Pediatric Reactive Airway Disease Follow-up

Updated: Feb 23, 2016
  • Author: Eric S Chin, MD; Chief Editor: Kirsten A Bechtel, MD  more...
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Follow-up

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)

See the list below:

  • 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. [24, 25]
  • 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. [26]
  • 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). [27, 28]
  • 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. [29]
  • 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. [30]
  • 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). [31]
  • 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. [32]
  • A daily low-dose regimen of budesonide has not been shown to be superior to other treatments. [33]
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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. [34] 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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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. [35]

Avoid second-hand tobacco smoke, a well-known trigger of asthma attacks in infants and children.

Pediatric Asthma Controller Trial (PACT) [36] 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. [37]

Annual influenza vaccination is recommended to prevent the complications from infection. The CDC's Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) recommend annual influenza vaccination for all persons aged at least 6 months.

In addition to the pneumococcal conjugate vaccine (PCV13) that is administered per schedule for healthy children, asthmatics should receive the 23-valent pneumonococcal polysaccharide vaccine (PPSV23) at least 8 weeks after they have completed immunization with PCV13. [38]

The trivalent inactive influenza vaccination administered intramuscularly is preferred over the live-attenuated vaccination administered intranasally. [39, 40]

Bronchial thermoplasty is a novel procedure approved by the FDA in 2010 for severe asthmatics (aged at least 18 years) who are not well controlled with medications. Ablation or radiofrequency is used to destroy the overgrowth of smooth muscle in the airway. The concept behind the treatment is that with less muscle, there is a decrease of the ability of the airways to constrict and narrow during a bronchospasm. The procedure is not without risk and does not cure asthma, but rather decreases the severity of asthmatic episodes. [41]

A new drug being tested is mepolizumab—a monoclonal antibody against interleukin 5—and is thought to inhibit eosinophilic airway inflammation. A multicenter, double-blind, placebo-controlled trial found mepolizumab to be effective and well-tolerated treatment that reduces the risk of asthma exacerbations in patients with eosinophilic asthma. [42]

FDA has approved tiotropium bromide Inhalation Spray for use in the treatment of asthma. It is approved by the FDA for the long-term, once-daily, maintenance treatment of asthma in patients 12 years of age and older. When used as an add-on treatment to inhaled corticosteroid maintenance therapy, a study has shown a significant reduction in severe asthma exacerbations.  [43]

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Complications

See the list below:

  • 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 "outgrow" 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, visit eMedicineHealth's Asthma Center. Also, see eMedicineHealth's patient education article Asthma.

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