Asthma

Objectives

OUTPATIENT ASTHMA DIAGNOSIS AND MANAGEMENT
Sande Okelo MD, PhD

Epidemiology

Approximately 6 million children in the United States have an asthma diagnosis, making it one of the most common diseases of childhood (National Asthma Education and Prevention Program: Expert Panel Report 3 2007) . Incidence and prevalence are increasing, most likely due to: 1) better recognition and diagnosis; 2) changing environmental factors such as increased allergens, and 3) changing lifestyle factors including increased stress (Guill, MF 2004) .

Asthma can be diagnosed at any age, but the majority (80%) of children have symptoms within the first six years of life. During early and late childhood, approximately 60% of children with asthma are males, but by adulthood, asthma is more prevalent in females. Two-thirds to three-fourths of pre-school aged children who are "early wheezers" will not continue to wheeze beyond 5 years of age (Martinez, FD 1995) . However, risk of persistent asthma between six and 13 years significantly increases if the child has a history of eczema by 2-3 years of age, parental history of asthma OR two of the following including a) physician diagnosed allergic rhinitis by 2-3 years of age, b) <4% peripheral eosinophils, or c) wheezing not associated with URIs (Martinez, FD 1995) . Studies evaluating the effect of pets in the home on the likelihood of persistence of early wheezing continue to be inconclusive. (Chen, CM 2010)

Although asthma is more prevalent in African American and some Latino (e.g., U.S. Puerto Rican) ethnic populations, these children are three to four times more likely to be hospitalized for asthma and to die from asthma than Caucasian children-numbers that are out of proportion with the population differences in asthma prevalence. The reason for this disparity is not clear; there may be many contributing factors such as lack of access to health care; episodic care as opposed to consistent, preventive management; physician under-diagnosis and/or under-treatment of asthma (e.g., lack of use of daily anti-inflammatory therapy (Naqvi et al. 551-57)); and environmental factors (Guill, MF 2004) .

Recap

• Asthma is the most common chronic childhood illness, most often beginning before the age of 6 years, and affecting more than 1 in 10 children in the U.S.
• Asthma in the pre-school age group tends to persist among those who are atopic or whose parents have a history of atopy.
• Ethnic disparities exist in quality of asthma care, asthma hospitalizations, and asthma mortality.

Pathophysiology

In the past, bronchospasm was thought to be a major contributor to asthma pathophysiology, but now airway inflammation is believed to be the primary underlying mechanism. In 2007, the National Heart, Lung and Blood Institute's National Asthma Education and Prevention Program (NAEPP) published their "Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma" which details current understanding of the pathophysiology and natural history of asthma (National Asthma Education and Prevention Program: Expert Panel Report 3 2007) .

Asthma is a chronic inflammatory disorder of the lower airways in which inflammatory cells (mast cells, eosinophils, neutrophils), chemical mediators (histamine, leukotrienes, platelet-activating factor) and chemotactic factors (cytokines) all play a role (Lasley, VM 2003) . Airway inflammation causes airway hyper-responsiveness (bronchoconstriction/bronchospasm) and lower airway obstruction, as well as edema, mucus production and recruitment of inflammatory cells into the airway.

Viral respiratory infections are the most common cause of asthma exacerbations (accounting for upwards of 80% of all asthma exacerbations). For children not diagnosed with asthma, viral respiratory infections potentially increase future risk of developing this disease (National Asthma Education and Prevention Program: Expert Panel Report 3 2007) . Allergen exposure also commonly precipitates asthma exacerbations, with the subsequent bronchospasm occurring in two phases. In the early phase, occurring approximately 15 minutes after exposure, mast cells degranulate, increasing histamine and leukotrienes and leading to bronchoconstriction. Released cytokines and chemokines also stimulate migration of inflammatory cells, such as eosinophils, neutrophils and lymphocytes, to the airways, thereby increasing edema and mucus production and causing a second phase (4-12 hours after the exposure) of bronchospasm. Chronic inflammation can lead to airway remodeling due to basement membrane thickening, epithelial cell injury, angiogenesis, and smooth muscle hypertrophy and hyperplasia; this remodeling results in irreversible structural changes and progressive loss of pulmonary function (National Asthma Education and Prevention Program: Expert Panel Report 3 2007) (Nelson, HS 2006) (Guill, MF 2004) .

