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Management of Asthma in Children - Article
ABSTRACT: The prevalence of asthma in children has increased 160 percent since 1980, and the disease currently affects nearly 5 million children in the United States. The National Asthma Education and Prevention Program provides guidelines for improved asthma care. The goals of this program are to limit the frequency, severity and costliness of asthma exacerbations through extensive education of physicians, children and caregivers. The four components of asthma management include regular assessment and monitoring, control of factors that contribute to or aggravate symptoms, pharmacologic therapy and education of children and their caregivers. The guidelines recommend a stepwise approach to pharmacologic treatment, starting with aggressive therapy to achieve control and followed by a "step down" to the minimal therapy that will maintain control. Quick relief of symptoms can be achieved preferentially by the use of short-acting beta2 agonists. Medications for long-term control should be considered for use in children with persistent symptoms. Inhaled corticosteroids are the most potent long-term anti-inflammatory medications. Other options include long-acting beta2 agonists, cromolyn sodium and nedocromil, antileukotriene agents and theophylline. All have advantages and disadvantages in individual situations.
Work-Related Asthma - Article
ABSTRACT: Work-related asthma accounts for at least 10 percent of all cases of adult asthma. Work-related asthma includes work aggravation of preexisting asthma and new-onset asthma induced by occupational exposure. Occupational exposure to very high concentrations of an irritant substance can produce reactive airway dysfunction syndrome, while exposure to allergenic substances can result in allergic occupational asthma. An important step in the diagnosis of work-related asthma is recognition by the physician of the work relatedness of the illness. A thorough history can elucidate the work relation and etiology. Objective tests, including pulmonary function, nonspecific and specific bronchial hyperresponsiveness, serial peak expiratory flow rates, and skin allergies, should be performed to confirm the diagnosis of asthma and demonstrate a work correlation. Treatment for occupational asthma--use of anti-inflammatory medications such as inhaled steroids and bronchodilators--is the same as that for nonoccupational asthma. Prevention is an integral part of good medical management. In patients with work-aggravated or irritant-induced asthma, reduction of exposure to aggravating factors is essential. In patients with allergic occupational asthma, exposure should be eliminated because exposure to even minute concentrations of the offending agent can trigger a potentially fatal allergic reaction.
ABSTRACT: Despite increased scientific knowledge about asthma and improved therapeutic options, the disease continues to cause significant morbidity and mortality. The National Asthma Education and Prevention Program Expert Panel has updated its clinical guidelines on asthma medications, prevention of disease progression, and patient self-management. Diagnostic criteria have not changed, and identification of the disease relies on the physician's analysis of the patient's symptoms, family history, and spirometric measurements of lung function. Classification of asthma severity also has not changed, but many obstacles remain, including the variability of asthma and the classification system's inability to account for physical activity levels, which may result in significant underestimation of the severity of asthma. The National Asthma Education and Prevention Program recommends the use of written action plans with or without monitoring of peak expiratory flow, although evidence supporting these management techniques is inconclusive. Patients with asthma may benefit from earlier use of inhaled corticosteroids, which have been proven safe in the usual dosages. However, further studies are needed to determine whether inhaled corticosteroids can prevent the progression of asthma.
Childhood Asthma: Treatment Update - Article
ABSTRACT: The prevalence of childhood asthma has risen significantly over the past four decades. A family history of atopic disease is associated with an increased likelihood of developing asthma, and environmental triggers such as tobacco smoke significantly increase the severity of daily asthma symptoms and the frequency of acute exacerbations. The goal of asthma therapy is to control symptoms, optimize lung function, and minimize days lost from school. Acute care of an asthma exacerbation involves the use of inhaled beta2 agonists delivered by a metered-dose inhaler with a spacer, or a nebulizer, supplemented by anticholinergics in more severe exacerbations. The use of systemic and inhaled corticosteroids early in an asthma attack may decrease the rate of hospitalization. Chronic care focuses on controlling asthma by treating the underlying airway inflammation. Inhaled corticosteroids are the agent of choice in preventive care, but leukotriene inhibitors and nedocromil also can be used as prophylactic therapy. Long-acting beta2 agonists may be added to one of the anti-inflammatory medications to improve control of asthma symptoms. Education programs for caregivers and self-management training for children with asthma improve outcomes. Although the control of allergens has not been demonstrated to work as monotherapy, immunotherapy as an adjunct to standard medical therapy can improve asthma control. Sublingual immunotherapy is a newer, more convenient option than injectable immunotherapy, but it requires further study. Omalizumab, a newer medication for prevention and control of moderate to severe asthma, is an expensive option.
