医学交流课件：Childhood Asthma Optimizing Control

ChildhoodAsthma

OptimizingControl

AsthmaControl:

-Impairment-RiskDiagnosisRiskfactorsAsthmamedicationsDeliverydevices,techniqueControl-BasedAsthmaManagementinChildren≤5YearsGlobalInitiativeforAsthma.GlobalStrategyforAsthmaManagementandPrevention.2015.SymptomsSuggestAsthmaSuspectAsthmaConfirmtheDiagnosisofAsthmaHistoryandExamBronchodilatororICSresponseNormalCXRDiagnosingAsthmaintheYoungChildAllThatWheezesisNOTAsthmaCharlie:2Year-oldChildPresentswithahistoryof“chroniccough”

TreatmenthasincludedcoughmedicineandantibioticswithoutmuchsuccessHewasgivenalbuterolwhich“quicklyandtemporarilyhelpshiscough”Heawakensfromhiscough,whichscareshisparentsashe“coughstothepointofvomiting”

Charlie:2Year-oldChildPastMedicalHistoryBornat7lb.withoutcomplicationAt8months,hedevelopeda“badcold”withwheezingandcough.Inthelastyear,4visitstohisphysicianforsymptomsofcoughandwheezing.Treatmentincludedalbuterolandantibiotics.NormalCXREnvironmental&FamilyHistoryHismothersmokes,butonly“onthebackporchandwhenthewindowsaredowninthecar”HesleepsonaDacronpillowonanewmattressandthehomehas15-year-oldcarpetingThefamilyhastwocatsHismotherhasasthmaandhisfatherisallergictodogsCharlie’smotherhasmanyquestionsandconcerns!!“Whatcanwedotohelphimstopcoughing?”

“Willheevergetbetterandhissymptomsgoaway?”“I’vebeentoldthathemayhaveasthma.Isitpossibleforachildthisyoungtohaveasthma?”Charlie:2Year-oldChildInchildrenwithknowasthma,aretrospectiveevaluationfortheonsetofasthmasymptomsOnsetofsymptomsofasthma30%ofchildrenbefore1year70%willhavetheonsetofsymptomsbyage3OnsetofSymptomsinChildrenWithKnownAsthmaMcNicolKN,etal.BMJ.1973;WainwrightC,etal.MedJAust.1997AsthmaDiagnosisinChildren≤5YearsViralInducedWheezeAsthmaDiagnosisSymptoms(cough,wheeze,heavybreathing)for<10daysduringupperrespiratorytractinfections1-3episodesperyearNOSYMPTOMSBETWEENEPISODESSymptoms(cough,wheeze,heavybreathing)for>10daysduringupperrespiratorytractinfections>3episodesperyear,orsevereepisodesand/ornightworseningBETWEENEPISODESCHILDMAYHAVEOCCASIONALCOUGH,WHEEZEORHEAVYBREATHINGSymptoms(cough,wheeze,heavybreathing)for>10daysduringupperrespiratorytractinfections>3episodesperyear,orsevereepisodesand/ornightworseningBetweenepisodeschildhascough,wheezeorheavybreathingduringplayorwhenlaughingATOPY,ORFAMILYHISTORYOFASTHMAGlobalInitiativeforAsthma.GlobalStrategyforAsthmaManagementandPrevention.2015.DefiningtheRiskofAsthma

ModifiedAsthmaPredictiveIndex

Allergytomilk,eggorpeanutEosinophilia(>4%)Wheezeapartfromcolds

MinorCriteriaParentalasthmaAtopicDermatitisAllergicSensitizationMajorCriteriaChangetal.

JAllergyClinImmunolinPractice.2013;1:152-6.OR>4

wheezingepisodesinayearPositive:If1majoror2minor,then72%likelihoodofpersistentwheezingNegative:Ifnomajorsandlessthan2minors,92%likelihoodofnotdevelopingclinicalasthma12CharlieisdiagnosedwithasthmaCharlie’smotherisworriedandconcerned!!

“Doesheneedadailymedication?”WhatisthebestmedicationforCharlie?Charlie:2Year-oldChild2134GlobalInitiativeforAsthma.GlobalStrategyforAsthmaManagementandPrevention.2015.PoorsymptomcontrolActivitylimitation≥3exacerbationsperyearWheezingepisodesevery6–8weeks.

