Diagnosis and management of asthma in preschoolers: A Canadian Thoracic Society and Canadian Pediatric Society position paper

Question 1

What is associated with recurrent preschool wheezing?

Answer 1

Substantial morbidity
10% lowered FEV1
May impact long-term health

Question 2

What terms should not refer to asthma in preschoolers?

Answer 2

Bronchospasms
Reactive airway disease
Wheezy bronchitis
Happy wheezer

Question 3

What are some factors that heighten suspicion of asthma but are not necessary for diagnosis?

Answer 3

1. Personal atopy (e.g. eczema, food allergy, etc.)

2. Family history of asthma

Question 4

When should the diagnosis of asthma should be considered in children 1-5yo?

Answer 4

Children with recurrent (>2) asthma-like symptoms or exacerbations (episodes with asthma-like signs), even when only triggered by viral respiratory infections

Question 5

What are symptoms of airflow obstruction?

Answer 5

1. Wheezing
2. Decreased breath sounds
3. Tachypnea
4. Prolonged expiration
5. Signs of accessory muscle use
6. Hypoxemia
7. Altered LOC
8. Cough (not specific)
9. Chronic cough occurs during sleep, allergen exposures, exertion, laughing or crying

Question 6

What are the operational diagnostic criteria for asthma in children one to five years of age?

Answer 6

1. Documentation of airflow obstruction
   - Preferred: documented wheezing and other signs of airflow obstruction by MD or trained HCP
   - Alternative: convincing parental report of wheezing or other symptoms of airflow obstruction
2. Documentation of reversibility of airflow obstruction
   - Preferred: documented improvement in signs of airflow obstruction to SABA +/- oral corticosteroids by physician or trained HCP
   - Alternative: convincing parental report of symptomatic response to a 3m trial of a medium dose of ICS (w/ as-needed SABA)
   - Alternative: convincing parental report of a symptomatic response SABA
3. No clinical evidence of an alternative diagnosis

Question 7

How does bronchiolitis usually present?

Answer 7

First episode of wheezing in a child <1y of age

Question 8

What are signs/symptoms (red flags) suggesting an alternative diagnosis to asthma?

Answer 8

1. Persistent nasal discharge –> infectious/allergic rhinosinusitis
2. stridor or noisy breathing worse when crying, eating, supine or w/ respiratory infection –> upper airway narrowing:
   a) infection: croup, tracheitis
   b) intrinsic: laryngomalacia, tracheal stenosis
   c) extrinsic: vascular ring, tumor
3. Acute onset of cough, wheeze or stridor during eating or playing, history of choking, recurrent pneumonia in the same location –> foreign body inhalation, aspiration of food/gastric contents

4 First episode wheeze in child <1yo –> bronchiolitis

5. Sick contacts, focal signs on CXR –> pneumonia, atelectasis, TB, pertussis
6. Severe, paroxysms of cough, possibly initially associated w/ a “whoop” –> pertussis
7. Premature birth, needed prolonged supplemental O2 +/- mechanical ventilation –> BPD
8. Symptoms since infancy, recurrent pneumonia, focal signs on CXR –> congenital pulmonary airway malformation
9. Chronic wet cough, clubbing, FTT, recurrent pneumonia, onset in infancy, +/- steatorrhea –> bronchiectasis, CF
10. Neonatal respiratory distress, early onset year-round daily cough & nasal congestion +/- situs inversus –> Primary ciliary dyskinesia
11. Cough when supine, when feeding, vomiting after feeding, abdominal discomfort –> GERD
12. Dysphagia, cough triggered by eating/drinking –> Eosinophilic esophagitis
13. Feeding intolerance, wet cough, or noisy breathing after eating –> swallowing problem +/- aspiration
14. Recurrent, persistent, severe or unusual infections –> immune dysfunction
15. Cardiac murmur, cardiac failure, cyanosis when eating, FTT, tachypnea, hepatomegaly –> pulmonary edema due to: a) acute myocarditis/pericarditis
    b) congenital heart disease

Question 9

When does the peak SABA effect?

Answer 9

20 minutes

Question 10

When does the response to oral corticosteroids start?

Answer 10

4 hours

Question 11

How to do a therapeutic trial for documenting reversibility of airflow obstruction?

Answer 11

1. Mild clinical findings
   - inhaled ventolin >4puffs r/a in 30min
2. Mod or severe exacerbation:
   - inhaled ventolin >4puffs 2-3 doses w/in 60min then r/a in 60min
   - oral steroids r/a in 3-4h
   prednisone 1-2mg/kg (max 50mg) OR dexamethasone 0.15-0.6mg/kg (max 10mg)
3. Mild intermittent symptoms or exacerbatons
   - inhaled ventolin 2-4puff q4-6h prn then r/a in 30min
4. Frequent symptoms or mod or severe exacerbations
   - inhaled ventolin 2puffs q4-6h prn then r/a in 30min
   - daily inhaled corticosteroids then r/a in 3m
   a) beclomethasone 100ug BID
   b) ciclesonide 200ug daily
   c) fluticasone 100-125ug BID

Question 12

How to do a therapeutic trial for documenting reversibility of airflow obstruction?

