Our management of asthma is not going well. Morbidity and mortality have increased worldwide over the past 18 years.1 Death rates per 100,000 in the United States decreased from 1.68 in 1969 to .68 in 1977, but then something reversed this trend. Mortality rates increased to .92 in 1978 and then to 2.41 per 100,000 in 1991. 2 This trend held for both children and adults. Asthma death rates for ages 5 to 14 increased 10.1% per year, and pediatric hospitalizations rose 4.5% annually during the 1980s.3 Children with asthma miss three times as many school days compared with well children, and typical severe asthma can cost $18,000 per year.4
Why is this happening? We aren't sure, but there is some consensus that we as physicians do not do well at managing asthma: we underdiagnose and undertreat this problem in general.1,4 O'Brien3 states that "...most experts now agree that deaths and hospitalizations from asthma are largely preventable."3 How can we fix this? What plan will we and managed care use to decrease morbidity, mortality, and hospitalizations/emergency visits (ie, costs)?
Let's start at the extreme end of this problem - death from asthma. What are the risk factors, and what insight do they give us into how to do better? Briefly, children who die from asthma are more likely to have a history of prior severe attacks, recent decrease in steroid use, behavioral stresses/problems (conflicts at home, denial of severity of attack, poor compliance, conflicts between family and health-care providers), and low socioeconomic or minority status.2,5'7 The underlying theme is undertreatment, especially for severe disease or poor children. In recognition of the need for better asthma management guidelines, the National Heart, Lung, and Blood Institute convened a panel of experts that led to publication of "The National Asthma Education Program" in 1991. Although this had the right concepts, it has not achieved wide use. It is too long (136 pages) to be read by busy pediatricians.4
The first problem we have is underdiagnoses of asthma. Some causes of this are:
* The definition is vague: episodic wheeze and/or cough with no other disease to explain this, and a tendency to be exertional, nocturnal, and seasonal.1,8 A history of asthma or other atopy in the family and responsiveness to a trial of asthma treatment also support a diagnosis of asthma.
* Pediatricians are reluctant to diagnose repeated wheezing that occurs with viral infections or exercise as asthma. Asthma also can present as exertional chest pain9 or as episodes of coughing with minimal wheeze, especially after exercise. (Readers will note the different emphasis about tiie latter - "cough variant asthma" - in the articles by William Corrao and Tim Newson/Sheila McKenzie in this issue. My view parallels that of William Corrao).
* We delay making an "official diagnosis" of asthma because it could be classified as a (noncovered) preexisting illness when the patient changes insurance carriers.
* We also may be reluctant to tag the patient as having a chronic disease. Doing this adds the need to explain to parents how common asthma is, that most children outgrow it, that with good management asthma should not interfere much with the child's life, and that parents shouldn't describe or consider such a child differently.
Okay, so what are the solutions to better management of asthma? Excellent opportunities are summarized by the International Paediatric Asthma Consensus Group1'8 and O'Brien's "Managed Care and the Treatment of Asthma"4 and include:
* better education - physician and patient,
* collaborative management between the parent/ patient, general pediatrician, and pediatric pulmonary/allergy specialist,
* avoidance of asthma precipitators,
* better understanding of pharmacology, and
* if the above fail, behavioral factors may be the explanation.
One dollar spent on education of physicians can save up to $200 of treatment costs while education of parents can save between $1.08 and $1 1.22 per dollar spent.4 Education should begin with the training of general pediatricians by subspecialists and health maintenance organization (HMO) staff*. The education should be succinct and to the point, but diplomatic. Once general pediatricians are trained, they can educate patients or train their staff to do this. Health maintenance organizations should reimburse subspecialty physicians for this training, and primary care physicians to train parents and patients. This is probably not happening very often but HMOs are starting to reinforce more effective management of asthma through physician "report cards" and capitated reimbursement.4
Parents should be trained in the home management of asthma: how to recognize an attack, that early treatment is most effective, and to assume more responsibility whenever possible. Reliable parents should keep corticosteroids in the home. General pediatricians and subspecialists should work in concert. O'Brien suggests an allergy/pulmonary referral after one admission or two visits to die emergency room for asthma.4 Although this seems overly aggressive, it may improve care until we are better at managing these children.
The management of asthma begins with avoiding tobacco smoke. The pediatrician should help willing parents (and adolescent patients) with smoking cessation by the techniques outlined in the December 1995 Pediatric Annals. But general pediatricians must control hostility and remain constructive in attacking nicotine-addicted parents (especially when we are having a bad day). Remember that conflicts between providers and families have been a risk factor for asthma deaths. Second most important is avoidance of house mite antigens in dust. This is also very difficult. However, long-term exposure may increase the chances a child will eventually develop asthma.10 Of significance is the ongoing controversy about the effectiveness of desensitization immunotherapy for asthma. We were arguing about this 30 years ago; if desensitization was very effective, we would know this by now. So immunotherapy should be reserved for patients with a clear history of reaction to specific (unavoidable) allergens or when all else fails.
