PHILADELPHIA - A proactive approach, with education as a key component, is necessary for effectively managing asthma in children. In fact, physicians should have two asthma management plans for each patient: a daily management plan and an action plan for handling acute exacerbations.
"The daily management plan is basically the regular medications and measures to keep a patient's asthma under control. The action plan is used for an acute exacerbation: what to take, when to contact the physician and/or when to go to the emergency room," said John W. Georgitis, MD, at the recent meeting of the American College of Allergy, Asthma and Immunology held here.
"Ideally, asthma control for children is no coughing; no difficulty breathing; no wheezing or chest tightness; no nocturnal episodes; and normal activity in terms of play, sports, exercise, school and day care. In addition, you don't want to have acute episodes that require an emergency visit to a doctor, a visit to the emergency room or, ultimately, a hospital stay," said Georgitis, who is a professor of pediatrics at Wake Forest University School of Medicine in Winston-Salem, N.C.
To achieve asthma control, a variety of medications are available. Quick-relief medications include short-acting bronchodilators like albuterol, ipratropium and oral steroids. "Long-term or controller medications, which are given to patients with persistent asthma to prevent exacerbation, include cromolyn, nedocromil and inhaled steroids. Also in that category are leukotriene modifiers - the new players on the market - as well as long-acting bronchodilators and oral steroids," he added.
Management for the child with severe, persistent asthma includes high-dose inhaled corticosteroids with a spacer or a face mask. Systemic corticosteroids can be added if needed. For the patient with moderate, persistent asthma, a medium-dose inhaled corticosteroid is used. "In this category, once controlled, you can use the medium-dose inhaled corticosteroid and nedocromil, or a medium-dose inhaled corticosteroid and a long-acting bronchodilator," Georgitis said.
"For patients with mild, persistent asthma, cromolyn or nedocromil may be your first choice, but recognize that they need to be given three to four times a day. A low-dose of an inhaled corticosteroid or a face mask can also be used. This is where the leukotriene modifiers currently fit in," he said.
The patient with mild, intermittent asthma does not need daily medication. A quick-relief medication can be used for asthma episodes.
According to Georgitis, there is an advantage to using spacers or holding chambers in children. "By using these, children younger than 5 are able to use inhalers that were previously used only by older children. Spacers also decrease the oropharyngeal deposition classically associated with corticosteroids. Therefore, in turn, you also decrease the possible side effects," he explained.
While inhaled corticosteroids are often used to control asthma, there is concern that they have an effect on linear growth or growth velocity. Recent studies have had varied results.
"Because children with mild to moderate asthma or persistent asthma are managed with a medium-dose corticosteroid, a possible growth delay or linear growth effect is possible. In addition, in children with severe, persistent asthma, there is a clear-cut adverse growth effect when extremely high doses of inhaled steroids are used. However, this effect is probably the same, maybe a little bit more, as with chronic use of an oral corticosteroid. So, you must take that into account," Georgitis said.
Poorly controlled asthma, by itself, can also delay growth. "Children with asthma tend to have a longer period of reduced growth rate, and they tend to be a bit delayed in terms of their puberty development. Unfortunately, this occurs more in boys than in girls," he said.
Successful asthma management, according to Georgitis, begins with a proactive approach that includes educating the family. It may take several visits to educate the family and the patients about the diagnosis and the steps for clinical care.
He also noted the importance of talking to family members and patients on an eighth-grade level. "Additionally, you want to teach them how to tailor their approach in terms of their asthma management needs. You do have to take into account the patient's cultural beliefs and practices. Nowadays, unfortunately, you need to also take into account your health care team in terms of what they allow and what they don't allow. It is also important that your staff members give a consistent message to all of your patients and families," he said.
Barriers to successful asthma management include poverty, single-parent families, multiple caregivers, financial incentives that promote acute episodic care rather than continuity of care, limited or no health insurance, multiple parental responsibilities, lack of school health professionals in the schools and lack of community resources. "We can be proactive in overcoming these barriers through involvement," he said.
For more information:
- NIH, NHLBI. Guidelines for the diagnosis and management of asthma Bethesda, Md. July 1997. NIH publication.
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