Although anti-inflammatory medicines such as inhaled corticosteroids (ICS) control asthma exacerbations, they may not preclude further progression of disease severity, i.e., remodeling associated with decline in lung function (National Asthma Education and Prevention Program: Expert Panel Report 3 2007) . There is also evidence that the trajectory of decline in lung function varies widely between individuals, and that any one individual's trajectory of lung function may be determined very early in life (Sears, MR 2003) (Sears, MR 2007) (Guilbert, T 2003) . While stressing the important role of inflammation in asthma pathogenesis, the 2007 NAEPP guidelines also note that individual patients demonstrate variability in their patterns of inflammation; such variability is likely related to genetics and has implications for the effectiveness of therapies (National Asthma Education and Prevention Program: Expert Panel Report 3 2007) .

Recap:

• Asthma is a disease of lower airway inflammation that results in airway hyper-responsiveness and reversible lower airway obstruction-causing immediate and delayed symptoms. Patients with asthma may be at risk for the development of airway remodeling and irreversible lower airway obstruction-with resultant premature and/or accelerated lung function decline.

Diagnosis, Assessment and Monitoring

Patient Self-Assessment

The Expert Panel Report (EPR-3) recommends that clinicians incorporate use of patient self-assessment tools to determine from the perspective of the patient and/or the patient's family whether the asthma is well controlled and the impact of the asthma on patient quality of life. The two general self-assessment methods are (1) a daily diary and/or (2) a periodic self-assessment form to be filled out by the patient and/or family member, usually at the time of the follow-up visit to the clinician. Patients are less likely to see completion of diaries and forms as a burden if they receive feedback from the clinician that allows them to see value in self-monitoring. The daily diary should include the key factors to be monitored at home: symptoms and/or peak flow, medication use, and restricted activity (See "Component 2: Education for a Partnership in Asthma Care."). The self-assessment questionnaires that can be completed at office visits are intended to capture the patient's and family's impression of asthma control, self-management skills, and overall satisfaction with care. Use of these types of questionnaires helps to standardize, expedite and improve the quality of information retrieved by the physician and thereby facilitate better decision-making about the patient's care (Halterman, J 2006) . A number of asthma self-assessment questionnaires have been developed to assess patient asthma, although relatively few are for use in children:

• Pediatric Asthma Quality of Life Questionnaire (Juniper, EF 1996)
• Pediatric Asthma Caregiver Quality of Life Questionnaire (Juniper, EF 1996)
• Pediatric Asthma Therapy Assessment Questionnaire (Diette, GB 2007)
• Asthma Control Test (Nathan, RA 2004) /
• Childhood Asthma Control Test (Schatz, M 2006)
• ACCI- Asthma Control and Communication Instrument (Patino, CM 2008) Journal of Allergy and Clinical Immunology - Volume 122, Issue 5 (November 2008)

A sample of the pediatric asthma control and communication instrument (PACCI) is included below as an example of a patient self-assessment questionnaire. The PACCI was developed for use with children 0 - 19 years of age with asthma (including reactive airway disease or recurrent wheezing that could be explained by asthma).

The PACCI assesses multiple dimensions of asthma health that physicians have reported as important in determining how to treat patients with asthma (Diette, GB 2007) (Okelo, SO 4-1-2009) interval changes in the child's asthma since the last prior visit with the doctor (direction), the impact of the asthma on the parental quality of life (bother), recent asthma exacerbations (risk), adherence to daily controller/anti-inflammatory asthma medications (adherence) and control (frequency of daytime symptoms, rescue medication use, attacks, activity limitation, nocturnal symptoms). The PACCI also provides for classification of asthma symptoms (using NIH asthma severity and control categories) and a treatment algorithm for prescribing and adjusting asthma medications. The PACCI may be interview-administered or self-completed by parents of children with asthma with or without assistance from the child in providing answers.

