. Furthermore, the presence of wheeze does not necessarily indicate asthma in children because this symptom might also be seen in children who have other problems who never go on to develop asthma. Natural history of asthma To further understand the ongoing challenge that asthma poses in pediatrics, one needs to look at the natural history of the disease throughout childhood. All parents wonder if their child will ‘‘outgrow’’ asthma. In a landmark prospective study of asthma incidence, Martinez and colleagues enrolled 1246 newborns into their study [22]. Of the 826 participants followed for the entire 6-year study period, nearly half of the children had at least one episode of wheezing during the first 6 years of life. Based on the reoccurrence of symptoms over time, these children were categorized into
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three groups: (1) transient early wheezers, (2) late-onset wheezers, and (3) persistent wheezers. Transient early wheezing generally resolved by 3 years of age and occurred most frequently in children who had smaller baseline lung volumes (likely related to smaller lung size). This group had a benign clinical course. The children who had later-onset wheezing experienced their first episodes of wheezing between 2 and 6 years of age, whereas the persistent wheezing group had recurring wheezing episodes throughout the 6-year study period. The children in the persistent wheezing group had a greater likelihood of a family history of asthma and having associated signs of atopy such as elevated serum IgE levels or positive allergy skin tests. How asthma progresses through childhood and adolescence into adulthood is not fully understood. In a review of the literature, Roorda points out that although it is a common belief that children outgrow asthma at puberty, the literature does not support this belief [23]. The literature shows that between 30% and 80% of children who have asthma continue to have asthma symptoms into adulthood. This review also reports that though many individuals experience a subjective ‘‘remission of symptoms’’ between 10 and 20 years of age, airway obstruction and bronchodilator responsiveness can nevertheless be seen on pulmonary function studies. Several investigators have found that atopy, a family history of asthma, and perinatal exposure to passive smoke are important predictors of continued asthma problems into adulthood [24,25]. Ongoing symptom monitoring Accurate assessment of asthma severity is critical for appropriate management in terms of an acute exacerbation and long-term treatment decisions related to the use of daily anti-inflammatory medications. Symptom monitoring can be a formidable task in childhood asthma. The child experiences the symptoms, which might or might not be perceived and communicated effectively to the parent, while the parent is dependent on various signs to evaluate symptom severity to determine (or at least participate in determining) the course of management. For this reason, objective peak flow monitoring might be particularly useful in pediatric patients who are older than 5 years of age and have significant disease severity. Successful peak flow monitoring requires a commitment from the family and the health care provider because children need to be trained in the procedure and families need to do an initial period of diary-keeping to establish the child’s ‘‘personal best.’’ It must be remembered that ‘‘personal best,’’ like shoe size, will change as the child grows (refer to another article in this issue for general principles of symptom monitoring). When personal best has been established, values are used to establish a personal action plan based on the zone system. See Fig. 1 for an example of a pediatric action plan. There is considerable controversy in the literature regarding the optimal method for monitoring asthma symptoms in children [16,26]. Yoos,
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Fig. 1. Asthma action plan. (From NY State Department of Health; with permission.)
McMullen, and Kitzman found that for the children who were at greatest risk for poor outcomes (children who had moderate to severe asthma and those from minority urban populations), peak flow monitoring significantly improved asthma outcomes such as number of symptom days and health care use [26].
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Developmental considerations in management Successful long-term management of asthma requires an ongoing partnership between the health care provider and the family. In that partnership, parents and children learn to take responsibility for the ongoing prevention and monitoring of symptoms and day-to-day management while health care personnel provide the educational tools and skills that make self-management possible [27]. Asthma management is a dynamic process when it involves children. Parents, children, and health care providers need to continuously re-evaluate and negotiate the responsibilities for disease management and tailor the education and the treatment plan to the individual child. Decisions related to the child’s responsibility for management should be based on an understanding of developmental milestones and expected competencies for the various age groups and an evaluation of the particular child’s capabilities (Table 1). Pharmacologic issues Pharmacologic management of asthma for children older than 5 years of age is similar to management in adults, with the emphasis being on the control of airway inflammation (see article by Conboy-Ellis). Table 2 delineates drugs and usual dosages for children. Of note, National Heart, Lung, and Blood Institute (NHLBI) guidelines outline minor variations in the stepwise approach for managing infants and children 5 years of age and younger (Fig. 2; Table 3). Differences are noted in the use of theophylline, a recommendation to use bronchodilators early in the course of viral respiratory illnesses, and an emphasis on using lower doses of inhaled corticosteroids (ICS) when possible [28]. Newly approved pharmacologic agents for use in children include budesonide inhalation suspension, which has been approved for use in children 12 months to 8 years of age. This is the first U.S. Food and Drug Administration-approved corticosteroid administered by way of a nebulizer [29]. Also relatively new for use with children is montelukast chewable tablets for use in 2- to 5-year-old patients. ICS emerged in the 1990s as the recommended preventive treatment of choice for persistent asthma symptoms. Although corticosteroids have been associated with a number of side effects, clinical trials have shown that the potential risk of growth delay in children older than 5 years of age that is linked to ICS use is temporary and possibly reversible [30,31]; however, few studies have been conducted that assess the benefits of ICS and the risk of growth retardation in infants and young children [32]. In the 2002 National Asthma Education and Prevention Program update to the Guidelines for the Diagnosis and Management of Asthma, the expert panel recommended ICS as a safe, effective, and preferred method to control and prevent inflammation in children who have asthma. The expert panel also reviewed evidence related to concerns about reduced bone mineral density, suppressed adrenal function, and cataracts and concluded that these are not
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Table 1 Developmental considerations in asthma management [19] Special considerations
Appropriate medication devices
Infancy
Diagnosis might be unclear.
Metered-dose inhaler (MDI) with small masked spacer. Allow the child to breathe 5–6 spontaneous breaths per puff with the spacer placed over the mouth and nose. Nebulizer administration should involve using a mask. Avoid the ‘‘blow-by’’ technique, which results in poor medication deposition [37]. Newer nebulizers with ‘‘breath enhanced nebulization’’ result in even greater nebulization and medication deposition [38,39].
Early management of wheezing is important because it might alter the course of asthma later on.
Toddler/preschool
Most acute wheezing episodes result from viral infections. Symptom evaluation and medication administration are completely the parent’s responsibility. Infants are developmentally unable to perform any voluntarily controlled inhalation/exhalation maneuvers; medication choices for this age group must be limited to those in which the medication can be inhaled passively during normal breathing. Upper respiratory infections continue to be a key precipitating factor of asthma symptoms. Important to prevent making medication administration a daily ‘‘battleground’’; let the child feel like a participant in medication administration. Use techniques such as distraction, reward, or making medication administration a game. This age child enjoys bright colors and pictures and ‘‘play-acting’’ with dolls in learning situations. The child might have multiple caregivers—all should know the treatment plan.
MDI with medium masked spacer Jet nebulizer compressor with mask or mouthpiece, based on patient’s ability
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Age group
School-aged child
MDI with spacer and mouthpiece Jet nebulizer compressor with mouthpiece Dry powder inhaler (DPI)
MDI alone MDI with spacer
DPI Jet nebulizer compressor with mouthpiece
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Adolescent
Child can now be helpful in terms of symptom monitoring; can also use a peak flow meter. Child is now able to control inhalation/exhalation efforts; therefore, more inhalation device options are now available. School-aged child responds to group learning situations; enjoys games, computers. Child now lives in multiple contexts—school, daycare, peers. Need to involve school in the treatment plan; school needs action plan. Reliable, prompt access to medications is essential; decisions need to be made about the child’s ability to carry and self-administer medications. Responsibility for medication administration shifts from parent to adolescent. ‘‘Denial’’ and ‘‘minimizing’’ might be primary coping strategies making ongoing ‘‘preventive’’ therapy appear to be irrelevant to the teen. Adherence might become an issue. Be aware of special issues such as reluctance to use inhaler in front of peers. Need to find out the adolescent’s goals and use good asthma management as the mechanism to help achieve goals. Adolescents respond best to peers and ‘‘peer-idols.’’