We have the most to offer in the medical treatment of asthma, and the pharmacology of asthma management is not complex. Part of the problem is that when we old timers were trained, treatment was based more on opinion than science. The science is much better now. There are two general pharmacological categories of drugs: bronchodilators and antiinflammatory agents. Within the last decade, it has become evident that bronchoconstriction and inflammation act together (and inflammation may be most significant) to produce wheezing as opposed to the older concept that inflammation was only a late manifestation of prolonged asthma. Thus, antiinflammatory agents are important (and underused) for early treatment and prophylaxis. The main antiinflammatory drugs are corticosteroids, which begin to act within 4 hours of initiation, and cromolyn, which begins to have effects 2 to 6 weeks after beginning treatment. There is no place for intermittent treatment of wheezing with cromolyn except in the prevention of exertional wheezing.
Recent evidence suggests theophylline may have anti-inflammatory activity in addition to being a bronchodilator. Theophylline is unpopular (and perhaps underused) now because its therapeutic and toxic levels are relatively close, and the media has emphasized its major toxic effects (hyperactivity, vomiting, and seizures), and more subtle learning problems. However, if serum levels are followed closely (significant toxicity begins at about 30 µg/mL while the newest lower recommendations for therapeutic levels are 5 to 15 ug/mL), theophylline is relatively safe. Further, a recent comparison of academic achievement scores among children taking theophylline for asthma compared with nonasthmatic siblings not on theophylline failed to show any learning problems,11 and a comparison of compliance of adolescents prescribed theophylline by tablet versus those given cromolyn or corticosteroids by metered dose inhaler indicated more than twice as many (73%) took their theophylline compared with the proportion who complied with inhaled corticosteroids (30%) or cromolyn (29%).12 Theophylline is also inexpensive and its use probably will rise again in managed care.
The bronchodilators consist primarily of the beta2'agonists, with albuterol as a prime example. These are best used by high-frequency nebulization up to toddler age, by inhalers after age 5 or 6 when the child can cooperate, and by inhalers with spacers or nebulization for those who can, at 3 and 4. Theophylline also has bronchodilating action but beta-agonists are the dominant bronchodilators.
How should we use the anti-inflammatory and bronchodilating agents? This depends on whether asthma is mild, moderate, or severe.8 A common reason for undertreatment is "underclassification."
* Mild asthma: low-grade symptoms that do not interfere with sleep and lifestyle or episodes of cough and wheeze occurring less than once per month. AU episodes respond to bronchodilators taken no more than two or three times per week,
* Moderate asthma: discrete attacks no more often than once a week or more chronic symptoms not affecting growth or development,
* Severe asthma: attacks more often than once a week or delayed growth and development. Patients who have infrequent but life-threatening attacks with normal lung function otherwise may be categorized as severe episodic.
For mild asthma, intermittent bronchodilator therapy by beta-agonists such as albuterol are all that is necessary. Parents and patients should always have treatment immediately available (a high-frequency nebulizer costs about $200 or less than most emergency room visits). Treatment should be needed no more than every 4 to 6 hours, and the wheezing should be controlled with this treatment alone within a day or two.
Moderate asthma adds anti-inflammatory treatment to intermittent beta-agonists. When beta-agonists every 4 to 6 hours fail, corticosteroid therapy should be initiated early. There is clear evidence that administration of corticosteroids parenterally or by mouth in the emergency center reduces admissions. However, you have to be able to observe the patient for at least 4 hours because this is when steroids begin to take effect. Dependable parents should have this treatment at home to administer after calling their physician. You then can make sure they do not have an active infection and have not been exposed to chicken pox. The early and aggressive use of corticosteroids when beta-agonists are not controlling asthma has more to offer than any other single treatment. Moderate asthma is also an indication for starting prophylaxis with cromolyn three or four times a day. Prophylaxis should continue at least as long as the allergy or viral season (depending on the history of what precipitates attacks). Long-term prophylaxis with beta-agonists is not recommended. If it is not possible to use cromolyn because of compliance or it doesn't work, theophylline is acceptable treatment if blood levels are monitored.
Severe attacks receive all of these treatments and often require intermittent intravenous or prolonged inhaled corticosteroids as well. Unfortunately, a patient must be able to use an inhaler or an inhaler with a spacer to receive FDA-approved inhaled corticosteroids in the United States because a nebulizable form is not available here. This is probably because no company has been willing to spend the money to test and get FDA approval - a failure of our system. Patients with moderately severe asthma who continue to need emergency visits or require admission should have a pediatric allergy/pulmonary consultation. Those with severe asthma are much easier to manage as a partnership.
In fact, the overall morbidity and mortality of asthma is at risk to become even worse under managed care. The generalist may be tempted to continue partially effective treatments too long, trying to avoid an HMO "black mark" for referrals. But hospitalization and emergency visits will end up costing more than consultations, so recognize your limitations.
The wild card in all of this is behavioral factors. Work with parents to try to make the child responsible for his or her own care as they are growing up (starting before adolescence) and minimize the invasiveness of your treatments (in the child's eyes) to give them the most acceptable lifestyle. Negotiate with the child and the parents - if they will not use a treatment or don't want it, you need to know. And use mental health consultations.
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