Based on responses to questions 7 - 11,the PACCI classifies patients into 4 categories of control/severity ranging from intermittent/controlled to severe persistent/very poorly controlled; intermittent/controlled indicating better asthma disease status and severe-persistent/very poorly controlled indicating poorer asthma disease status. Consistent with NIH asthma guidelines, the category is assigned based on the most severely reported response (selected response that is furthest to the right) among questions 7 - 11.

The treatment algorithm on page 3 of the PACCI is linked to the PACCI Control/Severity Category as classified by the clinician. For each control/severity classification, there is a recommended and ≥1 alternative medication regimens provided, based on NIH Asthma Guidelines. For any patients with asthma that is persistent/not well-controlled, there is a list of suggested explanations for the clinician to consider besides increasing the patient's medication regimen (e.g., poor inhaler technique). At the bottom of the treatment algorithm is a table of low-, medium- and high-dose inhaled steroid dosing based on age (less than 12 years of age or 12 years of age and older) to assist the clinician select an appropriate medication dose for the patient.

Pharmacologic therapy

Treatment goals are to maximize the quality of life and minimize morbidity. In general, if a patient is classified with asthma that is "persistent" (mild, moderate or severe) or that is not "well-controlled" should either: a) start use of a daily controller medication (e.g., inhaled steroid or leukotriene modifier); or b) be placed on a more intensive daily controller medication regimen. The NAEPP guidelines suggest a stepwise approach that emphasizes initiating a higher level of therapy at the onset of persistent or uncontrolled symptoms to get prompt control and least damage to the airways and then stepping down when the symptoms are under control. This requires continued involvement of the primary care provider to assess the adequacy of treatment. Medications are now categorized into 2 classes: quick relief medications (short acting beta2-agonists) to treat acute symptoms and exacerbations and long-term-control medications to achieve and maintain control and symptoms. Of note, in December 2008, the hydrogenated chlorofluorocarbons were removed from all MDIs, such that all MDIs are now labeled "HFA." It appears that HFA inhalers deliver medicine more effectively to the lungs than non-HFA inhalers. However, importantly patients will not feel the same force ("puff") upon actuation. Therefore, it is important to educate patients that they will be receiving medicine though the force of the medication "plume" may not feel the same as non-HFA inhalers. Whether the increased delivery to the lungs will lead to changes in dosing of inhaled corticosteroids remains to be elucidated.

Click here to see instructional diagrams for asthma medication.

Inhaled corticosteroids (ICS): Strong evidence from clinical trials has established that inhaled corticosteroids improve control of asthma for children with mild or moderate persistent asthma compared to as needed beta2-agonists. Studies comparing inhaled corticosteroids to cromolyn sodium, nedocromil, theophylline, and leukotriene receptor antagonists are limited, but available evidence show that none of these long-term control medications appear to be as effective as inhaled corticosteroids in improving asthma control (Sorkness, CA 2007) (Szefler, SH 2005) . The 2007 Update on the Expert Panel Report on Asthma recommends inhaled corticosteroids as preferred first line treatment for mild-moderate asthma (National Asthma Education and Prevention Program: Expert Panel Report 3 2007) . Along with leukotriene receptor antagonists, inhaled steroids may take approximately 4 weeks before the full benefits of the medication are seen-so parents need to be counseled about a realistic time-frame for onset of action.

• Side Effects:
• Concern of growth: Low-to-medium doses of inhaled corticosteroids may result in a transient decrease in the child's growth velocity, but likely do not affect growth in the long term (National Asthma Education and Prevention Program: Expert Panel Report 3 2007) (The Childhood Asthma Management Program Research Group 2000) (Chervinsky, P 1999) (Agertoft, L 2000) . In response to the concern of long-term adverse effects of chronic inhaled corticosteroid use in children on vertical growth, bone mineral density (BMD), ocular toxicity, and suppression of the adrenal/pituitary axis, the 2007 NAEPP asthma guidelines stated:
  "The potential risks of ICS are well balanced by their benefits. The potential for adverse effects on linear growth from ICS appears to be dose dependent. In treatment of children who have mild or moderate persistent asthma, low-to medium ICS therapy may be associated with a possible, but not predictable, adverse effect on linear growth. The clinical significance of this potential systemic effect has yet to be determined. High doses of ICS have greater potential for growth suppression. In general, the efficacy of ICSs is sufficient to outweigh any concerns about growth or other systemic effects. However, ICSs, as with any medications, should be titrated to as low a dose as needed to maintain good control of the child's asthma." (p. 222; National Asthma Education and Prevention Program 2007) (National Asthma Education and Prevention Program: Expert Panel Report 3 2007)
• Oral thrush: patients should rinse out their mouth after taking a dose of their ICS.
• Starting dose:
• Starting doses are dependent on the child's age, and asthma severity. It is critical initially to have close follow-up with patients after starting an ICS to make sure that the patient is well controlled on the prescribed dose.

