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This is not in your handout. Don’t panic. I made up a new sheet that’s on the back table, but I thought you might need to know this. Symptoms; when do you start prophylaxis? These are the guidelines. If you need to use a beta agonist more than twice a week for anything other than exercise, that’s too much. You need to start on prophylaxis. If you are having nighttime symptoms more than twice a month, you need to consider prophylaxis. If your peak flows aren’t normal when you are well, you need to consider prophylaxis. If you have been hospitalized more than once, if you’ve ever had a life-threatening exacerbation, and the last one is a little bit controversial but a lot of our kids in their first six years of life are actually well most of the time. They just get a cold, they wheeze, but in between they are perfectly normal. The recommendation that is going to be coming out is that if you have more than two moderate to severe exacerbations with a cold in a four month period, then you might want to consider prophylaxis during the cold season. That they won’t test you on because that’s a new addition to the when to start prophylaxis group.
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Chronic asthma; other things, give them their flu vaccine. Try to get them to stop smoking. We still have teenagers with asthma who smoke. And we certainly have the parents who are smoking. Environmental interventions we will talk about after we get down to the allergic rhinitis. Anybody with persistent asthma, the recommendation now is that if you put them on a daily preventative medication they need to have some intervention or some investigation for environmental allergies. We used to not do that. We used to only send over the kids that we couldn’t control. Spirometry, not just peak flow, spirometry at certain points, and when to do peak flow monitoring, a written management plan, those are the sicker kids. Moderate to severe or anybody who has had a life-threatening exacerbation. Cheap Amoxicillin online

This one is also in the handout that’s out there, when to refer to an allergist or a pulmonologist; if they’ve ever been sick enough that they were in the PICU, if you treat them and you just can’t get them better over 3-6 months, or maybe you need the allergist to help educate the patients further, or maybe you are just a pediatrician who doesn’t care about asthma, you have no interest in it, you want someone else to do it for you, that’s okay. If you are not sure about the diagnosis. It kind of looks like asthma, maybe it’s not, maybe it’s vocal cord dysfunction. I keep trying and it’s not working, or maybe I’ve got bad allergic rhinitis that I can’t control, or something like that. Obviously if you need allergy testing and if they are moderate persistent asthma, probably at any age they should be referred. And the last one depends on how good you are at asthma as a pediatrician, but mild persistent asthma in a real young child, you might consider referral also.
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Exercise-induced asthma; coughing and chest pain, or shortness of breath. It occurs about 6-8 minutes after starting to exercise, so it’s not right away. Usually exacerbated – especially if it’s cold or dry – so kids with exercise-induced asthma do real great as swimmers because the air is moist and it’s warm. They do well at exercise that doesn’t require them to raise their heart rate up real acutely real fast. You can either demonstrate this in the office … in our office what we will often do is take the resident and the child and send them into the hallway and have them both run stairs, and see if one – or the other – develops exercise-induced asthma and treat whoever needs it. But the treatment is primarily albuterol. Cromolyn and nedocromil can be used as an add-on if the albuterol isn’t giving you enough control, and salmeterol could be used as a single agent with long-term control, as we talked about.

Leukotriene modifiers; this was real exciting when these first came out, and unfortunately they are not ending up quite as powerful as we had hoped. Leukotrienes are chemical mediators that are released by leukocyte’s mast cells. They break down products of arachidonic acid. And different leukotrienes will do different things. Certain ones will cause mucus production, other ones will cause smooth muscle constriction, other ones will lead to edema, other ones will lead to an inflammatory infiltrate, act as a chemotactic factor. So they do everything that, as far as we can tell, is the pathophysiology of asthma. So the idea is that if I give something that either blocks the end receptor or stops the metabolism and prevents that from being produced, I should have a great drug for asthma. Unfortunately, most of these have really been tried so far just in kids with mild asthma, and primarily in adults. It is probably in the more severe asthmatic not as successful as using inhaled steroids. So, good choice for someone with mild persistent asthma. The other advantage to this is that it is given orally. Buy human growth hormone. The drug that we use in kids is montelukast. I did include some side effects on some other drugs, just in case you need to know them, but the only one really approved for kids is montelukast, which is Singulair, and it’s approved for kids above six-years-of-age. It’s not a bad drug in the mild asthmatic, but if you have a real moderate to severe asthmatic you are probably going to have to be using inhaled steroids. Female pink viagra online.

