So when we send them home, we
want them not to come back again.
And the way we’re going to prevent
them from coming back again
is by maintaining a better control of
their asthma than they’ve had before.
To decide about control, we first have
to decide what type of asthma they have.
Let’s talk about the different
categories of asthma.
Intermittent asthma is sometimes
called mild intermittent asthma.
That’s where you have
exacerbations now and then,
but it’s by no means
a regular condition.
Then you have mild persistent, moderate
persistent, and severe persistent.
These children have more and
more frequent exacerbations
and we’ll through
what that means.
But one key thing to remember
is asthma in the United States
is getting more common
and more severe.
Deaths in asthma are at an increased
rate now than ever before.
Children in the intermittent
category of asthma
are likely to die just
like any other category.
So categorizing them as
intermittent doesn’t mean
you no longer pay attention
to their asthma,
it means they need less
control or medication,
and that’s why we’re
determining their category.
How do we determine it?
We ask these questions.
Are you having night
How frequently do you use albuterol?
How much does your asthma interfere
with your normal activity?
And how often have you used systemic
steroids in this past year?
Now, you’re going to
take this information
and you’re going to then categorize
them into one of these categories.
These are all outlined in the National
Heart, Lung, and Blood Institute guidelines,
but I’ll summarize
them here for you.
So if you are an
you should have symptoms
less than two days a week,
you should wake up less
than two nights per month,
you should have used albuterol
less than two days per week,
you should have no interference
with your daily activities,
and you should only be
on steroids once a year.
If you have mild persistent
disease, these numbers go up,
where your symptoms are
two to six days a week,
your awakenings are three
to four nights a month,
and your albuterol use is
two to six days a week,
and you have minor interference
and that’s a subjective call.
Moderate persistent, likewise, it goes up.
Now you’re having daily symptoms,
you’re awakening frequently,
you’re needing albuterol every day,
it’s very much interfering with your life,
and you’re using steroids
more than two times a year.
If any of these things are true, you’re
now a moderate persistent asthmatic.
And now we get to severe persistent
and these patients are very sick
with daily symptoms all day long,
every night they’re waking up,
these patients have extreme problems
with getting through their day.
Now, we’re going to use this category to
decide what kind of inhalational therapy
they’re going to get as a controller.
When we choose a controller,
if they are intermittent and
between five and eleven years old,
they’re just going to
use the albuterol.
They don’t require a controller.
If they’re mild persistent, they’ll get two
puffs twice a day of a low dose steroid.
There are some inhaled steroid
formulations that are once a day,
but most are twice a day,
and you have to make sure they’re
getting it the right amount.
Moderate persistent, they’re going
to give a higher dose steroid
and the example I show here is fluticasone
110 micrograms per puff twice a day.
And then if they’re severe, you
may add multiple medications.
This patient is getting both
fluticasone and oral montelukast,
which is a leukotriene
If they’re older, we may be a
little bit more aggressive.
Once we hit that severe
now we’re really talking about
using combination therapy of both
or LABAs with a steroid.
Long-acting beta-agonists alone without
the steroid are contraindicated.
There’s a black box warning and it may
be associated with death in asthma.
The data aren’t very good.
But the point is in the United States,
because of that black box warning,
all LABAs or long-acting beta-agonists,
in this case salmeterol,
are combined with a steroid,
in this case fluticasone.
This drug is known as Advair on the market.
There are lots of drugs out there.
It doesn’t matter which kind you choose,
it’s simply getting the right category
and getting the right treatment
for the severity of
that child’s illness.
So let’s say a patient
is on a controller
and they’ve now come in with
an asthma exacerbation.
How do you figure out what
the right thing to do is?
They’re already on a controller, it
may be that their asthma is worse,
so the first question you ask is, is the
child taking the controller appropriately?
The reality is the vast majority of the
time, the answer is going to be no.
Either that family is noncompliant
and is forgetting doses,
the child often, especially in
the early adolescent years,
will stop taking their controller
because they just don’t want to.
Another possibility is they’ve
got the technique wrong.
Remember, the best technique
for one of these inhalers
that are meter-dosed
inhalers is to use a spacer
and in little children
a mask and a spacer.
Taking it without the
spacer, it doesn’t work.
They’re just swallowing
For the discus ones with the powder,
sometimes it requires a
little bit more coordination
and a child simply isn’t old
enough to figure it out.
So if the child is not taking
the controller appropriately,
then, really, the best thing
to do is to do more education,
to educate this child into how
to use the spacer correctly
or to change around what you’re
using that’s more age appropriate.
If the child is using
this is when you really want to
step up your controller medication
and there’s a lot of different ways
you can do that step-up therapy.
So, for example, if a patient
has a lot of allergic sequelae,
they may benefit a little bit more
from getting a leukotriene inhibitor
added as opposed to stepping up the
strength of their inhaled steroid.
Whatever the case may be,
understanding control of asthma
and prevention of asthma
is what’s incredibly important
to preventing death
and preventing long-term sequelae
from a patient with asthma.