Long-acting Beta2-agonists + Inhaled Corticolsteroids: Long-acting beta2-agonists -or LABAs-(e.g., Salmeterol or Fomoterol) provide bronchodilation and bronchoprotection effects lasting 8 - 12 hours. Because of concerns that LABAs are not anti-inflammatory medications and because of their black box label, their isolated use in asthma has fallen out of favor. LABAs are therefore available only in combination with inhaled steroids (Fluticasone/Salmeterol or Budesonide/Fomoterol) as dry powdered inhalers. Studies have shown that the addition of a LABA to a given dose of inhaled steroid provides similar improvement in symptom control and lung function to that seen in doubling the dose of inhaled steroid alone. Therefore, the regimen of combining LABA with an inhaled steroid has been suggested as a method of intensifying asthma therapy without increasing exposure to higher doses of inhaled steroids (a "steroid-sparing" approach to intensifying treatment). For children 6 years of age and older with persistent asthma, the 2007 NAEPP states that the addition of a long-acting inhaled beta2-agonist to low to medium doses of inhaled corticosteroids is an acceptable option for a child who requires more than low dose ICS (National Asthma Education and Prevention Program: Expert Panel Report 3 2007) .

• Side effects:
• Isolated use of LABAs in asthma has been shown to be associated with an increased risk of death (Nelson, HS 2006) . Therefore, in November, 2005 an FDA warning was issued about the use of LABAs or drugs containing LABAs (e.g., Salmeterol). The mechanism for the increased risk of death with isolated use of LABAs in asthma is unknown, but may be related to the development of tolerance/tachyphylaxis to the bronchodilation and bronchoprotection effects (Simons, FER 1997) . There is no apparent risk of increased risk of death when LABAs are used in conjunction with inhaled steroids (e.g., Advair), although studies have been underpowered to detect mortality effect. In addition, evidence suggests that tachyphylaxis may still develop (Simons, FER 1997) with regular use of LABAs even when used with inhaled steroids.
• Starting doses:
• For Salmeterol: 21mcg (Advair HFA)/dose, one-two actuations BID or 50mcg (Advair Diskus)/dose, one actuation BID
• For Formoterol: 9mcg (Symbicort HFA)/dose, one-two actuations BID or 12mcg (Foradil), one actuation BID
• ICS dose dependent on child age and asthma severity

Mast cell stabilizers: Cromolyn sodium (Intal) and nedocromil (Tilade) inhalation aerosol are mast cell stabilizers, thereby limiting one of the inflammatory pathways that contribute to asthma symptoms. Although nedocromil has distinct properties from cromolyn, both have their mechanisms of action by blockade of chloride channels, and modulating mast cell mediator release. Nedocromil also inhibits early and late asthmatic response to allergen challenge. It is felt to be more effective than cromolyn in non-allergic patients on inhaled steroids. It is recommended for qid use but some effectiveness has been shown with bid use. Like cromolyn, it has a strong safety profile. However, this class of drugs may only be useful in those with mild asthma since the anti-inflammatory and clinical effects are modest compared with inhaled steroids. The QID dosing regimen is also likely to have a poorer adherence profile than the once- or twice-daily dosing of leukotriene antagonists and inhaled steroids.

• Side effects: No known side effects.
• Starting dose: 2 puffs or nebs QID. Does not offer the same opportunities to "titrate" dose up/down like inhaled steroids.