Serevent, salmeterol; a long-acting beta agonist. Albuterol in the best of cases lasts 4-6 hours. Serevent or salmeterol can last up to 12 hours. Key point with salmeterol though; don’t use it in acute exacerbation. It takes longer to have an effect. It often takes up to about an hour or two hours before you get a peak effect with it, and what has happened is that there actually are some case reports of deaths in adults who started to get sick, took a hit of their Serevent, they weren’t better. Fifteen minutes later they took another hit and they kept doing that for hours and hours and basically got pretty high doses. It’s only used for long-term control. And the indications are there. If you have a person who is out of control, I’m starting him on inhaled steroids and yet he is still breaking through at night, because he’s still got some inflammation, this may last throughout the night and allow him not to have a lot of nocturnal symptoms. It does work for exercise-induced asthma. Interestingly enough – since it has a 12 hour effect – if you have a kid who has to go to a track meet at three in the afternoon, you can give him a dose in the morning before he leaves the house and still protect him, rather than having to carry the MDI with him. And in cases where you are already on a moderate dose of inhaled steroids, somewhere in the 400-800 range and you are not getting good control of symptoms, you actually have better control by leaving the same dose of steroids and adding in the salmeterol than you do by increasing the steroid dose. So it helps you keep your steroid dose down in kids with moderate to severe asthma.
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Theophylline; now it’s gone back and forth over the years. I think right now it’s a second line agent for long-term control, or maybe for controlling nocturnal symptoms while you are bringing someone under control. It causes a lot of GI upsets. You’ve got to be careful with levels, but the advantage is, it’s cheap. In the old days we used to control a lot of symptoms with theophylline. But basically a second line agent now. They might still ask you about theophylline side effects. Those are in your handout. The biggest that you need to know about are macrolides. If you put somebody on erythromycin you’ll shoot their theophylline level through the roof and might precipitate seizures and other things like that.

Okay, this is the approach, then. If I have mild intermittent asthma, I take a beta agonist as needed. I might need some prophylaxis for exercise. But I am not on anything daily. If I have mild persistent asthma, I’ll still use my beta agonist as needed and then I have basically four choices. Any of these agents are reasonable as a first line drug, with maybe the admonishment that in kids we’ll start with the cromolyn because of the lack of side effects. Moderate persistent; these individuals will be on moderate dose inhaled steroids and if they are not controlled with that, or if you want to bring the steroid dosage down, you add in something like salmeterol or nedocromil, and in the severe persistent – these are the people with daily, continuous symptoms – these are going to be handled by the allergist. They are on a whole host of almost everything you can think of and you are not going to be tested on this.

Inhaled steroids; still far and away the best long-term preventive agent for asthma, period. The problem is potential side effects. If basically decreases the late response. It doesn’t stop the initial bronchoconstriction but also deals with the hyper-responsiveness and you can see improvement within a few days in lung function, on inhaled steroids. Maxing out at about 2-4 weeks. You might want to know the dosage range for what’s considered low, medium, high, as a standard. It’s based off beclomethasone, which is the older steroid that we’ve all used. About 200-400 mcg per day is low dose, and medium is 400-800. This will be useful when you talk about side effects.
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What are the side effects of inhaled steroids? First of all, if you use a spacer, you decrease all of the side effects dramatically. You’ll see in the studies that look at effects on growth, the kids who use dry powder inhalers where a lot of it hits the back of the throat, or where they are not using a spacer, they have a lot more potential growth suppression than those that use a spacer. Use a spacer. It cuts down on side effects. In adults occasionally you get thrush or you get a little vocal cord adductor paralysis, really rare in kids. Both are resolved just over a few days by stopping the steroids. There is no clinically significant effect on adrenal axis or bone metabolism. Can you measure something biochemically? Yes. Is it significant clinically? No. Linear growth; this is still controversial. The best of studies suggest that if I put you on, say, a dose of 400 mcg per day of beclomethasone, that at the end of the year you will have lost maybe between one-half to one-and-a-half cm of height compared to what you would have done. But interestingly, some of the studies – and a lot of the studies – suggest that that’s a temporary loss. In one of the most recent studies that came out in the last year and a half, kids growth rates slowed by about 50% in the first six weeks that they were on the medication. But by 20 weeks they were back up to the same growth rate and maintained a normal growth rate after that. So there seems to be a period of time where when you first start the steroids there’s a stop, and then after that your growth rate comes back up. In fact, the metaanalysis, the long-term studies, don’t really show a big effect on adult height. Bottom line, if you’ve got frequent asthma and you are requiring frequent p.o. steroid doses, that’s going to make you short also. So in most cases we try to keep it to the lowest dose possible, and we do realize that you may lose maybe a centimeter of height, but it’s not like you are going to lose a centimeter per year. You are not going to be an adolescent who is 3’4″ tall, or something like that.
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No significant immunosuppression, and it may increase the risk of cataracts. There’s a recent study through the New England Journal, again based on patient recall, so you’ve got to take it with a grain of salt but it may.