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Medication
Dosage form
Inhaled corticosteroids (see estimated comparative daily dosages for Inhaled Corticosteroids below) Systemic corticosteroids Methylprednisolone 2, 4, 8, 16, 32 mg tablets 5 mg tablets; 5 mg/5 cc; 15 mg/5 cc
Child dose
0.025–2 mg/kg daily in single dose in AM or qod PM for control Short-course ‘‘burst’’: 1–2 mg/kg/d maximum 60 mg/d for 3–10 d
Prednisone 1, 2, 5, 5, 10, 20, 50 mg tablets; 5 mg/cc, 5 mg/5 cc Long-acting inhaled b2-agonists (should not be used for symptom relief or for exacerbations—use with inhaled corticosteroids.) Salmeterol MDI 21 mcg/puff 1–2 puffs q 12 h DPI 50 mcg/blister 1 blister q 12 h Formoterol DPI 12 mcg/single use capsule 1 capsule q 12 h Combined medication Fluticasone/salmeterol DPI 100, 250 or 500 mcg/50 mcg 1 inhalation bid; dose depends on severity of asthma Cromolyn and nedocromil Cromolyn MDI 1 mg/puff 1–2 puffs tid–qid Nebulizer 20 mg/ampule 1 ampule tid–qid Nedocromil MDI 1.75 mg/puff 1–2 puffs bid–qid Leukotriene modifiers Montelukast 4 or 5 mg chewable tablet 40 mg qhs (2–5 y) 10 mg tablet 5 mg qhs (6–14 y) 10 mg qhs (>14 y) Zafirlukast 10 or 20 mg tablet 20 mg daily (7–11 y 10 mg tablet bid) Zileuton 300 or 600 mg tablet Methylxanthines Theophylline Liquids, sustained-release tablets, capsules Starting dose 10 mg/kg/day; usual max: \1 year of age: 0.2 (age in weeks) + 5 = mg/kg/day 1 year of age: 16 mg/kg/day
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Prednisolone
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Table 2 Usual dosages for long-term control medications in children 12 years of age
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Fig. 2. Stepwise approach for managing infants and young children (5 years of age) who have acute or chronic asthma.
significant risks for children [28]. Even though the risk is small, the goal of therapy should be to achieve symptom control without causing side effects. A number of strategies can be used to reduce the risk of growth retardation. First, children’s growth should be monitored carefully at each encounter. Second, the lowest effective dose of ICS should be used and the dose should be stepped up and down depending on symptom severity (see article in this issue regarding stepwise approach to management). Third, other management strategies should be maximized, including optimizing trigger
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Table 3 Estimated comparative daily dosages for inhaled corticosteroids in children 12 years of age Brand name
Low daily dose
Medium daily dose
High daily dose
Beclomethasone CFC 42 or 84 mcg/puff
Beclovent Vanceril
42 mcg/puff: 2–8 puffs/d
84 mcg/puff: 4–8 puffs/d
84 mcg/puff: >8 puffs/d
84 mcg/puff: 1–4 puffs/d 40 mcg/puff: 2–4 puffs/d
80 mcg/puff: 2–4 puffs/d
80 mcg/puff: >4 puffs/d
80 mcg/puff: 1–2 puffs/d 0.5 mg/d
1.0 mg/d
2.0 mg/d
Beclomethasone HFA 40 or 80 mcg/puff Budesonide inhalation suspension for nebulization 0.25 mg and 0.5 mg/vial Budesonide DPI 200 mcg/inhalation Flunisolide 250 mcg/puff Fluticasone MDI: 44, 110 220 mcg/puff DPI: 50, 100, 250 mcg/inhalation Triamcinolone acetonide 100 mcg/puff
Pulmicort Respules Pulmicort Turbuhaler AeroBid Flovent
1–2 inhalations/d
2–4 inhalations/d
>4 inhalations/d
2–3 puffs/d 44: 2–4 puffs/d
>5 puffs/d 220: >2 puffs/d
Azmacort
50: 2–4 inhalations/d 100: 1–2 inhalations/d 4–8 puffs/d
4–5 puffs/d 110: 2–4 puffs/d 220: 1–2 puffs/d 100: 2–4 inhalations/d 250: 1–2 inhalations/d 8–12 puffs/d
Adapted from NAEPP Expert Panel Report 2002.
250: >2 inhalations/d >12 puffs/d
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Drug
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abatement, giving the influenza vaccine, and treating contributing conditions such as rhinitis, sinusitis, and GERD. Fourth, a second controller medication such as a long-acting b2 agonist or leukotriene inhibitor might be considered for more difficult-to-control asthma as an alternative to increasing the inhaled steroid dose. Finally, using appropriate spacer devices and rinsing the mouth after steroid use can be helpful in maximizing dose distribution and preventing side effects [33]. Parents might have concerns about the safety of ICS use that might not always be expressed openly [34]. Helping families understand the relationship between controlling inflammation and improved asthma outcomes is key to their acceptance of the treatment plan. The benefits of well-controlled asthma, including improved pulmonary function and improved quality of life for the child and family, should be emphasized. With appropriate education, parents can also understand and participate in strategies designed to use the lowest ICS dose necessary to achieve control. Although questions remain regarding whether or not optimal treatment can prevent progression of disease severity in asthma, clinicians can inform parents that there is evidence that children whose asthma is well controlled live more active lives and are more likely to have normal growth and development [35]. Medication administration Developmental competencies are an important consideration in medication selection and administration for children who have asthma. The medication choices and the devices used to administer them have increased in recent years. Health care provider understanding of the array of available inhaled medications and proper use of the necessary delivery systems is essential to assuring an optimal treatment plan in the pediatric population. Proper technique for inhaled medications directly affects the lung deposition of the medication prescribed. Such a technique-driven modality makes choosing the appropriate device based on developmental abilities and teaching technique refinement a critical aspect of ongoing asthma management (see Table 1) [36]. In infancy, children are developmentally unable to perform any voluntarily controlled inhalation/exhalation maneuvers. Medication choices for this age group must be limited to those in which the medication can be inhaled passively, during normal breathing, even if it does not reflect the most effective technique for maximal drug deposition. The nebulizer with mask or the spacer with mask are the only appropriate medication delivery choices for infants [37–39]. The toddler can present a new challenge to the parent and health care provider alike in terms of medication administration. The skill required for a toddler to reject a particular medication modality is acquired well before the ability to accomplish other, more sophisticated, inhalation maneuvers. In this age group, successful medication delivery involves working with
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parents in a trial-and-error approach to finding the modality that is most acceptable to the toddler. Developmentally, inhaled asthma medication still must be limited to metered-dose inhalers (MDIs) with spacer and mask or a nebulized form. A check of mask size for the child using a spacer are important because the infant-sized mask is likely to be too small for the toddler. The school-aged child has more treatment options available, and a climate of working as a team will be helpful in gaining the ongoing cooperation of the child in the treatment of asthma. At approximately 6 years of age children are able to consistently control their inhalation/exhalation efforts and to generate the inspiratory flow rates required for the majority of inhaled medication devices on today’s market. This is a variable guideline, however, and repeated checking of technique is important to ongoing asthma management. For the child using medication in an MDI, the spacer might appropriately be changed to one with a mouthpiece rather than a mask. This change must, however, come with patient re-education on the changed technique of a slow, deep inhalation followed by breath holding of 4 to 10 seconds [40]. Similarly, nebulizer sets can be changed to the mouthpiece type, optimally using the breath-enhanced Venturi-type of nebulizer set. These changes can have the added advantage of improved lung deposition of medication [39]. Evidence supports the notion that good technique with an MDI and spacer can be as effective for maintenance therapy of asthma medications as the use of a nebulizer [41], so the provider can focus on the method that is likely to work best for the particular child and family. School-aged children can also be considered for the medications available in dry powder inhalers (DPIs), which might improve lung deposition and adherence [42]. Health care providers must be familiar with the product they are prescribing to provide adequate teaching; however, there are some general principles related to DPIs. The devices provide the medication as a fine powder that is inhaled into the lungs during the force of the inspiratory effort. Because of this technique DPIs require a single fast, deep inspiratory effort to provide wide medication distribution in the lung. Unlike MDIs, DPIs do not require breath-holding [40]. In addition, one should mention that blowing into the device might result in a wasted dose. The onset of adolescence signals a shift in responsibility for asthma management from the parent to the teen patient. Issues related to adherence to the treatment plan often become a central issue in the home and office. Treatment of asthma might become the arena in which the adolescent explores independence from parents and the importance of being like their peers. This group is at particular risk because deaths from asthma occur in the greatest number in the adolescent age group, especially between the ages of 10 to 14 years [43]. Selection of medications and modes of administration should consider the difficulties with adherence within this group. Adolescents, on the
