Written by William C. Anderson III, MD
Is asthma the correct diagnosis?
With asthma being the most common chronic illness of childhood, a familiar approach for a patient initially presenting with episodic wheezing or cough is an empiric trial of albuterol or inhaled corticosteroids. However, when a patient is not responding to standard or escalating controller or quick-relief therapy, providers must consider other etiologies.
Differential diagnosis for pediatric asthma
History can guide the diagnosis of asthma, and objective measures can confirm it. Spirometry can provide an assessment of lung obstruction and bronchodilator reversibility. Within an allergist or pulmonologist's office, a fractional exhaled nitric oxide level (FeNO) can provide evidence of lower airway eosinophilic inflammation, and a bronchoprovocation test can assess airway hyperresponsiveness.
Is my patient's asthma well controlled?
National Heart, Lung and Blood Institute Expert Panel 3 guidelines provide a roadmap to pediatric asthma management. Asthma severity and subsequent treatment "step" choice is based both on the impairment domain (daily symptoms, nocturnal symptoms, albuterol use, activity limitation) and on the risk domain (number of exacerbations per year requiring steroids). Children with well-controlled asthma need albuterol during the day less than twice per week, wake at night with symptoms less than twice per month and receive steroids less than twice per year.
Did I pick the best controller for my patient?
When initiating a controller at step 2 in school-aged children, low-dose inhaled corticosteroids have been shown to improve asthma control, use of albuterol and pulmonary lung function responses more than leukotriene receptor antagonists. Children who are most likely to respond to inhaled corticosteroids have markers of allergic inflammation including elevated total eosinophil counts, serum IgE and FeNO.
When escalating therapy at step 3, most school-aged children have a preferential response to the addition of a long-acting beta agonist to a low-dose inhaled corticosteroid compared to an increasing dose of inhaled corticosteroid or the addition of a leukotriene receptor antagonist. Race and the presence of eczema can further predict which treatment option is best for patients.
Choosing the best step 3 controller medication in school-aged children inadequately controlled on low-dose inhaled corticosteroids
- No eczema: Add a long-acting beta agonist to inhaled corticosteroids.
- Eczema and African American race: Increase dose of inhaled corticosteroids.
- Eczema and Hispanic race: Add a leukotriene receptor antagonist to inhaled corticosteroids.
- Eczema and Caucasian race: Add a long-acting beta agonist or leukotriene receptor antagonist to inhaled corticosteroids.
Is my patient actually taking their controller?
Adherence to controller therapies in pediatric patients is low. A study showed only 20 to 30% adherence to inhaled corticosteroids, with only four to five prescription refills per year. Self-reporting of adherence is no better with a 30% discrepancy between reported and objective controller use in one study of school-aged children with asthma.
Pharmacy refill rates are one way to assess adherence but has its own limitations, as filling the prescription does not equate with use. Electronic monitoring devices (EMDs) are a new approach to monitoring adherence through objective, real-time data on medication use. EMDs can also provide patient reminders and feedback on medication use. If the provider confirms poor adherence, the provider must address the underlying reasons for poor adherence in order to rectify it.
Reasons for poor medication adherence
- Cultural factors surrounding medication use and choice
- Familial socioeconomic constraints (medication cost, lack of insurance)
- Lack of improvement from medication use
- Lack of parental supervision
- Medication-related side effects
- Ownership of disease management (child vs. parent)
- Parental and patient health literacy
- Secondary gain from poor disease control
- Treatment regimen complexity
If my patient is taking their controller, are they using it correctly?
Controller and quick-relief medication use can be confusing with several delivery devices available, emphasizing the need to educate patients on appropriate technique for each device. Spacers are recommended for use with all metered dose inhalers (MDIs), regardless of age.
A recent study indicated that while over 90% of patients had a healthcare provider explain the use of a spacer, less than 4% of patients and families could perform the essential steps to ensure proper spacer use with an MDI. The use of spacers with an MDI can reduce oropharyngeal drug deposition below 6% compared to 30 to 70% without a spacer.