Leukotriene receptor antagonists have a role in controlling asthma, as leukotrienes contribute to the inflammatory cascade. Montelukast (Singulair), and zafirlukast (Accolate) are leukotriene receptor antagonists that improve peak flows, reduce asthma symptoms, and attenuate the need for beta-adrenergic drugs. They have also been shown to partially block the asthmatic response to challenges with exercise or hyperventilation with dry, cold air, and to reduce the degree of exercise-induced bronchospasm. Zafirlukast and zileutron are only approved for children 12 years and older. Zyflo is a 5-lipoxygenase inhibitor (not an LTRA) and is metabolized by the p-450 enzymes and can increase the serum level of some drugs, including theophylline. This medication has also shown to prevent relapse for patients who presented to the ED for acute exacerbations (Silverman, RA 2004) . However, it requires QID dosing and Zafirlukast requires BID dosing. Montelukast can be taken as a tablet once daily, comes in a chewable tablet or granules, and is modestly effective in controlling mild-moderate persistent asthma. For asthma, it is FDA-approved for use in children starting at 12 months of age (unlike Zyflo or Accolate).

• Side effects: Anecdotally, patients (particularly pre-school age) may have nightmares. Earlier this year, FDA has started to examine if there is an increased risk of suicide.
• Starting dose: Dosing is based exclusively on age. For montelukast: 4mg for <5 years of age; 5mg for 5 - 15 years of age; 10mg for ≥15 years of age.

Means of Administering Medications

• Inhaled therapy is most efficacious and should be used in preference to oral therapy because the inhaled route is more effective, has a more rapid onset of action, and has fewer adverse reactions. Inhaled medication is available for nebulizer, metered-dose inhaler (MDI) or dry powder inhaler (disks/DPI).
• A meta-analysis examining effectiveness of MDI with spacer as compared to nebulized albuterol concluded that MDI with spacer was as least as effective as nebulized solution for mild to moderate exacerbations, with length of stay in the ED actually decreased with MDI with spacer (Osmond, M 2004) . MDIs also may be preferable in older children secondary to the MDI's portability and relative convenience.
• Spacers for MDIs: Without a spacer, the inhaler delivers the aerosol at too fast a velocity for anyone to be able to inhale into their lungs. Many patients also have difficulty coordinating their inspiration with activation of the inhaler. Simply adding a spacer to the regimen may significantly reduce oral deposition (and reduce the risk for systemic side-effects) and significantly improve lung deposition-leading to improved asthma control. Aerochamber, which has a facemask and requires little patient cooperation, can be effective in children as young as several months of age, depending on both the child's cooperation and the parent's comfort level. Spacers come in various shapes and sizes. For a child who needs medication during the school day, they will need an additional spacer at school. Managed care organizations will pay for 2 spacers, but if one is lost, they will not replace it for a year. When using a spacer, only one medication should be delivered to the chamber at a time. The same chamber can be used for all medications. The usual order is beta2-agonists first (if required), followed by corticosteroids or cromolyn sodium.

Written Action Plans

The 2007 NAEPP guidelines recommend providing families with a written asthma action plan (National Asthma Education and Prevention Program: Expert Panel Report 3 2007) . Specifically, the provider should include in the action plan daily medicines as well as how to recognize and respond to an exacerbation. These plans provide patients with clear information about the use of their medicines, the actions they are to take at home for asthma attacks, and the actual peak flow measurements that they should use as a guide. An asthma action plan may be developed for school or day care as well.

Recap of Asthma Pharmacotherapy:

• Anti-inflammatory medications are the mainstay for treatment for persistent asthma
• Anti-inflammatory/long-term controller treatment options include inhaled steroids (+/- LABA), leukotriene receptor antagonists, and mast cell stabilizers
• Inhaled corticosteroids as preferred first line treatment for mild-moderate asthma
• Delivery of inhaled corticosteroids may be via MDI w/ spacer, nebulizer, or dry powder inhalers-leukotriene antagonists are oral.

Environmental Control

Atopy has been found to be one of the major predictors of persistent asthma (Simons, FER 1997) . Therefore, environmental interventions are an important aspect of management for many patients. Essentially, this involves reducing exposure to irritants and allergens in the child's environment. Allergy testing is recommended for all patients with asthma >3 years of age.