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whole, are capable of coordinating all the maneuvers required of the various medication devices, so a wide variety of choices exist for them. Many of the newer DPIs offer effective medication delivered quickly with a single inhalation prepared in small, discrete, portable packaging. While spacer use is ideal with MDIs, adolescents might resist their use, in which case the health care provider must be diligent in teaching the effective open-mouth technique. Portable, handheld nebulizers also represent an option. Negotiating with teens regarding which medications and modalities fit best with their daily schedule and need for control and privacy is, arguably, one of the most important aspects of asthma care with this group. The child in multiple contexts The parent of a child who has asthma is accountable for assessing the child’s symptoms accurately and negotiating and supervising appropriate treatments; however, children are also a part of other systems of care and education throughout their development, including day care, school, and environments for extracurricular and leisure activities. In these situations, the adult who supervises the activity is accountable for monitoring the child’s asthma and making appropriate decisions about care and management. It is in the child’s best interest for the health care provider and parent to have an established plan of care that is simple and easily communicated to other child care providers or supervisors. A personal asthma action plan is an important tool for communication (see Fig. 1). This plan should be accompanied by specific and simple instructions on methods of medication administration and emergency medical contact information. Parents of infants and young children who have asthma should be encouraged to evaluate their child’s day care environment carefully. Attention by day-care staff to good hand-washing practices is essential in limiting the spread of respiratory viruses, a frequent trigger of asthma in young children. When possible, young children who have asthma should be in child care environments that have fewer children to minimize exposure to respiratory viral illnesses. For all children, exposure to passive smoke is associated with increased asthma morbidity and should be avoided [44]. Managing the child’s asthma in the school environment is a major challenge for school health professionals. The school environment often contains numerous potential asthma triggers, including physical education/ exercise programs, dust (including chalk dust), mold in showers and student lockers, viral exposures, and animals in the classroom [45]. It is important for the health care provider and parent of the child who has asthma to communicate with the school nurse at the beginning of each school year. Minimally, the school nurse should have a record of the child’s triggers, a personal action plan, and a supply of quick relief medication with health
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care provider orders for administration. Continued two-way communication between the parent and the school nurse during the year can alert both to asthma exacerbations at school or home and changes in the treatment regimen. If the child uses a peak flow meter (PFM) for asthma management at home, a second PFM should be provided for school use and personal zone numbers should be included in the child’s school action plan. School nurses should consider the practice of obtaining peak expiratory flow readings (PEFRs) on children who do not have established personal best PEFRs carefully. Interpretation of these PEFRs using published norms can be inaccurate and difficult to interpret [46]. The role of the school nurse in the care of the child who has asthma has expanded over the past 20 years, particularly as asthma-related morbidity in school absenteeism has increased. Health care providers have recognized that comprehensive asthma care can no longer occur only in the health care setting [47]. School-based programs often now include asthma education, case management services, and supplemental direct disease management services in school-based health clinics [48–52]. Expanded services are often found in schools serving inner city poor and minority populations, in which prevalence rates of asthma are higher and access to primary care services might be more fragmented. School-based clinics can be instrumental in identifying undiagnosed and undertreated children who have asthma, referring the child to more consistent primary care and providing supplemental asthma-related care that improves management and reduces absenteeism. Optimally, these clinics can strengthen the communication between parent and primary care provider by modeling important communication skills themselves. They might also help to reduce absenteeism by providing the child with access to care designed to monitor and intervene early in an exacerbation. These services also address the needs of parents who are challenged by work schedules and transportation difficulties and might reduce visits to the emergency department after work [50]. Ultimately, the child whose asthma is in good control is absent less often, performs better, and participates more fully in the school program. In recognition of increasing morbidity in childhood asthma, the Centers for Disease Control and Prevention issued a guide recently that provides six strategies to help schools manage the problems students have with asthma in the school environment. The guide encourages schools to develop strategies to support the student who has asthma. These strategies should address physical and mental health, improve the school environment, educate students and staff about asthma, improve physical education activities for these students, and coordinate school, family, and community activities that reduce illness and absenteeism from asthma [53]. Over the past 15 years scientists have devoted extensive efforts to developing asthma education programs for children and their families. These programs have been targeted to improve health outcomes and have reported that some interventions
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Table 4 Organizations providing asthma resources Organization
Contact information
Allergy and Asthma Network/ Mothers of Asthmatics (AAMNA)
2751 Prosperity Avenue, Suite 150 Fairfax, VA 22031 (800) 878-4403 fax (703) 573-7749 http://www.aanma.org
American Academy of Allergy, Asthma & Immunology (AAAAI)
611 East Wells Street Milwaukee, WI 53201 (800) 822-2762 (414) 272-6071 http://www.aaaai.org
American College of Allergy, Asthma & Immunology (ACAAI)
85 West Algonquin Road, Suite 550 Arlington Heights, IL 60005 (800) 842-7777 http://www.allergy.mcg.edu
American Lung Association (ALA)
61 Broadway, 6th floor New York, NY 10006 Nearly 200 local offices nationally (212) 315-8700 http://www.lungusa.org
Asthma and Allergy Foundation of America (AAFA)
1233 20th Street NW Suite 402 Washington, DC 20036 (202) 466-7643 fax (202) 466-8940 http://www.aafa.org
National Centers for Disease Control & Prevention (CDC)
Atlanta, GA http://www.cdc.gov/nceh/airpollution/asthma
National Asthma Education & Prevention Program; National Heart, Lung, & Blood Institute (NAEPP/NHLBI)
Information Center P.O. Box 30105 Bethesda, MD 20824 (301) 592-8573 fax (301) 592-8563 http://www.nhlbi.nih.gov/about/naepp/index.htm
National Jewish Medical and Research Center
1400 Jackson Street Denver, CO 80206 (800) 222-LUNG http://www.njc.org
U.S. Environmental Protection Agency (EPA)
Indoor Environments Division 1200 Pennsylvania Avenue, NW Mail Code 6609J Washington, DC 20460 Asthma Hotline (800) 315-8056 (202) 564-9370 fax (202) 565-2038 http://www.epa.gov/iaq/asthma http://www.noattacks.org
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improve self-management skills, knowledge of asthma, and health use outcomes for groups of children [54]. Evidence to date suggests that improving asthma management through education is multifaceted and might require innovative approaches that consider ethnic, cultural, and socioeconomic realities of the target populations.
Parent resources Diverse organizations are available for parents and other caregivers for help in managing the child’s asthma. Table 4 refers the reader to organizations that provide asthma resources.
Summary Childhood asthma has an adverse impact on children, families, and society. Treatment of asthma presents special challenges related to diagnosis, ongoing symptom monitoring, and treatment when the patient is a child. To be effective, treatment needs to be medically sound and developmentally appropriate. References [1] Adams PF, Marano MA. Current estimates from the National Health Interview Survey, 1994. Vital Health Statistics 1995;10:94–7. [2] Centers for Disease Control and Prevention. Surveillance for Asthma—US, 1960–1995, CDC surveillance summaries. MMWR 1995;47:1022–5. [3] National Heart, Lung, and Blood Institute. Data fact sheet. Asthma statistics. Bethesda (MD): National Institutes of Health, Public Health Services; 1999. [4] Weiss KB, Gergen PJ, Hodgson TA. An economic evaluation of asthma in the US. NEJM 1992;326:862–6. [5] Ostrom NK. Asthma management: proper use of pharmacotherapy. US Pharm 2001; 26:53–62. [6] Centers for Disease Control and Prevention (US). Asthma mortality and hospitalization among children and young adults—United States, 1980–1993. MMWR 1996;45:350–3. [7] Szilagyi P. Childhood asthma: we can do better! Pediatr Ann 1999;28:16–7. [8] Malveaux F, Houlihan D, Diamond EL. Characteristics of asthma mortality and morbidity in African Americans. J Asthma 1993;30:432–7. [9] Weiss KB, Gergen PJ, Crain EF. Inner-city asthma: the epidemiology of an emerging US public health concern. Chest 1993;101:362S–7S. [10] Essien J, Mobley CN, Griffith M, Creer T, Geller R. Pediatric asthma in African American children. In: Braithwaite R, Taylor S, editors. Health issues in the black community. San Francisco: Jossey Bass; 2001. p. 282–305. [11] Crain EF, Kercsmar C, Weiss KB, Mitchell H, Lynn H. Reported difficulties in access to quality care for children with asthma in the inner city. Arch Pediatr Adolesc Med 1998;152:333–9. [12] Eggleston PA, Malveaux FJ, Butz AM, Huss K, Thompson L, Kolodner K, et al. Medications used by children with asthma living in the inner city. Pediatrics 1998;101:349–54.