Okay, let’s talk real quickly about chronic asthma. The National Heart/Lung Institute has had two documents out over the last about five or six years. The Expert Panel’s Report on Asthma. If you guys are actually general pediatricians and take care of asthmatics, get on their web site and download the Expert Panel II. A wonderful document talking about all the different aspects of asthma. This is the new classification therapy. Asthmatics are either intermittent, and by definition they have to be mild, and if they are not mild they become persistent asthmatics with varying severity. And we’ll talk about how to treat each of these in a second. The way you categorize these kids into these areas depends on a couple of different things. It depends on how frequently they are having nocturnal symptoms, how often do they have breakthrough symptoms during the week that you have to use additional albuterol. How much is their asthma affecting their activity or their life? What is their normal peak flow when they are well. You don’t need to know the details for the Boards, although it would be useful for you as a general pediatrician.
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Our drugs are now in two groups; rescue agents, which are for your exacerbations, and the long-term control agents, which is the new preferred term. Notice that bronchodilators in general are not long term control agents. Kids aren’t supposed to be on bronchodilators on a daily basis unless they are very very severe.

Let’s talk about cromolyn. Still the first choice. Why? Not because it’s the best drug but because it has no side effects. It tends to block the early and late response, it helps in exercise asthma, it reduces airway hyper-responsiveness, but it’s slow. Generally it take 2-6 weeks before you see an onset and it’s not effective in everybody. And there’s some evidence that it may not be all that effective in the young kids. Unfortunately that’s where we are using it a lot because it comes in a nebulized formulation and we don’t have a nebulized steroid yet. The other thing is, if you use the MDI it’s fairly expensive compared to inhaled steroids. But again, if they ask you, “What drug would be appropriate to start on a four-year-old who is having mild persistent asthma and needs a preventive drug?” this would be your first line drug.
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Tilade or nedocromil; you can think of this – even though it is chemically different – think of it as a super-cromolyn. It has the same lack of any significant side effects and it works a little quicker. So you will actually see an improvement within a few days even. You often see changes in the pulmonary functions to as early as a few weeks. The only side effect is that in about 15-20% of patients they’ll take a puff on this thing and they’ll refuse to ever take it again and say it just tastes horrible. And you’ll take it and take a puff and you don’t taste a thing. “Are you crazy? What’s wrong with you?” There’s this idiosyncratic reaction to taste. But other than that, no real side effects. Again, it’s indicated for mild persistent asthma and can be used for exercise induced asthma. So kind of cromolyn plus is the way to think of it.

