Pediatric Reactive Airway Disease Follow-up

  • Author: Eric S Chin, MD; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Dec 1, 2011
 

Further Inpatient Care

Consider admission if the initial peak expiratory flow rate (PEFR) is less than 20-25% of predicted and posttreatment is less than 70% of predicted or if no improvement occurs after 4 hours.

If a child fails to improve within the first 2-3 hours of ED management, admission to an ED observation area, inpatient unit, or pediatric critical care unit is warranted.

If the patient is able to ambulate and tolerate fluids in the ED without distress, discharge may be considered.

Arrange for follow-up with the primary care provider within 24 hours.

The Children’s Asthma Care (CAC) measure set assesses whether pediatric patients admitted to hospitals with asthma exacerbation receive relievers (CAC-1) and systemic corticosteroids (CAC-2) during admission and whether they are discharged with a complete home management plan of care (CAC-3). A cross-sectional study using data for 30 US children’s hospitals found that CAC-1 and CAC-2 hospital compliance was high and that CAC-3 hospital compliance was moderate.[14] There was no significant association between CAC-3 hospital compliance and subsequent ED visits and asthma-related readmissions, suggesting that the CAC-3 measure needs further refinement to ensure evidence-based home management plans are being developed and conveyed to families in an effective manner.

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Further Outpatient Care

Monitoring

Follow-up of pediatric asthma patients may be conducted by phone or in person; may include physical examination and/or spirometry; and may be performed by a case manager, registered nurse, nurse practitioner, or physician. Follow-up is recommended:

  • Within 1 week of an asthma exacerbation
  • Within 4 weeks after initiation of therapy or any significant change in therapy, and every 2-4 weeks thereafter until control is obtained
  • Every 4-6 months to assess control for patients with persistent asthma

Assessment of severity and treatment plan

Assess the severity of the symptoms and effectiveness of treatment.[1]

  • Impairment:
    • Symptoms:
      • Mild - 2 days or more per week but not daily
      • Moderate - Daily
      • Severe - Throughout the day
  • Nighttime awakenings
    • Mild - 3-4 times per month
    • Moderate - More than 1 time per week but not nightly
    • Severe - Nightly (7 times a week)

Maintenance treatment (a recommended approach)

  • Mild - Low-dose inhaled corticosteroids
  • Moderate - Medium-dose inhaled corticosteroids and long-acting beta2-agonist
  • Severe - High-dose inhaled corticosteroids, long-acting beta2-agonist, and leukotriene modifier
  • Children aged 4-11 years with asthma who were treated with a fixed-dose combination of fluticasone and salmeterol had fewer serious asthma exacerbations and lower treatment costs than those who were given an inhaled corticosteroid and montelukast. In one study, risk was reduced by 96% of having an asthma-related inpatient hospital visit and a 56% lower risk of having an ED visit.[15, 16]
  • Best Add on Therapy Giving Effective Responses (BADGER), in phase III of clinical trials, compared how effectively the 3 different step-up treatments improved asthma control in 182 children aged 6-18 years. All participants had mild-to-moderate persistent asthma that was not controlled on low-dose inhaled corticosteroids. At the current stage of this ongoing study, adding a long-acting beta-agonist to inhaled corticosteroids was significantly more likely (1.5 times) to be the best step-up therapy compared to adding a leukotriene receptor antagonist to inhaled corticosteroids or to doubling inhaled corticosteroids.[17]
  • For patients 12 years and older with moderate-to-severe asthma, a combination of high-dose inhaler, long-acting beta2-agonist, and omalizumab, has shown significant reduction in the need for oral corticosteroids and has also improved lung function (FEV1).[18, 19]
  • Though not FDA approved for children aged 6 to younger than 12 years, reports of adding omalizumab to therapy in patients with moderate-to-severe asthma has shown promising results.[20]
  • Evaluating the Clinical Effectiveness and Long-Term Safety in Patients with Moderate to Severe Asthma (EXCELS) study is an ongoing observational study for patients 12 years and older using omalizumab (completion date, 2012.) In early observation, there may be an increase in ischemic heart disease; arrhythmias; cardiomyopathy and cardiac failure; pulmonary hypertension; cerebrovascular disorders; and embolic, thrombotic, and thrombophlebitic events with use of omalizumab and should be used with caution. Risk and benefits should be considered before starting omalizumab.[21]
  • Monitoring PEFR is an easily performed test that can be mastered for those as young as 3-4 years. PEFR monitoring is an important tool in asthma management that uses a zone system to optimize effectiveness of asthma control. Zone determination should also be based on symptom recognition.
    • Green zone (80-100% predicted or child's best) - Good control; no cough, wheeze, chest tightness, or shortness of breath
    • Yellow zone (50-80%) - Necessitates increased awareness and treatment; slight cough, wheeze, chest tightness, shortness of breath, mild chest congestion from cold or allergies; cannot perform all normal activities; waking up at night with cough
    • Red zone (< 50%) - Poor control, requires immediate intervention; persistent cough or wheeze, very short of breath; cannot do usual activities; waking up more than once a night with cough or wheeze, fast breathing, symptoms not getting better after 2 days in yellow zone
  • Spacer devices should be used in all children with asthma. They improve the deposition of drug into the lower airway, hence improving efficacy of medication.
  • Long-acting bronchodilators do not replace the need for routine preventers. Their slow onset means the short-acting dilators may still be required. However, long-acting bronchodilators combined with inhaled corticosteroids may provide better asthma control and compliance, hence decreasing the number of acute attacks.
  • SMART: Symbicort Maintenance and Relief Therapy, approved for use with a Turbuhaler device, can be used for maintenance and acute symptoms. With SMART, the need for rescue oral corticosteroids appears to be decreased. The combination budesonide/formoterol comes in a pressurized MDI in the United States but has not been approved for SMART (Turbuhaler device is not available in the United States).[22]
  • Little evidence is available to support or refute the use of alternative medicine such as acupuncture, osteopathic, chiropractic, physiotherapy, or respiratory therapeutic maneuvers.
  • There is no evidence that air ionizers improve asthma symptoms.[23]
  • A daily low-dose regimen of budesonide has not been shown to be superior to other treatments.[24]
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Inpatient & Outpatient Medications