Answer 12

1. Mild clinical findings
   - inhaled ventolin >4puffs r/a in 30min
2. Mod or severe exacerbation:
   - inhaled ventolin >4puffs 2-3 doses w/in 60min then r/a in 60min
   - oral steroids r/a in 3-4h
   prednisone 1-2mg/kg (max 50mg) OR dexamethasone 0.15-0.6mg/kg (max 10mg)
3. Mild intermittent symptoms or exacerbatons
   - inhaled ventolin 2-4puff q4-6h prn then r/a in 30min
4. Frequent symptoms or mod or severe exacerbations
   - inhaled ventolin 2puffs q4-6h prn then r/a in 30min
   - daily inhaled corticosteroids then r/a in 3m
   a) beclomethasone 100ug BID
   b) ciclesonide 200ug daily
   c) fluticasone 100-125ug BID

Question 13

What is the PRAM score?

Answer 13

1. Oxygen saturation:
   - >95% 0
   - 92-94% 1
   - <92% 2
2. Suprasternal retraction
   - Absent 0
   - Present 2
3. Scalene muscle contraction
   - Absent 0
   - Present 2
4. Air entry
   - Normal 0
   - Decreased at the base 1
   - Decreased at the apex and the base 2
   - Minimal or absent 3
5. Wheezing
   - Absent 0
   - Expiratory only 1
   - Inspiratory +/- Expiratory 2
   - Audible w/out stethoscope OR silent chest 3
   PRAM SCORE:
   - 0-3 Mild
   - 4-7 Moderate
   - 8-12 Severe

Question 14

What is the preferred diagnostic method for preschool asthmatics?

Answer 14

In children 1-5yo:

• recurrent >2 episodes of asthma-like sx and wheezing on presentation
• direct observation of improvement w/ inhaled bronchodilator (w/ or w/out oral corticosteroids) by MD or trained HCP confirms the diagnosis

Question 15

What is the alternative diagnostic method for preschool asthmatics?

Answer 15

Children 1-5yo:
- recurrent >2 episodes of asthma-like symptoms, no wheezing on presentation, frequent symptoms, or any moderate or severe exacerbation warrant 3m therapeutic trial w/ a med. daily dose of ICS (w/ prn SABA).
Clear consistent improvement in the frequency & severity of symptoms and/or exacerbations confirms the diagnosis

Question 16

What is the weaker alternative diagnostic method for preschool asthmatics?

Answer 16

Children 1-5yo:
- recurrent >2 episodes of asthma-like symptoms, no wheezing on presentation, infrequent symptoms, and mild exacerbations can be monitored & re-assessed by a HCP when symptomatic. Or a therapeutic trial w/ prn SABA suggested. Convincing parental report of a rapid and repeatedly observed response SABA suggests the diagnosis.

Question 17

How do you adequately interpret a therapeutic trial?

Answer 17

• ascertain adherence to asthma therapy
• inhalation technique
• parental report of monitored symptoms
• appropriately timed medical reassessment

Question 18

What are the inhaled corticosteroids dosing categories for children 1-5yo?

Answer 18

Corticosteroid options:
1. Beclomethasone (QVAR)
2. Ciclesonide (Alvesco)
3. Fluticasone (Flovent)
Low dose (100mcg, 100-125mcg)
Medium dose (200mcg, 200-250mcg)

Question 19

When should children 1-5yo be referred to an asthma specialist?

Answer 19

1. Diagnostic uncertainty
2. Suspicion of comorbidity
3. Poor symptom and exacerbation control despite ICS @ daily doses of 200-250ug
4. Life-threatening event (requiring intensive care admission and/or intubation)
5. Allergy testing to assess the possible role of environmental allergens
6. Other considerations (parental anxiety, need for reassurance, additional education)

Question 20

What are some non-pharmacological management plans for asthma?

Answer 20

1. Written self-management plan
2. 1-3yo spacer w/ facemask
3. 4-5yo spacer w/ mouthpiece
4. Avoidance of irritants e.g. cigarette smoke
5. Avoidance of environmental aeroallergens if child is sensitized

Question 21

What are the criteria for initiating controller therapy in preschool asthmatics?

Answer 21

1. Symptoms occurring >8d/mth
2. > 8d/mth w/ use of inhaled SABA
3. > 1 night awakening due to symptoms/mth
4. any exercise limitation/mth
5. any absence from usual activities to asthma symptoms
6. episodes requiring rescue oral corticosteroids or hospital admission

Question 22

What is the recommended therapy?

Answer 22

First-line low dose ICS
Second-line medium dose ICS
Third-line daily leukotriene receptor antagonists

Question 23

How to monitor asthma control?

Answer 23

Assess q3-4m using same criteria