Common Allergens:

Tobacco smoke: The incidence of asthma is increased in children who live in a home where the parent smokes. Such children have more frequent emergency room visits, a higher requirement for medication and poorer pulmonary function (Weitzman, M 1990) . Parents need to be provided with this information and encouraged to be active about stopping smoking.

House dust mite: One gram of house dust may contain as many as 1,000 mites and 250,000 fecal pellets. The mites live on human dander and are found in high levels in dust obtained from mattresses, pillows, carpets, upholstered furniture, bed covers, clothes and soft toys. House dust mites are dependent upon a humid environment for their survival. Reducing exposure to house dust mites has been shown to reduce asthma symptoms. There are many different means of reducing exposure though many of these may be difficult due to the expense:

1. Encase the mattress in an airtight cover
2. Encase the pillow or wash it weekly
3. Wash the bedding in hot water weekly
4. Avoid sleeping or lying on upholstered furniture
5. Remove carpets that are laid on concrete
6. Remove carpet from the bedroom
7. Limit the number of soft toys in the bedroom
8. Use an under-blanket which is washed frequently
9. Maintain a dry, cool environment

The type of mattress (foam, spring or water) does not appear to make a difference. Using an under blanket, however, does seem to reduce the dust mite concentration in the mattress, possibly by allowing human dander that collects on the under blanket to be removed when this blanket is washed (Martinez, FD 1995) .

Cockroach: Cockroach allergens appear to be particularly important in inner-city neighborhoods. Unfortunately, there are many negligent landlords who fail to exterminate patient's housing in a timely manner if at all. If available, a legal advocate can assist families in expediting the process.

Animal Allergens: All breeds of cats and dogs produce common allergens. The allergens are contained in the animal's dander and saliva. There is no "non-allergenic" dog: shorthaired dogs are just as allergenic as those with longer hair. To eliminate exposure to the allergens, the animal needs to be removed from the house. Relief may not be apparent for several months, as the allergens persist in dander and dried saliva for many months.

Pollens and molds: Exposure to outdoor allergens is best reduced by remaining indoors, but with cigarette smoking being as prevalent as it is, there are obvious disadvantages to staying indoors. Pollen and some mold counts tend to be highest during the midday and afternoon, so this may be a good time to be indoors. Children with a predictable seasonality to their asthma can be educated to limit the amount of time outdoors during their 'asthma season' or have their anti-inflammatory therapy increased in anticipation of an approaching season. Staying inside on the day after a heavy rainfall may also be useful. Grass pollen, which is abundant in the spring, is released into the atmosphere in greatly increased amounts on days following rainfall.

Asthma Exacerbations (and some additional information)

Identifying and treating an asthma exacerbation

There is no current consensus on what defines an asthma exacerbation or "attack". The 2007 NIH Asthma Guidelines suggest that an exacerbation is characterized by shortness of breath, cough, wheezing, and chest tightness-or some combination of these symptoms.
"Exacerbations are characterized by decreases in expiratory airflow that can be documented and quantified by simple measurement of lung function (spirometry or PEF). These objective measures more reliably indicate the severity of an exacerbation than does the severity of symptoms."

The American Thoracic Society and the European Respiratory Society have a joint publication that defines an exacerbation as: "events characterized by a change from the patient's previous status."

Exacerbations may be stratified by severity:

• Severe asthma exacerbations are events that require urgent action on the part of the patient and physician to prevent a serious outcome, such as hospitalization or death from asthma. The occurrence of severe asthma exacerbations should be used as a marker of poor asthma control. The definition should include at least one of the following:
1. Use of systemic corticosteroids (tablets, suspension, or injection), or an increase from a stable maintenance dose, for at least 3 days. For consistency, courses of corticosteroids separated by 1 week or more should be treated as separate severe exacerbations.
2. A hospitalization or ER visit because of asthma, requiring systemic corticosteroids.
• Moderate asthma exacerbations are events that should result in a temporary change in treatment, in an effort to prevent the exacerbation from becoming severe. It should include one or more of the following: deterioration in symptoms, deterioration in lung function, and increased rescue bronchodilator use. These features should last for 2 days or more, but not be severe enough to warrant systemic corticosteroid use and/or hospitalization, ER visits for asthma.