Oral steroids; these are the indications. These are pretty straightforward. If it’s a severe exacerbation, moderate to severe, you just go ahead and use them. If they are not responding well to the albuterol, if they are using steroids recently, the fourth one there. You always go home with one more medication than you came in on, if you’ve got asthma. So if you are using albuterol at home and you got sick enough to come see me, I’ve got to do something else to keep you out. History of life-threatening episode; if they’ve had a life-threatening episode, have a very low threshold for restarting those steroids. There’s a lot of art to medicine when it comes to dose and the way you give it, and how you give it, b.i.d., q.d. all that type of stuff. Basically what you need to know is IV, p.o. or IM are all equally effective and no tape is needed if it’s less than 7-10 days in duration. A few infections can potentially get worse with systemic steroids. These are the ones you need to know.
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Theophylline; fallen out of favor for most uses in asthma. It still has a few areas where we will consider using it. Not indicated in the emergency room. It won’t get kids out of the emergency room. It won’t help you prevent them from being admitted. There’s no evidence in kids who are well enough to be on the hospital floor that it has any advantage over optimal beta agonist treatment. And certainly now, with the addition of ipratropium, really there’s not much use on the hospital floor. In the ICU it’s still up for grabs. Nobody has ever really done hard-core studies looking at ICU patients, and yeah, to be honest, if you’ve got a kid going down the tubes it’s still used occasionally. And we’ll talk about the limited role in chronic asthma.
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Magnesium; it’s been in the news on and off. It is a bronchodilator. It has an onset within a few minutes. We think it lasts about two or three hours. One big disadvantage, you’ve got to give it IV. It doesn’t work when it’s nebulized and if you give it too fast it can cause a little hypotension and bradycardia. Exact role, still not known. If you’ve got a kid real sick in the ER a lot of people will give a dose or two, but it actually isn’t clear when it should be used.
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When can you send the patient home? Basically when they are pretty much better. They shouldn’t be hypoxic. They can have some wheezing but they should be better. And their peak flow should be about 70% and sustained, as a good rough guideline. The key thing is you have to be able to follow up on the patient, they’ve got to be able to give the medications, they’ve got to be able to come back if they get sicker.

Okay, risk factors for fatal asthma. These things are pretty self-evident most of the time. Previous life-threatening exacerbation. In adults, if you had almost died from asthma, 10% of those adults die within the following year from their asthma. It’s a big time, important problem if somebody gets intubated with asthma. Hospitalized more than once; usually your first time was kind of a mistake where nobody knew you were sick or it was your first presentation, if you’ve been hospitalized several times. If you are having frequent ER visits or office visits for moderate to severe asthma, then that is also a risk factor. Obviously the sicker you are with your asthma, the higher your degree of treatment, so if you are on oral steroids recently that indicates that your asthma is more severe. Lack of access to medical care, poor appreciation of severity of symptoms – either on the part of the patient or the doctor – psychological problems. In your notes I think it says two-bit agonist containers per month – most people would actually say one. As you will see when we talk about chronic asthma, you are not supposed to be using your albuterol every day to keep yourself under control. If you are, you have an inflammation and you need to be on something else. Poor compliance with therapy, and that’s where teenagers often fit in.
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Overall management for acute asthma; again, this is stuff that you guys know. Let’s run through it quickly. Give oxygen, you can always take if off if they get better. Keep their O2 sats above 95%. You are not going to hurt them. Frequent high dose steroids and systemic steroids are other things that we’ll talk about right now in more detail. Short-acting agonists. They are not going to ask you what the dose is, but they might say, “You have a child presenting with asthma, with wheezing, his peak flow is this … which one of the following might be reasonable treatments?” and certainly albuterol is the drug that we tend to use. High dose frequently, every 15 to 30 minutes for the first two hours if you need it, and the kid is not responding. Side effects are tachycardia and tremor and then the hypokalemia that we talked about. One thing that you do need to know, early steroid administration makes your beta-agonist better. If you have somebody who has been taking a puff off his albuterol, say every two to three hours, for the last 24 hours and you then give him a dose of steroids in the ER, you will up-regulate the number of beta receptors on the smooth muscle wall and he will then respond better to additional albuterol that you give him. So even though steroids will have an antiinflammatory effect six hours later, you can actually see a non-antiinflammatory effect, this up-regulation of receptors, in about an hour.
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Anticholinergics, ipratropium; a lot of stuff recently in Pediatrics and some of the other journals suggesting that if you use this in an acute asthmatic we can actually decrease hospitalization rates in the sickest of kids. It acts as an inhibitor of acetylcholine at the parasympathetic receptors, it takes a little longer to have an onset than albuterol, maybe works a little bit longer. The key thing is it’s not as potent as albuterol. If you have mild asthma it’s better just to give you another dose of albuterol. You get a much better effect. But if you are way down there below 50% and you are already maxing out on the albuterol treatments, this can be additive. So it’s useful in kids with severe exacerbations. It’s not necessary in somebody who is having a mild exacerbation. The other nice thing is that if you get someone who, on a beta agonist, is running heart rates of 200-210 and jumping off the table because they are so jittery, you can back down on the albuterol dose and use the ipratropium to try to provide adequate broncho-dilation.