Asthma in Children

Shannon Hoime, MD Avera Medical Group McGreevy Clinic 7 th Ave.

Pediatrics

Asthma Burden

 Single most common childhood chronic condition  Affects approx 23 million people (7 million children)  Costs over 20 billion dollars annually  12 million missed school days per year  10 million missed work days per year  1.7 million ED visits per year

Why do we have such a hard time with asthma??

References/Resources (for you)

  National Heart, Lung, and Blood Institute    National Asthma Education and Prevention Program Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma, published 2007 440 pages Guidelines Implementation Panel Report    Provides a summary of the recommendations 6 priority messages 52 pages (but nice one-page table)

First, make the diagnosis!

Do not use the term reactive airway disease -RAD doesn’t even have a billable code When we under-diagnose, we under-treat – leads to increased morbidity So, to make the diagnosis: recurrent episodes of airflow obstruction reversible or at least partially reversible -exclude other diagnoses

Choosing the right ICS/route

   K.I.S.S. principle Considering cost, efficacy, ease of use, and if approved for young age… these work across the board (for those who need to start on low-dose): 

Fluticasone

MDI 44 mcg: 2 puffs PO bid   OR

Budesonide

0.25 mg neb bid

TECHNIQUE MATTERS

Teach patient how to use MDI

   Inhaler particles come out at 40mph!

Use a spacer (valved holding chamber is best for younger children) Use MDI’s with dose counters!

Children 0-4 years

    

CAN use a MDI and

spacer – as long as it comes with a mask!

Small mask for those under one year Medium mask for 1-4y 5-6 breaths per puff Wait 30 seconds btwn puffs for best delivery

Children 5-6y and older

     If they can hold mouth around mouthpiece… Use a valved holding chamber Exhale, press down on inhaler, then inhale and hold breath for 10 seconds Wait 30-60 seconds between puffs In a bind (no chamber), can use toilet paper roll, paper or styrofoam cup, etc.

Moving on…follow-ups

  Follow-up in 1-2 mos (sooner if higher severity at dx) Step up or step down therapy depending on CONTROL  Degree to which symptoms are minimized and goals of therapy met (i.e. reduced impairment and risk)

EDUCATION

 Will need to adjust to “needs” of the parent  Establish credibility by gaining control quickly  Then do as much education as you have time for and you think they can absorb  What is asthma? Difference between normal lung and lung with asthma.

EDUCATION

 Demonstrate med delivery device techniques  Explain controller vs quick-relief medications  Provide an asthma action plan ASAP  Have a checklist inside the chart to help you

EDUCATION (f/u visits)

 Check medication compliance/technique  Verify if they know controller vs rescue med  Address obvious environmental triggers (smoke)  Use lung model or picture if possible

EDUCATION (continued)

 Explain chronic nature of asthma and the concept of chronic disease (demands daily attention!)  Boost confidence in home management skills  Review/update asthma action plan

Can we do better?

 Asthma action plans  Lung picture or model  Use MDI’s with dose counters  Use teach-back technique  Dispense spacers in the clinic  Make sure EHR is working for me (patient registries, flu shot reminders, etc)

Contact info

[email protected]

Websites

Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007 http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.ht

m Asthma Action Plans

http://rampasthma.org/AAP/AAPenglish.pdf

http://www.nhlbi.nih.gov/health/public/lung/asthma/asth ma_actplan.htm

EPR-3 asthma educational video, “Asthma in the Primary

Care Practice”

http://jeny.ipro.org/files/Asthma/