Infrequentviralwheezing,nointervalsymptomsAStepwiseApproachControlSymptomsandReduceRiskPreferredTreatmentInhaledCorticosteroidsAlternateTreatmentsLeukotrieneReceptorAntagonists(LTRA)IntermittentHighDoseICSAgesofChildren(yrs)CurrentFDA-ApprovedICS

MaintenanceTreatmentofAsthmaAbdullahAKandKhanS.JAsthma.2007.124567893010111213141516BudesonideDPIFlunisolideHFABeclomethasoneHFABudesonidesuspensionFluticasoneDPI&HFAFluticasone/SalmeterolDPIMometasoneDPIBudesonide/FormoterolHFAFluticasone/SalmeterolHFACiclesonide

HFADPI=dry-powderinhalerHFA=hydrofluoroalkanemetered-doseinhalerMometasone/FormoterolHFANAEPP,NHLBI,NIH.ExpertPanelReport3:GuidelinesfortheDiagnosisandManagementofAsthma.August2007,Randomized,multicenter,double-blind,placebo-controlled.Once-daily:non-ICS(mild-to-moderate);6monthsto8yrs;Twice-daily:ICS-dependent(moderatetomoderate/severe);4to8yrsCombination:on/ornotonICS;mild&moderate,6monthsto8yrs.>1000patientsBudesonideInhalationSuspensionInfantsandYoungChildrenKempetal.AnnAllergyAsthmaImmunol.1999;83:231-9;Shapiroetal.JAllergyClinImmunol.1998;102:789-96;Bakeretal.Pediatrics.1999;103:414-21.Evidenceforefficacyandsafetyin1018infantsandyoungchildren6monthsto8yearsofageReducedasthmasymptomsDecreaseinbronchodilatoruseImprovedlungfunctionReducedasthmaexacerbationsWellestablishedsafetyprofile,includinggrowthRecommendedinchildren1-8yearsofageNAEPP,NHLBI,NIH.ExpertPanelReport3:GuidelinesfortheDiagnosisandManagementofAsthma.August2007.Bakeretal.Pediatrics.1999;103:414-21;Kempetal.AnnAllergyAsthmaImmunol.1999;83:231-9;Shapiroetal.JAllergyClinImmunol.1998;102:789-96.BudesonideInhalationSuspensionInfantsandYoungChildrenSafetyOutcome:GrowthVelocityGrowthVelocity(cm/yr)

=

-0.8p=0.002

=0.8p=NS

=0.7p=NS

=0.1p=NSn=371n=156n=151n=58n=47n=25n=173n=73Kempetal.AnnAllergyAsthmaImmunol.1999;83:231-9;Shapiroetal.JAllergyClinImmunol.1998;102:789-96;Bakeretal.Pediatrics.1999;103:414-21.Scottetal.JAllergyClinImmunol1999;104,S200-209BudesonideInhalationSuspensionConventionalAsthmaTherapyChildren2to8yearsofageHadsymptomsofmildpersistentasthmaasdeterminedbyNAEPPguidelinesIntheyearbeforescreening,hadahistoryof≥3wheezingepisodesthatlasted>1dayandaffectedsleepRandomizedtoreceivedailyfor1year:-BudesonideInhalationSuspension(BIS)0.5mg-Montelukast4mgor5mgOutcomemeasuresincludedsymptoms,lungfunctionandasthmaexacerbationsComparisoninYoungChildrenwithAsthmaNebulizedCorticosteroids<RA’sSzeflerSJ.JAllergyClinImmunol.2007;120:1043-50.PeakExpiratoryFlow14.0321.070510152025MontelukastBIS9.4216.830510152025MontelukastBISAMPEFPMPEFP=0.007P=0.005Themeanchangesfrombaselinetotheaverageoverthefirst12weeksSzeflerSJ.JAllergyClinImmunol.2007;120:1043-50.RateofExacerbations*exacerbationsofrequiredstep-upBIStherapyororalcorticosteroidsrateofexacerbations*(number/subject/year)1.631.2300.511.52MontelukastBISunadjustedP<0.034thetotalnumberofexacerbationsreduction24.5%

SzeflerSJ.JAllergyClinImmunol.2007;120:1043-50.Childrenless<8yearsofagePharmacyandmedicalclaimsdatawereexaminedfora12-monthperiodbeforeandafterthefirstasthmaexacerbation(indexevent)Afterthefirstasthmaexacerbation,outcome(asthmaexacerbation)over12monthswerereportedbyclassofasthmamedicationsusedAsthmaExacerbationPre-IndexPost-Index12Months12MonthsJanuary1999–

June2001Day30CamargoCAJr,etal.AmJHealth-SystPharm.2007;64:1054-1061.RiskofRecurrentAsthmaExacerbation

BasedonControllerMedication*Multivariate-adjustedriskofarepeatasthmaexacerbationduringfollow-upbasedonasthmamedicationclass.HazardRatio(95%CI)LTRA0.55NebulizedBudesonideNon-nebulizedICS1.061.04SABALABAOCSOthers00.845%lowerrisk

ofrecurrentasthmaexacerbations(p<0.001)CamargoCAJr,etal.AmJHealth-SystPharm.2007;64:1054-10611.06ControllerMedicationsRiskofRecurrentAsthmaExacerbation

BasedonControllerMedication0.290HazardRatio(95%CI)0.8*Multivariate-adjustedriskofarepeatasthmaexacerbationduringfollow-upinpatientsreceivingnebulizedbudesonidecomparedwithpatientsreceivingnon-nebulizedICSs.71%lowerrisk

ofrecurrentasthmaexacerbations(p<0.001)InhaledCorticosteroidsCamargoCAJr,etal.AmJHealth-SystPharm.2007;64:1054-1061(NebulizedBudesonide)Non-nebulizedICS1.06RiskofRecurrentAsthmaExacerbation

