Asthma!

NEW GINA GUIDELINES FOR OUTPATIENT MANAGEMENT:

2020 GINA Guidelines!

  • “Preferred therapy for patients with symptoms less often than twice monthly is either (a) as-needed low-dose ICS/formoterol (formoterol is a long-acting β-agonist [LABA] with a quick onset of action) or (b) as-needed ICS whenever as-needed SABA is used. GINA strongly discourages use of as-needed monotherapy with a SABA (e.g., albuterol), even in patients with only mild symptoms — and that is a major departure from typical U.S. practice.”

2007 NAEPP Guidelines!

  • Inhaled corticosteroids (ICSs) continue as preferred long-term control therapy for all ages

PEARLS!

  • For systemic steroids, the “Number Needed to Treat” (NNT) of asthma exacerbations is 8 to avoid 1 hospitalization 
  • PRN ICS/LABA (eg Advair/Symbicort) as needed may be equivalent to a daily ICS 
  • Giving steroids to kids under age 5 may be a “Thing We Do For No Reason” 
  • Harms of Steroids: Short course Systemic Steroids lead to ~1.17x increased fracture in pediatric patients and is associated with increased risk of sepsis, VTE, and fractures in adults
  • Med-Peds Fun Fact: For adult asthma (and COPD) exacerbation, 40mg of prednisone is typically the standard of care treatment. For pediatric asthma exacerbations, 2mg/kg of prednisolone is used up to 60mg. i.e. your obese 14 year old may get a higher dose of steroids than your 40 year old. 

FURTHER READING!

  1. Decadron vs. Prednisolone in the Pediatric ED
  2. Peds In Review (Nov 2019)
  3. Check out this “Clinic Wiki” page for other pearls on asthma

QUESTIONS TO PONDER!

Outpatient:

  • How do you diagnose asthma in children?
  • Should we be using the Asthma Control Test (ACT) and / or Peak Flows to monitor asthma in our patients?
  • When should we recommend leukotriene modifiers (e.g. montelukast)?
  • What is the difference between Controlled asthma and Severity of asthma?
  • What are the PROs and CONs of oral steroids for an asthma exacerbation?
    • Decadron or Prednisone?

ED / Inpatient:

  • Why do we do DuoNebs in the ED but not after admission?
  • Why do we give fluids with Magnesium?
  • What is the difference between CPAP and BiPap?
  • What is the difference between an ABG and a VBG?

ICU:

  • How would you expect a blood gas to evolve during a worsening asthma exacerbation in the absence of treatment?
  • How might an asthma exacerbation lead to cardiac arrest?