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[13] Diaz T, Sturm T, Matte T, Bindra M, Lawler K, Findley S, et al. Medication use among children with asthma in East Harlem. Pediatrics 2000;105:1188–93. [14] Cornelius LJ. Barriers to medical care for white, black and Hispanic American children. J Natl Med Assoc 1993;85:281–8. [15] Lieu TA, Lozano P, Finkelstein JA, Chi FW, Jensvold NG, Capara AM, et al. Racial/ ethnic variation in asthma status and management practices among children in managed Medicaid. Pediatrics 2002;109:857–65. [16] National Asthma Education and Prevention Program. Expert panel 2 report. Guidelines for the diagnosis and treatment of asthma. NIH Publication No. 97–4051. Washington DC: Department of Health and Human Services; 1997. [17] Adams RJ, Fuhlbrigge A, Guilbert T, et al. Inadequate use of asthma medication in the United States: results of the Asthma in America National Population Survey. J Allergy Clin Immunol 2002;110(1):58–64. [18] Martinati LC, Boner AL. Clinical diagnosis of wheezing in early childhood. Allergy 1995;50:701–10. [19] American Academy of Allergy Asthma and Immunology. Pediatric asthma: promoting best practice. Milwaukee (WI): American Academy of Pediatrics; 1999. [20] Blumberg MZ. Determining the cause of chronic cough in children. Journal of Respiratory Diseases for Pediatricians 2001;3(2):80–8. [21] Putnam PE, Orenstein SR. GERD and respiratory disease: how strong the connection? J Respir Dis 1996;17(1):61–8. [22] Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M, Morgan WJ. The Group Health Medical Associates. Asthma and wheezing in the first six years of life. N Engl J Med 1995;332(3):133–8. [23] Roorda RJ. Prognostic factors for the outcome of childhood asthma in adolescence. Thorax 1996;51(Suppl 1):S7–12. [24] Ross S, Godden DJ, Abdalla M, McMurray D, Douglas A, Oldman D, et al. Outcome of wheeze in childhood: the influence of atopy. Eur Respir J 1995;8:2081–7. [25] Martinez FD. Links between pediatric and adult asthma. J Allergy Clin Immunol 2001;107:S449–55. [26] Yoos HL, Kitzman H, McMullen A, Henderson C, Sidora K. Symptom monitoring in childhood asthma: a randomized clinical trial. Ann Allergy Asthma Immunol 2002;88: 283–91. [27] Szilagyi P, Kemper K. Management of chronic childhood asthma in the primary care office. Pediatr Ann 1999;28:43–52. [28] National Asthma Education and Prevention Program. Executive summary of the NAEPP. Expert Panel Report. Guidelines for the diagnosis and management of asthma—Update on selected topics 2002. NIH. Publication No. 02–5075. Washington DC: Department of Health and Human Services; 2002. [29] Abbott MB, Levin RH. Newly approved drugs for children. Pediatr Rev 2001;22(10): 357–9. [30] Agertoft L, Pedersen S. Effect of long-term treatment of inhaled budesonide on adult height in children with asthma. N Engl J Med 2000;343:1064–9. [31] Allen DB, Bronsky EA, LaForce CF, Nathan RA, Tinkelman DG, Vandewalker ML, et al. Growth in asthmatic children treated with fluticasone propionate. Fluticasone Propionate Asthma Study Group. J Pediatr 1998;132(3 Pt):472–7. [32] Allen DB. Inhaled corticosteroid therapy for asthma in preschool children: growth issues. Pediatrics 2002;109(2 Suppl):373–80. [33] Skoner DP. Growth effects of asthma and asthma therapy. Curr Opin Pulm Med 2002;8(1):45–9. [34] Petersen-Sweeney K, McMullen A, Yoos H, Kitzman H. Parental perceptions of their child’s asthma: management and medication use. Journal of Pediatric Health Care 2003;17(3):118–25.
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[35] Childhood Asthma Management Program (CAMP) Research Group. Long term effects of budesonide or nedocromil in children with asthma. N Engl J Med 2000;343(15):1054–63. [36] Kamps AW, van Ewijk B, Roorda RJ, Brand PL. Poor inhalation technique, even after inhalation instructions, in children with asthma. Pediatr Pulmonol 2000;29:39–42. [37] Everhard ML, Clark AR, Milner AD. Drug delivery from jet nebulizers. Arch Dis Child 1992;67:586–91. [38] Knoch M. Nebulizers: improvement and expansion of applications. J Aerosol Med 1994; 7:301. [39] Devadason SG, Everard ML, Linto JM, Le Souef PN. Comparison of drug delivery from conventional versus ‘‘Venturi’’ nebulizers. Eur Respir J 1997;10:2479–83. [40] Dolovich MA, Anderson PJ, Camargo CA, Chew N, Cole CH, Dhand R, et al. Consensus statement: aerosols and delivery devises. Respiratory Care 2000;45(6):589–96. [41] Amiraz I, Newhouse MT. Metered-dose inhaler accessory devises in acute asthma: efficacy and comparison with nebulizers: a literature review. Arch Pediatr Adolesc Med 1997;151:876–82. [42] Hannemann LA. What is new in asthma: new dry powder inhalers. Pediatric Health Care 1999;13:159–65. [43] O’Hollaren MT. Symposium 5101. Warning signs that an asthmatic may be prone to a fatal or near-fatal attack. 58th AAAAI Annual Meeting, New York (NY): 2002. [44] World Health Organization. Tobacco or health: a global status report. Geneva (Switzerland): World Health Organization; 1994. [45] Epstien BL. Childhood asthma and indoor allergens: the classroom may be the culprit. J Sch Nurs 2001;17(5):253–7. [46] Voter KZ, Sidora K, Yoos H, Kitzman H, McMullen A. Published predicted values (PPV) for peak flow rates (PFR) are not accurate estimates of rates determined using personal best (PB) methods. 99th International Conference of the American Thoracic Society. Seattle (WA): 2003. [47] Yoos HL, McMullen A, Bezek S, et al. An asthma management program for urban minority children. J Pediatr Health Care 1997;11:66–74. [48] Lurie N, Bauer EJ, Brady C. Asthma outcomes at an inner city school-based health center. J Sch Health 2001;71(1):9–16. [49] Meng A. A school-based asthma clinic: a partnership model for managing childhood asthma. Nurse Practitioner Forum 2000;11(1):38–47. [50] Perry C, Toole K. Impact of school nurse case management on asthma control in schoolaged children. J Sch Health 2000;70(7):303–4. [51] Horner S. Asthma self-care: just another piece of school work. Pediatr Nurs 1999; 25(6):597–604. [52] Clark N, Feldman C, Evans D, et al. The impact of health education on frequency and cost of health care use by low income children with asthma. J Allergy Clin Immunol 1986;78:108–15. [53] Centers for Disease Control and Prevention. Strategies for addressing asthma within a coordinated health program. Available at: http://www.cdc.gov/healthyouth/healthtopics/ asthma. Accessed December 2002. [54] Colland VT. Learning to cope with asthma: a behavioral self-management program for children. Patient Educ Couns 1993;22:141–52.
Asthma management across the life span: the child with asthma H. Lorrie Yoos, PhD, CPNPa,b,*, Elaine Philipson, MS, PNPa, Ann McMullen, MS, CPNPa,b a
Department of Pediatrics, University of Rochester Medical Center, 601 Elmwood Avenue, Box 667, Rochester, NY 14642, USA b University of Rochester School of Nursing, 601 Elmwood Avenue, Box SON, Rochester, NY 14642, USA
Incidence and impact of childhood asthma Asthma is a leading cause of morbidity in childhood, affecting about 5 million children in the United States [1–3]. Childhood asthma has an adverse impact on children, families, health care institutions, health care finances, educational institutions, industry, and the economy. While asthma treatment overall cost an estimated $6 billion in 1990 in direct and indirect expenditures, that cost had more than doubled to $12.7 billion by the year 2000 [4,5]. Loss of school days alone (more than 10 million/year) caused decreased productivity among parents and caregivers at an estimated cost of $1 billion [4]. Asthma kills 5000 Americans each year, and among children aged 5 to 14 years the asthma death rate has nearly doubled since the 1980s [6]. The numbers alone do not, however, portray the real story of childhood asthma. Behind each of the statistics is a child who has difficulty breathing and a parent who has worried and sacrificed [7]. Disproportionate rates of death, hospitalization, emergency room use, and disability from asthma occur in specific age, gender, socioeconomic, and ethnic groups. Inner-city, poor, and black children have the highest prevalence and morbidity rates [1,8–10]. The reasons for these differences are not completely understood, but there is a growing body of research indicating that factors such as biological/genetic characteristics, environmental
* Corresponding author. Department of Pediatrics, University of Rochester Medical Center, 601 Elmwood Avenue, Box SON, Rochester, NY 14642. E-mail address: [email protected] (H.L. Yoos). 0029-6465/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0029-6465(03)00113-0
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exposures, socioeconomic status, differences in health care access, quality, and use, and cultural beliefs and practices of parents interact to produce these asthma disparities in different populations [11–15].
