ACAAI Provides 'Yardstick' for Controlling Asthma in Children

JULY 20, 2018
Kenneth Bender, PharmD, MA
Bradley Chipps, MDBradley Chipps, MD
The new ‘Pediatric Asthma Yardstick’ from the American College of Allergy, Asthma & Immunology (ACAAI) has provided new guidance to clinicians implementing sustained, step-up treatments for inadequately controlled asthma in children.

The novel concept of the yardstick, according to ACAAI President Bradley Chipps, MD, is unlike any other study in current literature.

"We created the yardstick because there are many options for treating pediatric asthma," Chipps said.

Last year, new guidelines were developed separately from those issued by the ACAAI for treating asthma in adults, to address the special challenges of managing uncontrolled disease in children at different ages and different stages of respiratory system development and with different response to, and tolerance of therapies.

Chipps, the lead author of the study analyzing the yardstick, said the ACAAI creation serves as a “roadmap for how to move forward with kids whose asthma is not udner control.”

“The yardstick describes controller treatments at different levels of severity for all ages, the choices available for parents for their child and how to step up therapy," Chipps noted.

The authors acknowledged and reference other guidelines, but suggested that these have not necessarily helped clinicians to know when and how to step up therapy.  The yardstick, intended to provide practical and clinically relevant recommendations, is structured around patient profiles which reflect 3 different age groups: 12-18 years, 6-11 years and under 5 years. It also reflects factors such as severity of symptoms, frequency of exacerbations, and response to previous therapies.

The age-related physiological changes considered in the guidelines for their impact on evaluating and treating asthma include bronchial hyperresponsiveness, which decreases during school age but is more severe with asthma.  Other described changes include lung compliance decreasing with age, with commensurate increase in elastic recoil pressure; and chest wall compliance, which also decreases with age and is associated with rib cage distortion and unstable functional residual capacity (FRC) in preschool children.

The authors noted that preschool children are at particular disadvantage in using inhalation treatments in which deposition of medication in the distal lung is affected by inspiratory flow velocity and particle size. 

For preschool children unable to follow instructions to take deep, slow breaths and likely to have much of the intended dose reach only to the oropharynx area, Chipps and colleagues suggested that jet nebulizers are often more appropriate. These dosing systems are effective with tidal breathing, they don't require a tight seal around the mouthpiece, and can be used with more confidence in the event of respiratory distress.

Depending on age group, asthma severity and with considerations of phenotype heterogeneity, the step-up strategies include increasing dose of inhaled corticosteroid and adding leukotriene receptor antagonist, tiotropium, and/or biologics. The authors reviewed current data on dosing and combining treatments, as well as on age-related adverse effect profiles.

They consider, for example, the recent FDA review of 4 large clinical safety trials with combinations of inhaled corticosteroid and long acting beta-adrenergic bronchodilators, and suggest that the agency finding the combination safe in treating asthma in adults, adolescents and children should inform updates of current guidelines.

In addition to addressing pharmacologic and pharmacokinetic differences between therapies, Chipps and colleagues examined socio-behavioral factors which can confound treatment outcome.

They noted the challenge for the adolescent to recognize symptoms and to agree that better control is desired.

"Other factors include challenges related to daily activities and emotional and social concerns, particular for adolescents," observed co-author Leonard Bacharier, MD.  "Comorbid conditions and non-adherence with treatment, e.g., due to the stigma of having a chronic condition and taking medicine, can affect outcomes for older children."

The study, "The pediatric asthma yardstick: Practical recommendations for a sustained step-up in asthma therapy for children with inadequately controlled asthma," was published online in the Annals Allergy, Asthma, & Immunology.

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