NebulizedBudesonidevsOtherICSsAsthmaControl:

-Impairment-RiskDiagnosisRiskfactorsAsthmamedicationsDeliverydevices,techniqueGlobalInitiativeforAsthma.GlobalStrategyforAsthmaManagementandPrevention.2015.Control-BasedAsthmaManagementinChildren≤5YearsSmalltidalvolumeNosebreathersNobreath-holdDon’tputthatonmyfaceShortattentionspanLackofcooperation

CryingDifferfromolderchildrenDeliveryDevices

TheChallengewithYoungChildren….NotCryingCryingTheEffectofCryingonLungDepositionGMurakamiAnnAllergy1990;64:383-7TheJoysofParenthood…FaceMaskLeak:pMDI+Spacer

VerySmallLeaksLeadtoNoDrugDepositionJEEsposito-Festenetal.JAerosolMed2004;17(1):1-6RelevantErrorsinDrug

DeliveryDeviceUseDesign:hands-onevaluationofinhalationtechniqueof150pediatricasthmapatientswithameanageof4.5years.

MDIs

(withspacer/holdingchambers)

(n=72)81%

demonstrated

properuse64%

demonstrated

properuse42%

demonstrated

properuseNebulizers

(n=124)DPIs

(n=19)101462326811020406080100120Goodtechnique,minorerrorsRelevanterrorsKofmanetal.RT2004;17:26-8DeliveryDevices

AdvantagesofNebulizedDeliveryMinimalcooperationAnyageUsewhilesleepingAdministrationofvariabledrugsanddosesDeliveryoftreatmentswithoxygenThoughttofosterconfidenceandadheranceCharlie’sparentsdecidedonstartingnebulizedbudesonideFollow-upwassuggestedin4-6weeksCharlie:2Year-oldAsthmaticInitialdose:0.5mgtotaldailydose,eitherdailyortwicedailyindivideddosesTitratedosedependingonclinicalresponseAdministrationwithsnugfittingfacemaskCharlie’sProgress2

monthlater,CharliereturnsforfollowupFamilypleasedwithprogressChestexamwasnormalAsthmacontrolwasassessed,usingtheTRACKQuestionnaireTheTestforRespiratoryandAsthmaControlinKids(TRACKTM)TheTRACKtoolisa5-itemstandardizedquestionnaireforcaregiversofchildrenyoungerthan5yearsTheTRACKtooladdressesboththeriskandimpairmentdomainsofrespiratorycontrol,consistentwithcurrentasthmaguidelinesThetestwasdesignedforwhoAreunder5yearsofageANDHaveahistoryof2ormoreepisodesofwheezing,shortnessofbreath,orcoughlastingmorethan24hoursANDHavebeenpreviouslyprescribedbronchodilatormedicinesforrespiratoryproblemsORhavebeendiagnosedwithasthmaMurphyKR,ZeigerRS,KosinskiM,etal.JAllergyClinImmunol2009;123:833-839;

MurphyKR&MellonMH.ConsultPeds.2009;8:S1-S16TestforRespiratoryandAsthmaControlinKids(TRACKTM).Availableat:.AsthmaAssessmentQuestionnaireImpairment(SymptomControl)ShortnessofbreathorwheezingNighttimeawakeningsduetoasthmaLimitationinactivitiesduetoasthmaShort-actingβ2-agonistuseforsymptomcontrolRiskNeedfororalsteroidinthelastyear

MurphyKR,etal.JAllergyClinImmunol.2009123(4):833-839TRACKQuestionsInpast4weeks:HowoftenchildbotheredbywheezingcoughingorSOB?HowoftenwheezecoughorSOBinterferedwithactivities?Howoftendidchildawakenwithbreathingproblems?Inpast3months:Howoftenwerechild’sbreathingproblemstreatedwithrescueoralbuterolmedication?Inthepast12months:Howmanycoursesoforalcorticosteroidswererequiredforasthmatreatment?MurphyKR,etal.JAllergyClinImmunol.2009123(4):833-839852015201515Charlie’sTRACKScoreWhatDoesYourChild’sTRACK

ScoreMean?Ifyourchild’sscoreis80ormoreYourchild’sbreathingproblemsareundercontrolMonitoryourchild’sbreathingproblemsonaregularbasisandbringanyconcernstotheattentionofhisorherhealthcareprovider.Continuetalkingwiththehealthcareprovideraboutyourchild’sprogressandwhichtreatmentplanisrightforyourchildWithcontrol,yourchildwillsleepbetter,participateineverydayactivities,andsufferfewerrecurringflare-upsofbreathingproblemsWhatDoesYourChild’sTRACK

ScoreMean?Ifyourchild’sscoreisLessthan80Yourchild’sbreathingproblemsarenot

undercontrolTalkwithyourchild’shealthcareprovideraboutreasonswhyyourchild’sbreathingproblemsmayn