Unique challenges in childhood asthma Although the means are now available to control virtually all asthma with safe and convenient treatments, asthma management nevertheless presents a significant challenge to patients and families [16]. It is estimated that only about 20% of children who have persistent asthma (who should all be on daily anti-inflammatory medication) receive appropriate therapy [17]. Special complexities related to diagnosis, ongoing symptom monitoring, and management arise when the patient is a child. Initial diagnosis Establishing the diagnosis of asthma often occurs over time and might be difficult in young children. Presentation is highly variable, ranging from children whose only symptom is cough to children who have persistent wheezing and airway compromise [18,19]. Recognition of asthma patterns can be further complicated by comorbid conditions that confuse the clinical picture. Conditions such as gastroesophageal reflux disease (GERD), tracheobronchial malacia, obstructive sleep apnea, postnasal drip, cystic fibrosis, vocal cord dysfunction, and habit cough are among the many diagnoses that mimic or aggravate the symptoms of asthma [19–21]. The insidious nature of a slow loss in lung function secondary to lung inflammation combined with difficulties related to testing infants and young children for changes in lung function result in a dependence on the physical examination for clinical data; however, the episodic nature of the bronchospasm is likely to result in an apparently normal physical examination, even when inflammation and airway obstruction exist. Furthermore, the presence of wheeze does not necessarily indicate asthma in children because this symptom might also be seen in children who have other problems who never go on to develop asthma. Natural history of asthma To further understand the ongoing challenge that asthma poses in pediatrics, one needs to look at the natural history of the disease throughout childhood. All parents wonder if their child will ‘‘outgrow’’ asthma. In a landmark prospective study of asthma incidence, Martinez and colleagues enrolled 1246 newborns into their study [22]. Of the 826 participants followed for the entire 6-year study period, nearly half of the children had at least one episode of wheezing during the first 6 years of life. Based on the reoccurrence of symptoms over time, these children were categorized into
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three groups: (1) transient early wheezers, (2) late-onset wheezers, and (3) persistent wheezers. Transient early wheezing generally resolved by 3 years of age and occurred most frequently in children who had smaller baseline lung volumes (likely related to smaller lung size). This group had a benign clinical course. The children who had later-onset wheezing experienced their first episodes of wheezing between 2 and 6 years of age, whereas the persistent wheezing group had recurring wheezing episodes throughout the 6-year study period. The children in the persistent wheezing group had a greater likelihood of a family history of asthma and having associated signs of atopy such as elevated serum IgE levels or positive allergy skin tests. How asthma progresses through childhood and adolescence into adulthood is not fully understood. In a review of the literature, Roorda points out that although it is a common belief that children outgrow asthma at puberty, the literature does not support this belief [23]. The literature shows that between 30% and 80% of children who have asthma continue to have asthma symptoms into adulthood. This review also reports that though many individuals experience a subjective ‘‘remission of symptoms’’ between 10 and 20 years of age, airway obstruction and bronchodilator responsiveness can nevertheless be seen on pulmonary function studies. Several investigators have found that atopy, a family history of asthma, and perinatal exposure to passive smoke are important predictors of continued asthma problems into adulthood [24,25]. Ongoing symptom monitoring Accurate assessment of asthma severity is critical for appropriate management in terms of an acute exacerbation and long-term treatment decisions related to the use of daily anti-inflammatory medications. Symptom monitoring can be a formidable task in childhood asthma. The child experiences the symptoms, which might or might not be perceived and communicated effectively to the parent, while the parent is dependent on various signs to evaluate symptom severity to determine (or at least participate in determining) the course of management. For this reason, objective peak flow monitoring might be particularly useful in pediatric patients who are older than 5 years of age and have significant disease severity. Successful peak flow monitoring requires a commitment from the family and the health care provider because children need to be trained in the procedure and families need to do an initial period of diary-keeping to establish the child’s ‘‘personal best.’’ It must be remembered that ‘‘personal best,’’ like shoe size, will change as the child grows (refer to another article in this issue for general principles of symptom monitoring). When personal best has been established, values are used to establish a personal action plan based on the zone system. See Fig. 1 for an example of a pediatric action plan. There is considerable controversy in the literature regarding the optimal method for monitoring asthma symptoms in children [16,26]. Yoos,
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Fig. 1. Asthma action plan. (From NY State Department of Health; with permission.)
McMullen, and Kitzman found that for the children who were at greatest risk for poor outcomes (children who had moderate to severe asthma and those from minority urban populations), peak flow monitoring significantly improved asthma outcomes such as number of symptom days and health care use [26].
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Developmental considerations in management Successful long-term management of asthma requires an ongoing partnership between the health care provider and the family. In that partnership, parents and children learn to take responsibility for the ongoing prevention and monitoring of symptoms and day-to-day management while health care personnel provide the educational tools and skills that make self-management possible [27]. Asthma management is a dynamic process when it involves children. Parents, children, and health care providers need to continuously re-evaluate and negotiate the responsibilities for disease management and tailor the education and the treatment plan to the individual child. Decisions related to the child’s responsibility for management should be based on an understanding of developmental milestones and expected competencies for the various age groups and an evaluation of the particular child’s capabilities (Table 1). Pharmacologic issues Pharmacologic management of asthma for children older than 5 years of age is similar to management in adults, with the emphasis being on the control of airway inflammation (see article by Conboy-Ellis). Table 2 delineates drugs and usual dosages for children. Of note, National Heart, Lung, and Blood Institute (NHLBI) guidelines outline minor variations in the stepwise approach for managing infants and children 5 years of age and younger (Fig. 2; Table 3). Differences are noted in the use of theophylline, a recommendation to use bronchodilators early in the course of viral respiratory illnesses, and an emphasis on using lower doses of inhaled corticosteroids (ICS) when possible [28]. Newly approved pharmacologic agents for use in children include budesonide inhalation suspension, which has been approved for use in children 12 months to 8 years of age. This is the first U.S. Food and Drug Administration-approved corticosteroid administered by way of a nebulizer [29]. Also relatively new for use with children is montelukast chewable tablets for use in 2- to 5-year-old patients. ICS emerged in the 1990s as the recommended preventive treatment of choice for persistent asthma symptoms. Although corticosteroids have been associated with a number of side effects, clinical trials have shown that the potential risk of growth delay in children older than 5 years of age that is linked to ICS use is temporary and possibly reversible [30,31]; however, few studies have been conducted that assess the benefits of ICS and the risk of growth retardation in infants and young children [32]. In the 2002 National Asthma Education and Prevention Program update to the Guidelines for the Diagnosis and Management of Asthma, the expert panel recommended ICS as a safe, effective, and preferred method to control and prevent inflammation in children who have asthma. The expert panel also reviewed evidence related to concerns about reduced bone mineral density, suppressed adrenal function, and cataracts and concluded that these are not
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Table 1 Developmental considerations in asthma management [19] Special considerations
Appropriate medication devices
Infancy
Diagnosis might be unclear.
Metered-dose inhaler (MDI) with small masked spacer. Allow the child to breathe 5–6 spontaneous breaths per puff with the spacer placed over the mouth and nose. Nebulizer administration should involve using a mask. Avoid the ‘‘blow-by’’ technique, which results in poor medication deposition [37]. Newer nebulizers with ‘‘breath enhanced nebulization’’ result in even greater nebulization and medication deposition [38,39].
Early management of wheezing is important because it might alter the course of asthma later on.
Toddler/preschool
Most acute wheezing episodes result from viral infections. Symptom evaluation and medication administration are completely the parent’s responsibility. Infants are developmentally unable to perform any voluntarily controlled inhalation/exhalation maneuvers; medication choices for this age group must be limited to those in which the medication can be inhaled passively during normal breathing. Upper respiratory infections continue to be a key precipitating factor of asthma symptoms. Important to prevent making medication administration a daily ‘‘battleground’’; let the child feel like a participant in medication administration. Use techniques such as distraction, reward, or making medication administration a game. This age child enjoys bright colors and pictures and ‘‘play-acting’’ with dolls in learning situations. The child might have multiple caregivers—all should know the treatment plan.