The child should be started on an inhaler corticosteroid for mild cases and addition of an oral steroid, prednisone or prednisolone (Prelone) (1-2 mg/kg/d) for 3-7 days, or dexamethasone for one additional day, for more severe cases.

Leukotriene receptor antagonists are an option for the preventive treatment of recurrent asthma exacerbations secondary to viral respiratory tract infections in children aged 5 years or younger who do not have evidence of persistent asthma.

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Deterrence/Prevention

  • Parents of asthmatic children should have at least 2 sets of inhalers (eg, one for school and one for home).
  • After an asthma exacerbation, the child may return to school when asymptomatic and the PEFR is within 20% of normal.
  • Reduction in allergen exposure results in reduction of asthma and rhinitis symptoms and medications needed.
  • Avoid outdoor exposure and/or physical activity during periods of high smog alerts in community.
  • Change home furnace filters, remove dust, change linen, and vacuum regularly to reduce potential triggers.
  • In humid climates, keep humidity below 50% by using a dehumidifier to keep mold from growing.
  • Fluctuations in humidity and temperature can cause exacerbation of asthma attacks up to 2 days later.[25]
  • Avoid second-hand tobacco smoke, a well-known trigger of asthma attacks in infants and children.
  • Pediatric Asthma Controller Trial (PACT)[26] compared the effectiveness of 3 regimens in achieving asthma control:
    • Fluticasone 100 mg twice daily (fluticasone monotherapy), fluticasone 100 mg/salmeterol 50 mg in the morning and salmeterol 50 mg in the evening (PACT combination), and montelukast 5 mg in the evening
    • The conclusions of the study were in favor of fluticasone monotherapy in treating children (>6 y) with mild-to-moderate persistent asthma.
  • Volunteers in the community can help as educators by providing home visits or in-school visits. Internet and MP3 players may help to engage adolescents in acquiring asthma knowledge.[27]
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Complications

  • Respiratory failure/mechanical ventilation
  • Atelectasis
  • Flaccid paralysis (self-limited)
  • Death
  • Pneumothorax
  • Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
  • Altered theophylline metabolism
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Prognosis

The prognosis is excellent with attention to general health and appropriate use of medications.

Fewer than 50% of patients "out grow" asthma.

Predictors of mortality risk

  • More than 3 ED visits per year
  • More than 2 hospitalizations per year
  • Hospitalization or ED visit in the last month
  • History of ICU admission
  • Mechanical ventilation
  • Use of 2 or more albuterol canisters in a month
  • Current use or recent discontinuation of systemic steroids
  • History of an acute onset of severe asthma exacerbation
  • Nocturnal symptoms
  • History of syncope
  • Comorbid cardiac disease
  • Illicit drug use
  • Serious psychosocial or psychiatric problems
  • Low socioeconomic situation
  • Limited access to health care
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Patient Education

Educate children and their families about asthma.

  • Avoidance of potential triggers
  • Emphasis on the use of anti-inflammatory inhalation
  • Instruct on peak expiratory flow and symptom monitoring

For excellent patient education resources, see eMedicine's Asthma Center. Also, visit eMedicine's patient education article, Asthma.

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Contributor Information and Disclosures
Author

Eric S Chin, MD  Consulting Staff, Department of Emergency Medicine, Kaiser Permanente Hospital, South San Francisco

Disclosure: Nothing to disclose.

Specialty Editor Board

Debra Slapper, MD  Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital

Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Grace M Young, MD  Associate Professor, Department of Pediatrics, University of Maryland Medical Center

Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD  Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston

Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research

Disclosure: Nothing to disclose.

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Patient peak flow record.
This nomogram results from tests carried out by S. Godfrey, MD, and his colleagues on a sample of 382 healthy boys and girls aged 5-18 years. Each child blew 5 times into a standard Wright Peak Flow Meter, and the highest reading was accepted in each case. All measurements were completed within a 6-week period. The outer lines of the graph indicated that the results of 95% of the children fell within these boundaries.
Stepwise approach for managing asthma in children 0 to 4 years of age. National Institutes of Health. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the diagnosis and management of asthma. August 2007. NIH publication no. 07-4051. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/index.htm. 3 Accessed December 30, 2007. PRN, As necessary.
Table 1. Peak Flow Rates in Liters per Minute[12]
Height in



Inches



Average



Rate



Range*Height in



Inches



Average



Rate



Range*
40150110-19056330240-420
41160115-20557340240-420
42170120-22058360260-460
43180130-22059375270-480
44190135-24560390280-500
45200145-25561400290-510
46210150-27062415300-530
47220160-28063430310-550
48230165-29564445320-570
49240175-30565460330-590
50250180-32066480345-615
51260190-33067500360-640
52270195-34568515370-660
53280200-36069530380-680
54300215-38570550395-705
55315225-40571570410-730
*Includes 95% of white males aged 7-20 years.



Derived and adapted from J Pediatr 1979;95:192-6.



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