GRAND ROUNDS PREVIEW

PATRICIA VISBAL EDMONDSON, M.D.

DIRECTOR, PEDIATRIC PULMONOLOGY

FHMC & JHMC
 ASTHMA GUIDELINES

Chronic inflammatory disorder

Treatment:
Controller anti-inflammatory
medications
 DECADES’ LONG MANTRA
FOR ASTHMA TX

You Must
Take Your CONTROLLER
Medications Everyday

SABA with flare-ups

 You Must Take Your Medications Everyday

#1 Chronic Illness

Treatment Barrier:

NONCOMPLIANCE
 You Must Take Your Medications Everyday

NONCOMPLIANCE
Close f/u
Education

Motivation

M&M Fear

Social Serv Consultation

Visiting Nurse
You Must Take Your Medications Everyday

Talk until
we’re blue
in the face ?

OK!
You Must Take Your Medications Everyday

How can I help you take your

medication EVERYDAY?

STAND ON MY
HEAD?
SURE!
You Must Take Your Medications Everyday

ACS?
We’re at our wits’
end.
 You Must Take Your Medications Everyday

Proposed New Asthma Guidelines?

PRN
Controller Medication

Controller Medication instead of

SABA
Proposed New Asthma Guidelines?
As Linda Richman would say:

I’m really
VERKLEMPT
 Proposed New Asthma Guidelines

ICS/LABA

Symbicort
(Budesonide / Formoterol)
 Proposed New Asthma Guidelines

Rationale
Noncompliance is high, esp in mild
asthma

SABA increases in noncompliance

PRN controllers with sxs Some ICS tx

and safer than just inc SABA use
 Proposed New Asthma Guidelines

Early 2000’s

SMART Studies

Prevention of severe exacerbations

Symbicort used as rescue superior to SABA

PRN
Proposed New Asthma Guidelines
 Proposed New Asthma Guidelines

1. Placebo bid + SABA prn = Terbutaline

2. Placebo bid + Symbicort prn= Symbicort prn
3. Budesonide bid + SABA prn= Bud maintance

Well controlled sxs

2 Better than 1
2 Inferior to 3

Exacerbations rates
2 and 3 better than 1
Rates were similar for 2&3
Proposed New Asthma Guidelines
Proposed New Asthma Guidelines
 Proposed New Asthma Guidelines

1. Placebo bid + Symbicort prn

2. Budesonide bid + SABA prn

Well controlled sxs

1 Inferior to 2

Exacerbations rates
1 was noninferior to 2
 Proposed New Asthma Guidelines

GINA GUIDELINES 2019

NEVER SABA alone for mild
asthma
Symbicort PRN, when SABA is
taken prn
Various choices for controller meds
Including Symbicort bid PLUS

Symbicort PRN
OUT-PT ASTHMA EXACERBATION TX

WHAT FORM OF SABA

SHOULD BE
PRESCRIBED?
 SABA

13 yo admitted FH in status asth

No SABA neb at home, MDI incorrect use w/ sp-mk
Mother had asked PCP for SABA neb: Told not
needed

Severe status
Required MgSO4 x 2
LOS 3 days
Mother asks for SABA neb: Told not needed
SABA MDI – sp-mk, no instructions for use
 SABA Nebulized vs MDI-Spacer

Neb SABA preferred

Multiple SABA mode of administration studies

QUESTION: Is Neb better than MDI-Sp

Neb = MDI-Sp
Contingent on: MDI-Sp correct use
 SABA Nebulized vs MDI-Spacer
Neb = MDI-Sp
Further Studies:
Is MDI-Sp superior to Neb in more signif exacerb
 Meta Analysis
 Less ED time (30 min less)
 Less tachycardia / tremor
 No difference adm rates

Effect: Recommend MDI-sp over Neb for home

Caveat
 Studies were not equal
 Required MANY DOSES OF MDI SABA
 Not home studies
 SABA Nebulized vs MDI-Spacer

British Guideline On The Management Of

Asthma (2003, Revised 2019)
Prescribe inhalers only after patients have received
training in the use of the device and have demonstrated
satisfactory technique.
In young children, a pMDI and spacer is the
preferred method of delivery of β2 agonists and
inhaled corticosteroids. A face mask is required
until the child can breathe reproducibly using the
spacer mouthpiece. Where this is ineffective a
nebuliser may be required.
 SABA Nebulized vs MDI-Spacer

Children and adults with mild and moderate asthma

attacks should be treated with a pMDI + spacer with
doses titrated according to clinical response.

Children under three years of age are likely to

require a face mask connected to the mouthpiece of a
spacer for successful drug delivery. Inhalers should
be actuated into the spacer in individual puffs
and inhaled immediately by tidal breathing (for
five breaths).
 SABA Nebulized vs MDI-Spacer

Two to four puffs of salbutamol (100 micrograms

via a pMDI + spacer) might be sufficient for mild
asthma attacks, although up to 10 puffs might be
needed for more severe attacks. Single puffs should
be given one at a time and inhaled separately with
five tidal breaths.
Relief from symptoms should last 3–4 hours.
If symptoms return within this time a further or
larger dose (maximum 10 puffs) should be given and
the parents/carer should seek urgent medical advice.
 SABA Nebulized vs MDI-Spacer

Increase β2 agonist dose by giving one puff every

30–60 seconds, according to response, up to
a maximum of 10 puffs.

When that fails:

Paramedics attending to children with an acute
asthma attack should administer nebulised
salbutamol, using a nebuliser driven by oxygen if
symptoms are severe, whilst transferring the child to
the emergency department.
 SABA Nebulized vs MDI-Spacer

There are insufficient data on which to

make recommendations in acute severe or
life-threatening asthma.
 SABA Nebulized vs MDI-Spacer

Give controlled supplementary oxygen to all

hypoxaemic patients with acute severe asthma
titrated to maintain an SpO2 level of 94–98%.
Do not delay oxygen administration in the absence of
pulse oximetry but commence monitoring of SpO2 as
soon as it becomes available.

Give steroids in adequate doses to all patients

with an acute asthma attack.