MDI with medium masked spacer Jet nebulizer compressor with mask or mouthpiece, based on patient’s ability
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Age group
School-aged child
MDI with spacer and mouthpiece Jet nebulizer compressor with mouthpiece Dry powder inhaler (DPI)
MDI alone MDI with spacer
DPI Jet nebulizer compressor with mouthpiece
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Adolescent
Child can now be helpful in terms of symptom monitoring; can also use a peak flow meter. Child is now able to control inhalation/exhalation efforts; therefore, more inhalation device options are now available. School-aged child responds to group learning situations; enjoys games, computers. Child now lives in multiple contexts—school, daycare, peers. Need to involve school in the treatment plan; school needs action plan. Reliable, prompt access to medications is essential; decisions need to be made about the child’s ability to carry and self-administer medications. Responsibility for medication administration shifts from parent to adolescent. ‘‘Denial’’ and ‘‘minimizing’’ might be primary coping strategies making ongoing ‘‘preventive’’ therapy appear to be irrelevant to the teen. Adherence might become an issue. Be aware of special issues such as reluctance to use inhaler in front of peers. Need to find out the adolescent’s goals and use good asthma management as the mechanism to help achieve goals. Adolescents respond best to peers and ‘‘peer-idols.’’
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Medication
Dosage form
Inhaled corticosteroids (see estimated comparative daily dosages for Inhaled Corticosteroids below) Systemic corticosteroids Methylprednisolone 2, 4, 8, 16, 32 mg tablets 5 mg tablets; 5 mg/5 cc; 15 mg/5 cc
Child dose
0.025–2 mg/kg daily in single dose in AM or qod PM for control Short-course ‘‘burst’’: 1–2 mg/kg/d maximum 60 mg/d for 3–10 d
Prednisone 1, 2, 5, 5, 10, 20, 50 mg tablets; 5 mg/cc, 5 mg/5 cc Long-acting inhaled b2-agonists (should not be used for symptom relief or for exacerbations—use with inhaled corticosteroids.) Salmeterol MDI 21 mcg/puff 1–2 puffs q 12 h DPI 50 mcg/blister 1 blister q 12 h Formoterol DPI 12 mcg/single use capsule 1 capsule q 12 h Combined medication Fluticasone/salmeterol DPI 100, 250 or 500 mcg/50 mcg 1 inhalation bid; dose depends on severity of asthma Cromolyn and nedocromil Cromolyn MDI 1 mg/puff 1–2 puffs tid–qid Nebulizer 20 mg/ampule 1 ampule tid–qid Nedocromil MDI 1.75 mg/puff 1–2 puffs bid–qid Leukotriene modifiers Montelukast 4 or 5 mg chewable tablet 40 mg qhs (2–5 y) 10 mg tablet 5 mg qhs (6–14 y) 10 mg qhs (>14 y) Zafirlukast 10 or 20 mg tablet 20 mg daily (7–11 y 10 mg tablet bid) Zileuton 300 or 600 mg tablet Methylxanthines Theophylline Liquids, sustained-release tablets, capsules Starting dose 10 mg/kg/day; usual max: \1 year of age: 0.2 (age in weeks) + 5 = mg/kg/day 1 year of age: 16 mg/kg/day
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Prednisolone
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Table 2 Usual dosages for long-term control medications in children 12 years of age
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Fig. 2. Stepwise approach for managing infants and young children (5 years of age) who have acute or chronic asthma.
significant risks for children [28]. Even though the risk is small, the goal of therapy should be to achieve symptom control without causing side effects. A number of strategies can be used to reduce the risk of growth retardation. First, children’s growth should be monitored carefully at each encounter. Second, the lowest effective dose of ICS should be used and the dose should be stepped up and down depending on symptom severity (see article in this issue regarding stepwise approach to management). Third, other management strategies should be maximized, including optimizing trigger
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Table 3 Estimated comparative daily dosages for inhaled corticosteroids in children 12 years of age Brand name
Low daily dose
Medium daily dose
High daily dose
Beclomethasone CFC 42 or 84 mcg/puff
Beclovent Vanceril
42 mcg/puff: 2–8 puffs/d
84 mcg/puff: 4–8 puffs/d
84 mcg/puff: >8 puffs/d
84 mcg/puff: 1–4 puffs/d 40 mcg/puff: 2–4 puffs/d
80 mcg/puff: 2–4 puffs/d
80 mcg/puff: >4 puffs/d
80 mcg/puff: 1–2 puffs/d 0.5 mg/d
1.0 mg/d
2.0 mg/d
Beclomethasone HFA 40 or 80 mcg/puff Budesonide inhalation suspension for nebulization 0.25 mg and 0.5 mg/vial Budesonide DPI 200 mcg/inhalation Flunisolide 250 mcg/puff Fluticasone MDI: 44, 110 220 mcg/puff DPI: 50, 100, 250 mcg/inhalation Triamcinolone acetonide 100 mcg/puff
Pulmicort Respules Pulmicort Turbuhaler AeroBid Flovent
1–2 inhalations/d
2–4 inhalations/d
>4 inhalations/d
2–3 puffs/d 44: 2–4 puffs/d
>5 puffs/d 220: >2 puffs/d
Azmacort
50: 2–4 inhalations/d 100: 1–2 inhalations/d 4–8 puffs/d
4–5 puffs/d 110: 2–4 puffs/d 220: 1–2 puffs/d 100: 2–4 inhalations/d 250: 1–2 inhalations/d 8–12 puffs/d
Adapted from NAEPP Expert Panel Report 2002.
250: >2 inhalations/d >12 puffs/d
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Drug
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abatement, giving the influenza vaccine, and treating contributing conditions such as rhinitis, sinusitis, and GERD. Fourth, a second controller medication such as a long-acting b2 agonist or leukotriene inhibitor might be considered for more difficult-to-control asthma as an alternative to increasing the inhaled steroid dose. Finally, using appropriate spacer devices and rinsing the mouth after steroid use can be helpful in maximizing dose distribution and preventing side effects [33]. Parents might have concerns about the safety of ICS use that might not always be expressed openly [34]. Helping families understand the relationship between controlling inflammation and improved asthma outcomes is key to their acceptance of the treatment plan. The benefits of well-controlled asthma, including improved pulmonary function and improved quality of life for the child and family, should be emphasized. With appropriate education, parents can also understand and participate in strategies designed to use the lowest ICS dose necessary to achieve control. Although questions remain regarding whether or not optimal treatment can prevent progression of disease severity in asthma, clinicians can inform parents that there is evidence that children whose asthma is well controlled live more active lives and are more likely to have normal growth and development [35]. Medication administration Developmental competencies are an important consideration in medication selection and administration for children who have asthma. The medication choices and the devices used to administer them have increased in recent years. Health care provider understanding of the array of available inhaled medications and proper use of the necessary delivery systems is essential to assuring an optimal treatment plan in the pediatric population. Proper technique for inhaled medications directly affects the lung deposition of the medication prescribed. Such a technique-driven modality makes choosing the appropriate device based on developmental abilities and teaching technique refinement a critical aspect of ongoing asthma management (see Table 1) [36]. In infancy, children are developmentally unable to perform any voluntarily controlled inhalation/exhalation maneuvers. Medication choices for this age group must be limited to those in which the medication can be inhaled passively, during normal breathing, even if it does not reflect the most effective technique for maximal drug deposition. The nebulizer with mask or the spacer with mask are the only appropriate medication delivery choices for infants [37–39]. The toddler can present a new challenge to the parent and health care provider alike in terms of medication administration. The skill required for a toddler to reject a particular medication modality is acquired well before the ability to accomplish other, more sophisticated, inhalation maneuvers. In this age group, successful medication delivery involves working with
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parents in a trial-and-error approach to finding the modality that is most acceptable to the toddler. Developmentally, inhaled asthma medication still must be limited to metered-dose inhalers (MDIs) with spacer and mask or a nebulized form. A check of mask size for the child using a spacer are important because the infant-sized mask is likely to be too small for the toddler. The school-aged child has more treatment options available, and a climate of working as a team will be helpful in gaining the ongoing cooperation of the child in the treatment of asthma. At approximately 6 years of age children are able to consistently control their inhalation/exhalation efforts and to generate the inspiratory flow rates required for the majority of inhaled medication devices on today’s market. This is a variable guideline, however, and repeated checking of technique is important to ongoing asthma management. For the child using medication in an MDI, the spacer might appropriately be changed to one with a mouthpiece rather than a mask. This change must, however, come with patient re-education on the changed technique of a slow, deep inhalation followed by breath holding of 4 to 10 seconds [40]. Similarly, nebulizer sets can be changed to the mouthpiece type, optimally using the breath-enhanced Venturi-type of nebulizer set. These changes can have the added advantage of improved lung deposition of medication [39]. Evidence supports the notion that good technique with an MDI and spacer can be as effective for maintenance therapy of asthma medications as the use of a nebulizer [41], so the provider can focus on the method that is likely to work best for the particular child and family. School-aged children can also be considered for the medications available in dry powder inhalers (DPIs), which might improve lung deposition and adherence [42]. Health care providers must be familiar with the product they are prescribing to provide adequate teaching; however, there are some general principles related to DPIs. The devices provide the medication as a fine powder that is inhaled into the lungs during the force of the inspiratory effort. Because of this technique DPIs require a single fast, deep inspiratory effort to provide wide medication distribution in the lung. Unlike MDIs, DPIs do not require breath-holding [40]. In addition, one should mention that blowing into the device might result in a wasted dose. The onset of adolescence signals a shift in responsibility for asthma management from the parent to the teen patient. Issues related to adherence to the treatment plan often become a central issue in the home and office. Treatment of asthma might become the arena in which the adolescent explores independence from parents and the importance of being like their peers. This group is at particular risk because deaths from asthma occur in the greatest number in the adolescent age group, especially between the ages of 10 to 14 years [43]. Selection of medications and modes of administration should consider the difficulties with adherence within this group. Adolescents, on the
