Pediatric Asthma: An Update for Pharmacists

Asthma is a chronic illness that affects the airways of the lungs. Uncontrolled asthma can lead to asthma attacks where the individual experiences coughing, trouble breathing, wheezing, and/or pain in the chest.¹

Uncontrolled asthma leads to exacerbation of the disease, hospitalizations, impaired quality of life, and death. According to the CDC, an estimated 39.5 million people in the United States-12.9% of the population-have been diagnosed with asthma in their lifetime. Children particularly have a high incidence of asthma with 10.5 million (14%) having received a diagnosis for asthma in their lifetime, with 7.1 million (9.5%) with active asthma.²

Uncontrolled asthma leads to preventable morbidity and increased health-care utilization. Asthma costs the United States $56 billion each year. In 2009, there were 479,300 asthma-related hospitalizations, 1.9 million asthma-related emergency department visits and 8.9 million asthma-related doctor visits.¹ It cost an average $1039 per year to care for a child with asthma in 2009.¹

Pathophysiology, Diagnosis, and Triggers

Asthma is a disease with many variations, but it is usually characterized by common airflow obstruction, bronchial hyper-responsiveness, and airway inflammation.³ Two key defining features assist in diagnosing asthma: a history of respiratory symptoms such as wheezing, shortness of breath, chest tightness, and cough that vary in time and intensity; and evidence of variable expiratory airflow limitation, which is measured by one of two methods, peak expiratory flow (PEF) rates or spirometry.^3-4 When a patient exhibits symptoms of asthma, a detailed history and physical examination can help further define the type of asthma and its triggers, and comorbid conditions that can contribute to disease severity.⁴ The diagnosis of asthma in children should be made based on the history of symptoms as well as evidence of variable airflow limitation.^3-4

PEF rate is the most commonly used method of testing lung function. If the average daily PEF rate variability is greater than 13%, it suggests a diagnosis of asthma in children.² Spirometry measures the forced vital capacity (FVC), which is the maximum volume exhaled after taking a deep breath in, and the forced expiratory volume in one second (FEV1). These are measured at baseline and after administration of a short-acting bronchodilator to test for reversibility. When FEV1 increases by more than 12% from baseline/predicted value, this is evidence of bronchodilator reversibility. In pediatric patients, the FEV1/FVC ratio is normally greater than 0.9. If the result is less than this value, it is usually suggestive of airflow limitation.⁴ The greater the variation, the more confidence a health-care professional can have in diagnosing asthma.⁴

There are several stimuli that trigger asthma exacerbations in children. Severe weather changes and outdoor and indoor environmental exposures to allergens and pollutants are among the major contributors to asthma morbidity in the pediatric population.^5-6 According to the American Academy of Allergy, Asthma and Immunology, educating patients and caregivers on minimizing exposure to indoor environmental elements such as dust mites, rodents, cockroaches, pet dander, second-hand smoke, and nitrogen dioxide gas are an important step in delivering individually tailored asthma care. In some cases, these practices have shown similar efficacy and cost in minimizing exacerbations when compared to medications to control asthma.⁵

Treatment

The cornerstones of asthma management are to reduce the impairment associated with asthma and to reduce the risk. Reducing impairment consists of preventing chronic symptoms, decreasing the need for rescue medications, and maintaining normal lung function and optimal activity levels. Reducing risk consists of preventing exacerbations, minimizing emergency care and hospitalizations, preventing loss of lung function, and minimizing adverse effects of therapy.^3-5

The general approach to treatment is based on initial assessment of asthma severity. For patients 12 years and older, the four key components that are assessed to determine treatment include: daytime symptoms, nighttime awakenings, frequency of rescue inhaler use, and activity limitations. Lung function and exacerbation frequency are also considered. Criteria for younger patients are similar, but more specific.^3-4 The goals of asthma management in young children are similar to those in older patients: to achieve optimal symptom control, maintain normal activity levels, and minimize the risk of exacerbation, impaired lung development, and medication side effects.^3-4

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Figure 1

Treatment recommendations are presented for three age groups: 0 to 4 years of age, 5 to 11 years of age, and 12 years and older. The differences between groups exist because the course of asthma may change over time, the relevance of different measures of impairment or risk may vary, the potential short and long-term impact of medications may be age-related, and because there are varied levels of evidence available for these age groups. The stepwise approach expands to six steps to simplify actions within each step.^3-4 (See Figure 1, click to expand.)

