Children are referred to me on a weekly basis because of poorly controlled asthma despite appropriate medications. In about 10% to 15% of these patients, the diagnosis is wrong or incomplete. Usually, however, the reasons for poor control are more subtle and are related to a combination of minor details that doom the regimen to failure.
Many management details may be debated among asthma specialists, and we all have our own biases. We must continually dedicate ourselves to practicing evidence-based medicine. However, clinical research on the management of childhood asthma is limited, and each child is different. We often have to extrapolate from adult studies, which frequently are short-term (less than 6 months) and are designed to acquire FDA approval for certain medications. How does that help pediatricians and family physicians concerned about long-term use of medication?
Asthma is sometimes difficult to control, and the current drugs are not perfect. Adherence to therapy is a major factor, and nonadherence is not always simply the result of inadequate patient education. Who can blame parents for being suspicious about long-term side effects of medications?
While it is imperative to integrate new evidence into our practice, it is equally important never to become too dogmatic. My approach constantly changes, and this may be true for all physicians who listen to their patients and work hard to help them.
In this article, I will offer practical suggestions to help manage asthma in children.ASTHMA GUIDELINES
Any review of asthma management should begin with the excellent guidelines from the National Asthma Education and Prevention Program (NAEPP)1 and the Global Initiative for Asthma (GINA). I do not believe physicians must follow these guidelines exactly, but they should know when and why to adapt them.
I recommend that all physicians review the NAEPP guidelines for the diagnosis and management of asthma, which were first published in 1992 and were revised in 1997. In June 2002, an update focused on the management of asthma in children. These documents can be accessed on the National Heart, Lung, and Blood Institute Web site1: http://www.nhlbi. nih. gov/guidelines/ asthma/ index.htm.
Pocket guides and quick-reference sheets designed for physicians, nurses, patients, and parents are available on the GINA Web site2: http://www.ginasthma.com.OUTPATIENT MANAGEMENT
The office visit for children with asthma involves a number of important steps:
Review the goals of management at every visit.
Insist on routine periodic visits just for asthma.
Decide whether preventive or intermittent therapy is indicated.
Use either a peak expiratory flow (PEF) meter or spirometry to help quantify the severity of the child's asthma.
Give each patient a written asthma action plan at every visit.Goals
During each office visit, it is key to ask children with asthma (and their parents) whether they believe that therapy is meeting their needs. Tell them that they should not settle for inadequate control and that the regimen will be changed if it is not working.
Suggested management goals are listed in Table 1.Routine visits
The most important recommendation is that all children with asthma should have periodic office visits specifically for asthma (Table 2). The details of the preceding interval can be reviewed, and parents, patients, and physicians can agree on a clear action plan for the next interval (usually 3 to 6 months) (Table 3).
Unfortunately, many children with asthma see their physicians only when they are sick or during yearly health maintenance visits. There usually is inadequate time during these visits to manage asthma properly .Preventive versus intermittent therapy
Some parents might prefer to give medications only when needed, but this approach is not always appropriate. Many children thought to have mild intermittent asthma do not really have mild intermittent asthma.
Parents should focus on their child's asthma control during the past 6 months--whether the asthma has interfered with activities of daily living or the child has missed school, has had emergency department (ED) visits or hospital admissions, has coughed all night, or has been feeling less than well. In these cases, I believe the potential risks of taking daily medications are outweighed by the benefits.
The NAEPP guidelines suggest that each child should be classified into 1 of 4 categories, based on clinical condition before treatment or before asthma has been adequately controlled (Table 4).Assessing lung function
Periodic quantification of lung function by PEF meter or office spirometry can help determine the appropriate treatment strategy. Most physicians are familiar with the PEF meter, but many have not yet added the spirometer to their armamentarium. I encourage every primary care provider to obtain an inexpensive office spirometer, which gives much more information than just the PEF.3,4
How can a spirometer help? One of the goals of asthma management is for patients to have normal or near-normal lung function when they are well and not taking medications. Spirometry is more sensitive and less effort-dependent than PEF measurement.