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whole, are capable of coordinating all the maneuvers required of the various medication devices, so a wide variety of choices exist for them. Many of the newer DPIs offer effective medication delivered quickly with a single inhalation prepared in small, discrete, portable packaging. While spacer use is ideal with MDIs, adolescents might resist their use, in which case the health care provider must be diligent in teaching the effective open-mouth technique. Portable, handheld nebulizers also represent an option. Negotiating with teens regarding which medications and modalities fit best with their daily schedule and need for control and privacy is, arguably, one of the most important aspects of asthma care with this group. The child in multiple contexts The parent of a child who has asthma is accountable for assessing the child’s symptoms accurately and negotiating and supervising appropriate treatments; however, children are also a part of other systems of care and education throughout their development, including day care, school, and environments for extracurricular and leisure activities. In these situations, the adult who supervises the activity is accountable for monitoring the child’s asthma and making appropriate decisions about care and management. It is in the child’s best interest for the health care provider and parent to have an established plan of care that is simple and easily communicated to other child care providers or supervisors. A personal asthma action plan is an important tool for communication (see Fig. 1). This plan should be accompanied by specific and simple instructions on methods of medication administration and emergency medical contact information. Parents of infants and young children who have asthma should be encouraged to evaluate their child’s day care environment carefully. Attention by day-care staff to good hand-washing practices is essential in limiting the spread of respiratory viruses, a frequent trigger of asthma in young children. When possible, young children who have asthma should be in child care environments that have fewer children to minimize exposure to respiratory viral illnesses. For all children, exposure to passive smoke is associated with increased asthma morbidity and should be avoided [44]. Managing the child’s asthma in the school environment is a major challenge for school health professionals. The school environment often contains numerous potential asthma triggers, including physical education/ exercise programs, dust (including chalk dust), mold in showers and student lockers, viral exposures, and animals in the classroom [45]. It is important for the health care provider and parent of the child who has asthma to communicate with the school nurse at the beginning of each school year. Minimally, the school nurse should have a record of the child’s triggers, a personal action plan, and a supply of quick relief medication with health
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care provider orders for administration. Continued two-way communication between the parent and the school nurse during the year can alert both to asthma exacerbations at school or home and changes in the treatment regimen. If the child uses a peak flow meter (PFM) for asthma management at home, a second PFM should be provided for school use and personal zone numbers should be included in the child’s school action plan. School nurses should consider the practice of obtaining peak expiratory flow readings (PEFRs) on children who do not have established personal best PEFRs carefully. Interpretation of these PEFRs using published norms can be inaccurate and difficult to interpret [46]. The role of the school nurse in the care of the child who has asthma has expanded over the past 20 years, particularly as asthma-related morbidity in school absenteeism has increased. Health care providers have recognized that comprehensive asthma care can no longer occur only in the health care setting [47]. School-based programs often now include asthma education, case management services, and supplemental direct disease management services in school-based health clinics [48–52]. Expanded services are often found in schools serving inner city poor and minority populations, in which prevalence rates of asthma are higher and access to primary care services might be more fragmented. School-based clinics can be instrumental in identifying undiagnosed and undertreated children who have asthma, referring the child to more consistent primary care and providing supplemental asthma-related care that improves management and reduces absenteeism. Optimally, these clinics can strengthen the communication between parent and primary care provider by modeling important communication skills themselves. They might also help to reduce absenteeism by providing the child with access to care designed to monitor and intervene early in an exacerbation. These services also address the needs of parents who are challenged by work schedules and transportation difficulties and might reduce visits to the emergency department after work [50]. Ultimately, the child whose asthma is in good control is absent less often, performs better, and participates more fully in the school program. In recognition of increasing morbidity in childhood asthma, the Centers for Disease Control and Prevention issued a guide recently that provides six strategies to help schools manage the problems students have with asthma in the school environment. The guide encourages schools to develop strategies to support the student who has asthma. These strategies should address physical and mental health, improve the school environment, educate students and staff about asthma, improve physical education activities for these students, and coordinate school, family, and community activities that reduce illness and absenteeism from asthma [53]. Over the past 15 years scientists have devoted extensive efforts to developing asthma education programs for children and their families. These programs have been targeted to improve health outcomes and have reported that some interventions
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Table 4 Organizations providing asthma resources Organization
Contact information
Allergy and Asthma Network/ Mothers of Asthmatics (AAMNA)
2751 Prosperity Avenue, Suite 150 Fairfax, VA 22031 (800) 878-4403 fax (703) 573-7749 http://www.aanma.org
American Academy of Allergy, Asthma & Immunology (AAAAI)
611 East Wells Street Milwaukee, WI 53201 (800) 822-2762 (414) 272-6071 http://www.aaaai.org
American College of Allergy, Asthma & Immunology (ACAAI)
85 West Algonquin Road, Suite 550 Arlington Heights, IL 60005 (800) 842-7777 http://www.allergy.mcg.edu
American Lung Association (ALA)
61 Broadway, 6th floor New York, NY 10006 Nearly 200 local offices nationally (212) 315-8700 http://www.lungusa.org
Asthma and Allergy Foundation of America (AAFA)
1233 20th Street NW Suite 402 Washington, DC 20036 (202) 466-7643 fax (202) 466-8940 http://www.aafa.org
National Centers for Disease Control & Prevention (CDC)
Atlanta, GA http://www.cdc.gov/nceh/airpollution/asthma
National Asthma Education & Prevention Program; National Heart, Lung, & Blood Institute (NAEPP/NHLBI)
Information Center P.O. Box 30105 Bethesda, MD 20824 (301) 592-8573 fax (301) 592-8563 http://www.nhlbi.nih.gov/about/naepp/index.htm
National Jewish Medical and Research Center
1400 Jackson Street Denver, CO 80206 (800) 222-LUNG http://www.njc.org
U.S. Environmental Protection Agency (EPA)
Indoor Environments Division 1200 Pennsylvania Avenue, NW Mail Code 6609J Washington, DC 20460 Asthma Hotline (800) 315-8056 (202) 564-9370 fax (202) 565-2038 http://www.epa.gov/iaq/asthma http://www.noattacks.org
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improve self-management skills, knowledge of asthma, and health use outcomes for groups of children [54]. Evidence to date suggests that improving asthma management through education is multifaceted and might require innovative approaches that consider ethnic, cultural, and socioeconomic realities of the target populations.
Parent resources Diverse organizations are available for parents and other caregivers for help in managing the child’s asthma. Table 4 refers the reader to organizations that provide asthma resources.
