Treatment of Pediatric Asthma

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Author: V. Dimov, M.D.

National Heart, Lung, and Blood Institute (NHLBI) guidelines for diagnosis and management of asthma (2007) are only available online. Key concepts:

- severity dictates therapy
- distinction between intermittent and persistent asthma - "rule of 2s”
- 4 levels of asthma severity - intermittent; 3 sublevels of persistent
- inhaled corticosteroids (ICS) preferred for all levels of persistent asthma
- use of asthma action plans
- spirometry recommended

Rule of 2s - if symptoms are present for more than 2 days per week or for more than 2 nights per month, asthma categorized as persistent. Within this category, disease must be classified as mild, moderate, or severe. However, as severity of asthma not constant, must monitor patients for changes; as severity changes, therapy should change too.

The category of “mild intermittent” asthma was eliminated in the 2007 guidelines - now it is just called “intermittent” asthma.

The concepts of “impairment”, “risk”, and “control” were introduced in the 2007 guidelines:

- impairment - refers to symptoms
- risk - refers to likelihood that the patient will eventually have exacerbation of asthma and present to emergency department (ED) or hospital, or need course of oral corticosteroids
- control - refers to the level of patient’s asthma control

ICS therapy probably does not make difference in prevention of airway remodeling.

Classification of asthma severity:

- impairment domain - daytime and nighttime symptoms (rule of 2's), use of short-acting beta-agonist (SABA), interference with normal activities

- risk domain - number of exacerbations per year (if more than 2, daily controller medication is needed). Increased risk is conferred by parental history of asthma or history of eczema.

Childhood Asthma Control Test (ACT) is validated down to age 4 yr. Adult ACT questionnaire should be used for teenagers (cutoff age is 11 years).

Treatment steps:

- step 1 - SABA as needed
- step 2 - low-dose ICS monotherapy vs. leukotriene receptor antagonist (LTRA)
- step 3 - low-to-medium dose ICS plus long-acting beta-agonist (LABA)
- step 4 - high-dose ICS therapy plus LABA and (if needed) systemic corticosteroids. Omalizumab (Xolair; anti-IgE antibody) is prescribed before placing patient on daily oral corticosteroids.

Which ICS to choose?

- delivery system best for patient’s developmental stage
- optimal lung deposition

Particle size may play a role in lung deposition of ICS - ciclesonide (Alvesco) has smaller particle size that results in good lung deposition.

References

New NHLBI guidelines for asthma: is anything really new? Michael J. Welch, MD. Audio-Digest Pediatrics, Volume 56, Issue 01, January 7, 2010.

Published: 06/01/2010

Updated: 06/01/2010