Asthma- Stepping up & stepping down treatments; handling exacerbations by Dr. Balaji Chinnaswami

M3 India Newsdesk Oct 17, 2019

Dr. Balaji Chinnaswami offers a guide for diagnosis, medication prescription, and treatment of asthma in children; when and how doctors should step up/down treatment and how to handle frequent exacerbations.


Key practice points

  1. Recurrent afebrile episodes of wheezing in children relieved by bronchodilators, with strong family or personal history of atopy suggest the diagnosis of asthma.
  2. Treatment of asthma is provided in a step by step manner with stepping up and stepping down depending upon the level of control. For best outcomes start ICS containing treatment as early as possible.
  3. Use spacer (with face mask for <3 years) along with MDI to avoid hand mouth incoordination.
  4. Before stepping up treatment assess for adherence of treatment, usage of correct technique and treat comorbidities like allergic rhinitis, GERD etc.
  5. If the intended response is not there and child continues to be symptomatic consider evaluation for other causes.

Case 1-  Diagnosis of Asthma in children

A 6-year-old presents with recurrent episodes of cough for about 1 year. Fever is not often present. Such episodes responded well to nebulisation. As an infant he suffered from atopic dermatitis. Father is a known case of asthma.

Science behind diagnosis of asthma

  • Recurrent afebrile episodes ( ≤3) of wheezing/ coughing relieved by bronchodilators suggest asthma
  • Specific season, activity, night time, triggers like dust, pollen etc exacerbate asthma
  • Personal history of atopy eg. allergic rhinitis, atopic dermatitis etc or family history of atopy/asthma strongly suggest asthma

Investigations to run

Asthma is a clinical diagnosis. Investigations help to rule out other causes and not to prove asthma.

  • CBC - Eosinophilia may be present
  • Chest X-ray - Hyperinflated
  • Spirometry in older children when diagnosis is in doubt

Initial management of asthma

The child diagnosed with asthma is seen for recurrent cough and wheezing for last one year. On further questioning, cough is present once every two months lasting for three to four days.

Science behind management

  1. Reliever is used to treat acute attack of wheezing e.g. Inhaled salbutamol (SABA).
  2. Controller is used daily on a long term basis to control inflammation and prevent future attacks e.g. Inhaled corticosteroids (ICS).
  3. Use Metered dose inhaler (MDI) with spacer to avoid hand breath incoordination. If <3 years also use face mask.
  4. Asthma medications are added or decreased in a step by step fashion depending upon the level of symptoms.
  5. Recent GINA 2019 guidelines suggest that inhaled steroids should be added to all patients either intermittent or continuous depending upon severity.

How will you treat the patient?

*ICS- inhaled corticosteroid, LABA- long-acting B2 agonist, SABA- short-acting B2 agonist

*For school children, inhaled Budesonide, Fluticasone, Beclamethosone doses are low dose- 100 to 200 µg, medium dose- 200 to 400 µg, high dose >400µg

Rx

THe child has less than 2 episodes of wheezing per month. Hence step1 treatment can be started.


Advice to give to parents

  1. Demonstrate the correct technique of using spacer, face mask along with Metered dose inhaler.
  2. Avoid triggers that cause asthma like smoke, dust, strong perfumes, mosquito repellants, pollen etc.

Stepping up treatment in Case 1

The child and his parents come for follow up after 6 months. They say that he is wheezing a lot more often than before. He needs reliever puff more than twice a week.

Science behind management

  1. Asthma is a dynamic condition. Titration of medication is based on the assessment of control.
  2. In the past four weeks any child with no daytime symptoms (<2/wk) or no reliever requirement (<2/ wk), no nocturnal symptoms, no limitation of activities is considered controlled.
  3. Children not fulfilling the above criteria are partly controlled / uncontrolled and treatment needs to be increased to the next step.
  4. Before stepping up check technique of drug administration and adherence. Rule out comorbidities like allergic rhinitis, GERD etc.

Rx

Since the child needs reliever more than twice a week, his symptoms are not controlled and hence treatment needs to be increased from Step 1 to Step 2.


Advice to give to parents

  1. Educating parents about need for taking inhaled steroids regularly for a long time.
  2. Teaching correct technique of using inhaler and spacer.
  3. Regular follow up to assess response.
  4. Avoid triggers that cause asthma like smoke, dust, strong perfumes, mosquito repellants, pollen etc.

Case 2- Children with frequent exacerbations

An eight year old child has been hospitalised for wheezing four times in the last six months and has had almost weekly midnight visits to ER. She is not on any controller medication. How will you treat her?

Science behind management

  1. Waking up atleast weekly once in the night will qualify for starting with step 3 treatment.
  2. In children more than five years, Long Acting Beta 2 agonists (LABA) e.g. Formeterol, Salmeterol can be added before increasing the dose of steroids. LABA has synergistic effects with steroids and reduces the dose of inhaled steroids.
  3. In children <5 years LABA is not recommended and hence Medium dose ICS is recommended.

Rx


Advice to give to parents

  1. Demonstrate the correct technique of using spacer, face mask along with Metered dose inhaler.
  2. Avoid triggers that cause asthma like smoke, dust, strong perfumes, mosquito repellants, pollen etc.

Stepping down treatment

The child was reviewed after three months. She is better. No day time symptoms, nocturnal symptoms or need for reliever medication. Now there is no limitation in activities.

Science behind management

  1. Children with asthma should be reviewed every three months. If good control, 25%-50% reduction in ICS dose should be done till low dose ICS is reached.
  2. When low dose ICS reached and if on LABA combination then stop LABA.
  3. If there is good control on low dose ICS for 1 year then daily low dose ICS can be stopped. Thereafter use intermittent low dose ICS & SABA only when needed.

Rx


Advice to give to parents

  1. Education to parents, emphasis on adherence and technique, trigger avoidance same as above cases.
  2. Review after three months and assess control.

 

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. Balaji Chinnaswami is a professor of Paediatrics at a reputed medical college in Chennai.

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