Summary Childhood asthma has an adverse impact on children, families, and society. Treatment of asthma presents special challenges related to diagnosis, ongoing symptom monitoring, and treatment when the patient is a child. To be effective, treatment needs to be medically sound and developmentally appropriate. References [1] Adams PF, Marano MA. Current estimates from the National Health Interview Survey, 1994. Vital Health Statistics 1995;10:94–7. [2] Centers for Disease Control and Prevention. Surveillance for Asthma—US, 1960–1995, CDC surveillance summaries. MMWR 1995;47:1022–5. [3] National Heart, Lung, and Blood Institute. Data fact sheet. Asthma statistics. Bethesda (MD): National Institutes of Health, Public Health Services; 1999. [4] Weiss KB, Gergen PJ, Hodgson TA. An economic evaluation of asthma in the US. NEJM 1992;326:862–6. [5] Ostrom NK. Asthma management: proper use of pharmacotherapy. US Pharm 2001; 26:53–62. [6] Centers for Disease Control and Prevention (US). Asthma mortality and hospitalization among children and young adults—United States, 1980–1993. MMWR 1996;45:350–3. [7] Szilagyi P. Childhood asthma: we can do better! Pediatr Ann 1999;28:16–7. [8] Malveaux F, Houlihan D, Diamond EL. Characteristics of asthma mortality and morbidity in African Americans. J Asthma 1993;30:432–7. [9] Weiss KB, Gergen PJ, Crain EF. Inner-city asthma: the epidemiology of an emerging US public health concern. Chest 1993;101:362S–7S. [10] Essien J, Mobley CN, Griffith M, Creer T, Geller R. Pediatric asthma in African American children. In: Braithwaite R, Taylor S, editors. Health issues in the black community. San Francisco: Jossey Bass; 2001. p. 282–305. [11] Crain EF, Kercsmar C, Weiss KB, Mitchell H, Lynn H. Reported difficulties in access to quality care for children with asthma in the inner city. Arch Pediatr Adolesc Med 1998;152:333–9. [12] Eggleston PA, Malveaux FJ, Butz AM, Huss K, Thompson L, Kolodner K, et al. Medications used by children with asthma living in the inner city. Pediatrics 1998;101:349–54.
H.L. Yoos et al / Nurs Clin N Am 38 (2003) 635–652
651
[13] Diaz T, Sturm T, Matte T, Bindra M, Lawler K, Findley S, et al. Medication use among children with asthma in East Harlem. Pediatrics 2000;105:1188–93. [14] Cornelius LJ. Barriers to medical care for white, black and Hispanic American children. J Natl Med Assoc 1993;85:281–8. [15] Lieu TA, Lozano P, Finkelstein JA, Chi FW, Jensvold NG, Capara AM, et al. Racial/ ethnic variation in asthma status and management practices among children in managed Medicaid. Pediatrics 2002;109:857–65. [16] National Asthma Education and Prevention Program. Expert panel 2 report. Guidelines for the diagnosis and treatment of asthma. NIH Publication No. 97–4051. Washington DC: Department of Health and Human Services; 1997. [17] Adams RJ, Fuhlbrigge A, Guilbert T, et al. Inadequate use of asthma medication in the United States: results of the Asthma in America National Population Survey. J Allergy Clin Immunol 2002;110(1):58–64. [18] Martinati LC, Boner AL. Clinical diagnosis of wheezing in early childhood. Allergy 1995;50:701–10. [19] American Academy of Allergy Asthma and Immunology. Pediatric asthma: promoting best practice. Milwaukee (WI): American Academy of Pediatrics; 1999. [20] Blumberg MZ. Determining the cause of chronic cough in children. Journal of Respiratory Diseases for Pediatricians 2001;3(2):80–8. [21] Putnam PE, Orenstein SR. GERD and respiratory disease: how strong the connection? J Respir Dis 1996;17(1):61–8. [22] Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M, Morgan WJ. The Group Health Medical Associates. Asthma and wheezing in the first six years of life. N Engl J Med 1995;332(3):133–8. [23] Roorda RJ. Prognostic factors for the outcome of childhood asthma in adolescence. Thorax 1996;51(Suppl 1):S7–12. [24] Ross S, Godden DJ, Abdalla M, McMurray D, Douglas A, Oldman D, et al. Outcome of wheeze in childhood: the influence of atopy. Eur Respir J 1995;8:2081–7. [25] Martinez FD. Links between pediatric and adult asthma. J Allergy Clin Immunol 2001;107:S449–55. [26] Yoos HL, Kitzman H, McMullen A, Henderson C, Sidora K. Symptom monitoring in childhood asthma: a randomized clinical trial. Ann Allergy Asthma Immunol 2002;88: 283–91. [27] Szilagyi P, Kemper K. Management of chronic childhood asthma in the primary care office. Pediatr Ann 1999;28:43–52. [28] National Asthma Education and Prevention Program. Executive summary of the NAEPP. Expert Panel Report. Guidelines for the diagnosis and management of asthma—Update on selected topics 2002. NIH. Publication No. 02–5075. Washington DC: Department of Health and Human Services; 2002. [29] Abbott MB, Levin RH. Newly approved drugs for children. Pediatr Rev 2001;22(10): 357–9. [30] Agertoft L, Pedersen S. Effect of long-term treatment of inhaled budesonide on adult height in children with asthma. N Engl J Med 2000;343:1064–9. [31] Allen DB, Bronsky EA, LaForce CF, Nathan RA, Tinkelman DG, Vandewalker ML, et al. Growth in asthmatic children treated with fluticasone propionate. Fluticasone Propionate Asthma Study Group. J Pediatr 1998;132(3 Pt):472–7. [32] Allen DB. Inhaled corticosteroid therapy for asthma in preschool children: growth issues. Pediatrics 2002;109(2 Suppl):373–80. [33] Skoner DP. Growth effects of asthma and asthma therapy. Curr Opin Pulm Med 2002;8(1):45–9. [34] Petersen-Sweeney K, McMullen A, Yoos H, Kitzman H. Parental perceptions of their child’s asthma: management and medication use. Journal of Pediatric Health Care 2003;17(3):118–25.
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H.L. Yoos et al / Nurs Clin N Am 38 (2003) 635–652
[35] Childhood Asthma Management Program (CAMP) Research Group. Long term effects of budesonide or nedocromil in children with asthma. N Engl J Med 2000;343(15):1054–63. [36] Kamps AW, van Ewijk B, Roorda RJ, Brand PL. Poor inhalation technique, even after inhalation instructions, in children with asthma. Pediatr Pulmonol 2000;29:39–42. [37] Everhard ML, Clark AR, Milner AD. Drug delivery from jet nebulizers. Arch Dis Child 1992;67:586–91. [38] Knoch M. Nebulizers: improvement and expansion of applications. J Aerosol Med 1994; 7:301. [39] Devadason SG, Everard ML, Linto JM, Le Souef PN. Comparison of drug delivery from conventional versus ‘‘Venturi’’ nebulizers. Eur Respir J 1997;10:2479–83. [40] Dolovich MA, Anderson PJ, Camargo CA, Chew N, Cole CH, Dhand R, et al. Consensus statement: aerosols and delivery devises. Respiratory Care 2000;45(6):589–96. [41] Amiraz I, Newhouse MT. Metered-dose inhaler accessory devises in acute asthma: efficacy and comparison with nebulizers: a literature review. Arch Pediatr Adolesc Med 1997;151:876–82. [42] Hannemann LA. What is new in asthma: new dry powder inhalers. Pediatric Health Care 1999;13:159–65. [43] O’Hollaren MT. Symposium 5101. Warning signs that an asthmatic may be prone to a fatal or near-fatal attack. 58th AAAAI Annual Meeting, New York (NY): 2002. [44] World Health Organization. Tobacco or health: a global status report. Geneva (Switzerland): World Health Organization; 1994. [45] Epstien BL. Childhood asthma and indoor allergens: the classroom may be the culprit. J Sch Nurs 2001;17(5):253–7. [46] Voter KZ, Sidora K, Yoos H, Kitzman H, McMullen A. Published predicted values (PPV) for peak flow rates (PFR) are not accurate estimates of rates determined using personal best (PB) methods. 99th International Conference of the American Thoracic Society. Seattle (WA): 2003. [47] Yoos HL, McMullen A, Bezek S, et al. An asthma management program for urban minority children. J Pediatr Health Care 1997;11:66–74. [48] Lurie N, Bauer EJ, Brady C. Asthma outcomes at an inner city school-based health center. J Sch Health 2001;71(1):9–16. [49] Meng A. A school-based asthma clinic: a partnership model for managing childhood asthma. Nurse Practitioner Forum 2000;11(1):38–47. [50] Perry C, Toole K. Impact of school nurse case management on asthma control in schoolaged children. J Sch Health 2000;70(7):303–4. [51] Horner S. Asthma self-care: just another piece of school work. Pediatr Nurs 1999; 25(6):597–604. [52] Clark N, Feldman C, Evans D, et al. The impact of health education on frequency and cost of health care use by low income children with asthma. J Allergy Clin Immunol 1986;78:108–15. [53] Centers for Disease Control and Prevention. Strategies for addressing asthma within a coordinated health program. Available at: http://www.cdc.gov/healthyouth/healthtopics/ asthma. Accessed December 2002. [54] Colland VT. Learning to cope with asthma: a behavioral self-management program for children. Patient Educ Couns 1993;22:141–52.