Practically speaking, patients classified with moderate or severe persistent asthma, or those classified as having very poorly controlled asthma-can be considered to be having some degree of an ongoing asthma exacerbation and therefore warrant treatment with some type(s) of rescue medication(s). Rescue medications may include short-acting beta2 agonists (SABA) and systemic corticosteroids. The role of these two medications is:

1. SABA to relieve airflow obstruction, with addition of inhaled ipratropium bromide in severe exacerbations.
2. Systemic corticosteroids to decrease airway inflammation in moderate or severe exacerbations or for patients who fail to respond promptly and completely to a SABA.

Early recognition and appropriate treatment (e.g., increasing the frequency of SABA use) is important to successful management of an exacerbation. The following strategies are not effective in treating the exacerbation:

1. doubling the dose of inhaled steroid (for those prescribed an ICS prior to the exacerbation);
2. drinking large volumes of liquid
3. exposure to moist air (e.g., shower steam)
4. over-the-counter products such as cough suppressants, anti-histamines, or cold remedies.

Exercise Induced Bronchospasm:

This is a commonly under diagnosed variant of asthma. Exercise-induced bronchospasm (EIB) occurs in 80-90% of patients with asthma, and in 40-50% of children who have allergic rhinitis without a diagnosis of asthma. It is a transient increase in airway resistance following brief, rigorous activity. Factors affecting EIB include: intensity (especially bursts of intensive exercise lasting 2-8 minutes), duration, stress, and environment. Clinical symptoms of EIB include: coughing, wheezing, SOB, chest pain and itching or scratching sensation in chest. If untreated, it can limit and disrupt otherwise normal lives. The bronchospasm usually occurs during exercise, peaks 5-10 minutes after the exercise stops and lasts for about 20-45 minutes.

Pharmacologic treatment for Exercise Induced bronchospasm (EIB) includes:

1. Use of a beta2-agonist shortly before exercise, which may help up to 2 hours
2. Cromolyn and nedocromil
3. Lengthy warm up (including breathing through the nose; breathing warm, humidified air and/or avoiding hyperventilation during warm-up); and
4. Long term therapy if appropriate for other symptoms such as anti-inflammatory agents.

When to refer to a specialist? For children younger than 5 years, consultation with an asthma specialist is recommended for moderate persistent or severe persistent disease. For all patients, the criteria include:

• Patient has had a life-threatening asthma exacerbation
• Patient is not meeting the goals of asthma therapy after 3 to 6 months of treatment
• Signs and symptoms are atypical or there are problems in differential diagnosis
• Other conditions complicate asthma or its diagnosis (e.g., sinusitis, nasal polyps, aspergillosis, severe rhinitis, vocal cord dysfunction, gastroesophageal reflux, chronic obstructive pulmonary disease)
• Additional diagnostic testing is indicated (e.g., allergy skin testing, rhinoscopy, complete pulmonary function studies, provocative challenge, bronchoscopy)
• Patient requires additional education and guidance on complications of therapy, problems with adherence or allergen avoidance
• Patient is being considered for immunotherapy
• Patient requires continuous oral corticosteroid therapy or high-dose inhaled corticosteroids or has required more than two bursts of oral corticosteroids in 1 year

WEBSITES:
www.nhlbi.nih.gov/guidelines/asthma/ to find 2007 asthma guideline updates.
www.aafa.org The asthma and allergy foundation of America
www.aanma.org The allergy and asthma network mothers of asthma

Appendix 1

Estimated Comparative Daily Dosages of Inhaled Corticosteroids for Children <12 Years*

*All doses in mcg unless otherwise noted

Estimated Comparative Daily Dosages of Inhaled Corticosteroids for Children >12 Years*

*All doses in mcg unless otherwise noted

Reference List

Naqvi, M. et al. "Inhaled corticosteroids and augmented bronchodilator responsiveness in Latino and African American asthmatic patients." Ann.Allergy Asthma Immunol. 100.6 (2008): 551-57.

Citations