What comorbidities could be impacting my patient's asthma?
Poor asthma control may stem from associated comorbidities. Up to 85% of children with asthma are atopic, and 40% of pediatric patients have allergic rhinitis.
- Tree, grass and weed pollen sensitivity can contribute to variability in asthma control, especially during peak pollen and respiratory viral seasons.
- Animal dander is a common perennial allergen that can lead to poor asthma control due to persistent airway inflammation. Contrary to popular belief, there is no such thing as a hypoallergenic dog.
Families can employ avoidance strategies to minimize allergen exposures.
Comorbidities associated with poor asthma control
- Allergic rhinitis
- Environmental allergen exposure
- Gastroesophageal reflux disease
- Obstructive sleep apnea
- Psychiatric disorders
- Psychosocial stressors
- Secondhand tobacco smoke exposure
- Vocal cord dysfunction
Strategies to reduce environmental aeroallergen exposure
- Keep windows closed and use air conditioning if possible, especially in the bedroom.
- Stay indoors when pollen levels are high.
- Bathe and change clothes after coming indoors.
- Avoid mowing lawns or raking leaves.
- Always keep pets outside of the bedroom and off upholstered furniture.
- Bathe and change clothes after visiting someone who has an animal.
- Have someone without allergies brush and regularly bathe the pet outdoors.
- Vacuum at least twice a week using a vacuum with a HEPA filter.
- Use dust mite proof covers for mattress and pillows.
- Use a dehumidifier to keep the home dry.
- Vacuum the carpet regularly.
Compared to children with asthma and no secondhand smoke exposure, children with asthma and secondhand smoke exposure are more likely to be hospitalized, present to the emergency department, wheeze and demonstrate lower lung function. Smoking cessation should be offered to every smoking caregiver.
Am I addressing psychosocial factors that may be impacting my patient?
Recent studies show that psychosocial factors explain poor asthma control in over 50% of children seen in a subspecialty asthma clinic for poor control.
- Financial constraints can limit access to medications or prohibit environmental control interventions.
- Chaotic and stressful home environments often disrupt routine medication administration and may make attending appointments difficult.
Working with social workers or providing community resources to your patient’s family in these situations may improve their asthma management more than any escalation of therapy.
When should I refer my patient to an asthma specialist?
Asthma specialists can be allergists or pulmonologists. Primary care providers should consider referring any child who has poorly controlled disease despite medium-dose inhaled corticosteroids or above, as those patients are at increased risk for medication side effects and severe exacerbations. Allergists should be involved when a patient's asthma is poorly controlled due to allergic triggers or when they have other atopic conditions. Pulmonologists should be involved when the diagnosis is unclear, especially under the age of 2, as the differential for recurrent wheeze and cough is broad.
Reasons to refer a patient to an allergist or pulmonologist
- Diagnosis remains uncertain
- Need for additional testing (i.e., spirometry, FeNO, methacholine challenge, sweat chloride test)
- Evaluation of possible allergic triggers
- Increased asthma education required
- NHLBI step 3 therapy or higher for asthma control
- Poor control despite guidelines-based therapy
- Life-threatening asthma exacerbation
- Hospitalization or recurrent emergency room visits for asthma
- Management of other atopic comorbidities
- Consideration for immunotherapy
What is the Multidisciplinary Asthma Clinic at Children’s Hospital Colorado?
The Multidisciplinary Asthma Clinic provides a comprehensive, team-based approach to the care of difficult-to-treat and severe asthma. Patients will have a dedicated team of providers including allergists, pulmonologists and social workers, with access to speech therapists, nutritionists and psychologists as needed. This team will be able to evaluate for comorbid conditions complicating their asthma, identify triggers for asthma, optimize care for their allergies and explore psychosocial barriers to their care. A dedicated patient navigator helps families coordinate a potentially complicated medical system.
Our team strongly emphasizes asthma education for families including symptom recognition and medication use. Call 720-777-6181 to make a referral.