Inhaled corticosteroids (ICS) are the mainstay treatment for pediatric patients with asthma for maintenance therapy and are referred to as “controller” medications.^3-5 Short-acting beta agonists (SABAs) are the agents of choice to relieve sudden symptoms and are referred to as “rescue” or “quick-relief” medications. Other agents used in the treatment of asthma in pediatric patients include long-acting beta agonists (LABAs), combination ICS/LABA agents, and leukotriene modifiers. Oral and/or intravenous corticosteroids may also be warranted in severe asthma exacerbations. (See Table 1, click to expand.) ^3-4

According to the 2017 Global Initiative for Asthma (GINA) report and the 2007 Expert Panel Report-3 Guidelines for the Diagnosis and Management of Asthma, a stepwise treatment approach is recommended based on symptom patterns, risk of exacerbations, and side effects.^3-4 The route of administration must also be considered when treating pediatric patients; children less than 4 years of age generally require delivery of agents via nebulizer through a face mask that should fit snugly over nose and mouth, while metered-dose and dry-powder inhalers are suitable for children ages 4 and up.⁴ A regular daily low-dose ICS is recommended as the preferred initial controller treatment in children 5 years of age and younger, and should be given for at least 3 months to establish its effectiveness in achieving asthma control.^3-4

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Table 1

Children age 6 and above should also be evaluated to determine symptom control and response to ICS therapy (respiratory symptoms, lung function, airflow limitation) as well as future risk of adverse outcomes.^3-4 If patients are deemed to have poor symptom control and poor control of exacerbation on current ICS regimen, the practitioner should assess the following before a step-up in treatment is considered: confirm symptoms are due to asthma and rule out other etiologies, check and correct inhaler technique, confirm adherence to the prescribed dose, and inquire about risk factors and environmental triggers such as allergens and smoke exposure.^4,5 Then, a moderate ICS or leukotriene inhibitor may be considered for adequate control.^3-4 Patients who exhibit well-controlled asthma should be stepped-down in therapy to a lower-dose ICS and monitored for maintenance of control.⁴

Pharmacists and Asthma

Pharmacists are especially well equipped to deliver asthma-focused medication therapy management sessions to patients and their caregivers to improve health outcomes.⁶ Patients can be educated to manage their asthma effectively on their own. This self-management includes assessing the level of asthma control and recognizing symptoms of worsening asthma. Patients can also to be taught to follow a written asthma action plan that includes daily actions to control asthma and how to adjust medications when needed to regain control of symptoms.⁶

Pharmacists are invaluable assets for providing patient education and patient self-care training in chronic diseases. They practice in various settings and, with asthma, are knowledgeable about the medications commonly prescribed, medication administration technique, recommended immunizations, and sick-day management for children.

The CDC recommends routine annual influenza vaccination for individuals 6 months or older with no contraindications. High-risk groups such as those with pulmonary disorders including asthma, children aged 6 to 59 months, and patient contacts and caregivers are a priority for annual influenza vaccine to aid in preventing viral infection.⁷ The CDC also recommends the pneumococcal conjugate vaccine in children with chronic lung disease. (See Figure 2.) Both vaccines may be administered at the same time.^31-32

Pharmacists should make every effort to consistently educate patients and caregivers about how cold and flu viruses can colonize on hands. Regular hand washing can help protect from contracting minor respiratory infections, particularly during “cough and cold season.”³² Patients and caregivers should be taught to wash hands for 20 seconds with soap and water; use an alcohol-based hand sanitizer; avoid touching the eyes, nose, and mouth with unwashed hands; stay away from people who are sick; and cough or sneeze into a tissue or upper shirt sleeve, completely covering the mouth and nose.³²

During a minor illness, patients and caregivers should also be reminded that OTC medication for children may help relieve some symptoms, such as fever, aches, runny nose, and congestion, but that they do not shorten the length of time children are sick or treat asthma symptoms such as cough, wheeze, or shortness of breath. Proper use of rescue and controller medications are critical during an acute respiratory illness. Ibuprofen or acetaminophen may be given to children 6 months or older (oral ibuprofen, 5 to 10 mg/kg every 6 to 8 hours as needed, maximum 4 doses/day; oral acetaminophen, 10 to 15 mg/kg every 4 to 6 hours as needed, maximum 5 doses/day) for fever or pain.^34-35 Saline nose drops, humidifiers, or cool-mist vaporizers can be used to relieve a stuffy nose. Caregivers should not administer OTC cough and cold medications for children younger than 4 years of age unless instructed by their health-care provider.^33-35

Conclusion

A stepwise approach to medication management is recommended for patients with asthma, with specific therapy changes based on level of asthma control.³⁶ The recommendations vary slightly with age, but the cornerstone for maintenance therapy is ICS or controller medication for all age groups. Patients with asthma should also be prescribed a rescue inhaler or a short-acting beta-agonist for quick relief of acute symptoms. Barriers to appropriate medication adherence include complexity of medication regimens, inappropriate inhalation technique, cost, and forgetfulness.³⁷ Education strategies should be tailored to the patients’ culture and level of education.

By remaining current in practice guidelines and strategies to attain and maintain asthma control, pharmacists will be well-positioned to make a significant impact on pediatric patients with asthma and their caregivers to promote better outcomes.

Disclosure

The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria.

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