If spirometry shows significant obstruction when the patient is not taking medications, he or she may have subtle symptoms consistent with chronic bronchospasm. Often, patients appear well in the office and deny any complaints until they (or their parents) are told of their spirometric results. Then, they may describe having had low-level morning cough, difficulty in exercising, or more frequent use of their rescue inhaler.
When parents recognize and correlate these symptoms with pulmonary function, they are much more likely to insist that the child take daily medications. If the symptoms are consistent with mild intermittent asthma and the child has normal lung function when well and not taking medications, parents and physicians are more likely to agree that intermittent therapy seems most appropriate.
Obtaining reliable spirometric results is challenging, particularly for children younger than 6 years. With practice, some can perform reproducible maximal forced expiratory maneuvers as young as age 3 or 4 years. If the procedure is rushed or the expiratory maneuver is inadequate (such as inhalation not deep enough, expiration not as hard as possible, lungs not emptied completely, or best effort not made), the results can be misleading. Knowing how to distinguish between accurate and inaccurate results is a vital skill for any physician managing asthma in children.
Case scenario: Anna was a 10-year-old whose asthma appeared to be triggered only by viral infec- tions. She was not taking any routine medications, and she denied any symptoms within the past 6 months.
Physical examination findings were normal. However, spirometry revealed significant obstruction. After checking the patient's flow-volume curves, I suspected that the nurse might not have coached her to blow as hard as she could. I repeated the procedures and found no significant airway obstruction. The 2 sets of results shown in Table 5 demonstrate that these tests are effort-dependent, and the results can be very misleading if not interpreted properly.Asthma action plan
Giving the patient a written asthma action plan at the end of every visit is important. Asthma is often poorly controlled because of confusion or miscommunication. If few exacerbations occur, parents may forget what to do. Mark the date on the action plan so that parents can follow the current plan rather than an obsolete one.PERSISTENT ASTHMA
The 2002 NAEPP update1 lists the following regarding the treatment of persistent asthma:
Low daily doses of inhaled corticosteroids remain the first and most effective choice (Table 6).
While long-term inhaled corticosteroid therapy can temporarily decrease growth velocity, evidence suggests that final adult height is not affected.5
Low to medium doses of long-term inhaled corticosteroids have no effect on bone mineral density in children nor do they increase the risk of cataracts or glaucoma.6
The doses of inhaled corticosteroids can often be lowered significantly between exacerbations. Asthma can be controlled in some children with the use of once-daily doses (except during viral exacerbations), which markedly improves adherence. If low doses are inadequate, I suggest adding a second medication rather than using higher doses of inhaled corticosteroids.7 Basically, there are 2 choices: a leukotriene modifier or a long-acting ß2-agonist.
The addition of a leukotriene modifier is appealing for children who have chronic allergic rhinitis, because this medication can also help the upper respiratory tract.8,9 Literature on the use of long-acting ß2-agonists in children has been developing slowly, but these agents are very effective in adults.10 I believe that long-acting ß2-agonists are safe and effective when they are combined with inhaled corticosteroids.11 I do not recommend giving children daily long- or short-acting ß2-agonists alone. To minimize the corticosteroid dose, more children are now given all 3 medications: inhaled corticosteroids, inhaled long-acting ß2-agonists, and leukotriene modifiers.
Given parents' and physicians' concerns about corticosteroids, it is not surprising that the leukotriene modifiers, such as montelukast(Drug information on montelukast), have rapidly become popular therapy for mild persistent asthma, although generally, low daily doses of inhaled corticosteroids are more effective monotherapy.12
I am reluctant to give very young children (younger than 3 or 4 years) any long-term asthma medication unless there is no other choice. For instance, data from young animals suggest that corticosteroids can have a deleterious effect on lung growth.13,14 I am not aware of data that suggest this is a problem with commonly prescribed doses of inhaled corticosteroids, but I believe our approach should be conservative in young children, especially those who were born prematurely.