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Consultant for Pediatricians. Vol. 8 No. 9 A Guide to Monitoring and Achieving Asthma Control in Children Younger Than 5 Years
By KEVIN R. MURPHY, MD
Boys Town National Research Hospital, Omaha, Neb MICHAEL H. MELLON, MD Southern California Permanente Medical Group, San Diego, Calif | September 3, 2009 Dr Murphy is director of allergy, asthma & pulmonology research at Boys Town National Research Hospital in Omaha, Neb. Dr Mellon is an asthma staff pediatric allergist at Southern California Permanente Medical Group in San Diego, Calif.
IS THE DIAGNOSIS ASTHMA? Case Study: Matt History of present illness. The mother states that Matt was recently seen at an after-hours clinic because he has been coughing more, especially at night, which results in his awakening. He usually is sick after an upper respiratory tract infection (URTI), which almost always “goes to his chest,” she said. After these episodes, he seems to get out of breath when he “runs around too much” at the playground. However, between these episodes, he basically is in good health. Past medical history. A review of Matt's chart shows that he was first seen in the office for an acute respiratory infection with wheezing at 7 months of age. Over the past year, he has had 4 sick visits for respiratory complaints with diagnoses of recurrent pneumonia and reactive airway disease. He recently had an urgent care visit and was treated with nebulized albuterol and oral prednisolone for 4 days, which appeared to resolve the episode. Allergies/medications. Matt has no known allergies. He currently uses a jet nebulizer and compressor to deliver albuterol treatments as needed. Matt's mother reports that Matt uses his albuterol medication about once or twice a week, especially during the winter months. Family history. Matt's mother notes that she herself has had asthma since childhood and that Matt's father suffers from “sinus” allergies in the fall. Physical examination (PE). Remarkable findings upon PE include increased nasal secretions and some mucosal swelling. The lungs are clear. Symptoms and physical exam. In preschool-aged children, the diagnosis of asthma is based largely on clinical judgment and the assessment of symptoms and PE.9 Components of the diagnostic evaluation for this age-group include a detailed medical history; an assessment of the frequency, type, and pattern of symptoms (Table 1); as well as a PE.6 A patient's medical history allows the HCP to evaluate factors that indicate a likely diagnosis of asthma. Key indicators suggestive of asthma are wheezing, recurrent respiratory symptoms, a history of nighttime cough, symptoms that occur or worsen in the presence of a trigger, and responsiveness to a bronchodilator. Although no one indicator is diagnostic, the presence of multiple indicators increases the probability of an asthma diagnosis. Preschool-aged children with asthma often present with recurrent wheezing associated with a viral infection or complaints of recurrent pneumonia or bronchitis.10 Some of the physical findings suggestive of asthma include hyperexpansion of the thorax, wheezing on chest auscultation, increased nasal secretions, mucosal swelling, atopic dermatitis, or other allergic manifestations. 6 During the evaluation, HCPs should also consider possible alternative diagnoses and perform appropriate tests, if indicated (Table 2). Some possible alternative diagnoses in infants and children include allergic rhinitis, cystic fibrosis, and gastroesophageal reflux disease. Chest radiographs, pulmonary function tests (in older children), and allergy testing are some of the additional studies that aid in the evaluation of children with recurring symptoms suggestive of asthma. Therapeutic trials. For a child whose medical history, family history, and PE are suggestive of asthma (Figure 1),7,11 a therapeutic trial of SABA therapy (eg, albuterol), antiinflammatory therapy (eg, inhaled corticosteroid [ICS]), or both clinically helps one decide whether a child has asthma.9 Observation of symptom improvement after administration of albuterol while the child is in the office or at home during wheezing episodes also assists in establishing the diagnosis. If a SABA alone, administered by nebulizer or metered- dose inhaler (MDI) every 4 to 6 hours, does not control symptoms, the HCP should initiate a short course of an oral corticosteroid (OCS) and observe the effect of this combination on the wheezing. The role of OCSs in the future management of the child's wheezing episodes then should be decided and included in the asthma management plan. For children with persistent asthma, as defined by the impairment or risk domains of the EPR-3, a trial of an ICS is indicated.6 Response should be monitored carefully for reduction in impairment symptoms, a reduction in the frequency and severity of exacerbations, or both. If there is no clear response to the therapeutic trial within 4 to 6 weeks, adherence to the treatment recommendation and device technique should be evaluated.6 Alternative diagnoses or adjustment of therapies should be considered if both adherence and technique are satisfactory. Marked clinical improvement during treatment with SABAs and ICSs and a return of symptoms when treatment is stopped support a diagnosis of asthma.9 |
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