ABSTRACT: Leukotriene inhibitors are the first new class of medications for the treatment of persistent asthma that have been approved by the U.S. Food and Drug Administration in more than two decades. They also have been approved for the treatment of allergic rhinitis. Prescriptions of leukotriene inhibitors have outpaced the evidence supporting their use, perhaps because of perceived ease of use compared with other asthma medications. In the treatment of persistent asthma, randomized controlled trials have shown leukotriene inhibitors to be more effective than placebo but less effective than inhaled corticosteroids. The use of leukotriene inhibitors has not consistently shown an inhaled-steroid-sparing effect, a reduction in need for systemic steroid treatment, or a cost savings. For exercise-induced asthma, leukotriene inhibitors are as effective as long-acting beta2-agonist bronchodilators and are superior to placebo; they have not been compared with short-acting bronchodilators. Leukotriene inhibitors are as effective as antihistamines but are less effective than intranasal steroids for the treatment of allergic rhinitis. The use of leukotriene inhibitors in treating atopic dermatitis, aspirin-intolerant asthma, and chronic idiopathic urticaria appears promising but has not been studied thoroughly. Leukotriene inhibitors have minimal side effects and are well tolerated in most populations.
The Role of Allergens in Asthma - Article
ABSTRACT: The National Asthma Education and Prevention Program Expert Panel guidelines for the management of asthma recommend that patients who require daily asthma medications have allergy testing for perennial indoor allergens and that, when triggers are found, exposure to allergens and pollutants be controlled through avoidance and abatement. For patients whose symptoms are not controlled adequately with these interventions and who are candidates for immunotherapy, the guidelines recommend referral to an allergist. However, the data supporting these recommendations are not consistent. Although there is evidence that simple allergen avoidance measures are ineffective, there is good evidence for the effectiveness of a comprehensive approach based on known sensitization. Thus, allergen avoidance may include removal of pets, use of high-efficiency particulate air filtration and vacuum cleaners, use of allergen-impermeable mattress and pillow covers, cockroach extermination, smoking cessation, and measures to control mold growth in the home. All allergen-specific treatment is dependent on defining sensitization. This can be achieved through serum assays of immunoglobulin E antibodies or skin tests with aeroallergens. Information on sensitization can be used to educate patients about the role of allergens in their symptoms, to provide avoidance advice, or to design immunotherapy.
The Diagnosis of Wheezing in Children - Article
ABSTRACT: Wheezing in children is a common problem encountered by family physicians. Approximately 25 to 30 percent of infants will have at least one wheezing episode, and nearly one half of children have a history of wheezing by six years of age. The most common causes of wheezing in children include asthma, allergies, infections, gastroesophageal reflux disease, and obstructive sleep apnea. Less common causes include congenital abnormalities, foreign body aspiration, and cystic fibrosis. Historical data that help in the diagnosis include family history, age at onset, pattern of wheezing, seasonality, suddenness of onset, and association with feeding, cough, respiratory illnesses, and positional changes. A focused examination and targeted diagnostic testing guided by clinical suspicion also provide useful information. Children with recurrent wheezing or a single episode of unexplained wheezing that does not respond to bronchodilators should undergo chest radiography. Children whose history or physical examination findings suggest asthma should undergo diagnostic pulmonary function testing.
Albuterol vs. Levalbuterol for Asthma Treatment in Children - AFP Journal Club
Genetic Factors In Drug Metabolism - Article
ABSTRACT: Patients vary widely in their response to drugs. Having an understanding of the pharmacokinetic and pharmacodynamic properties of various medications is importantwhen assessing ethnic differences in drug response. Genetic factors can account for 20 to 95 percent of patient variability. Genetic polymorphisms for many drug-metabolizing enzymes and drug targets (e.g., receptors) have been identified. Although currently limited to a few pathways, pharmacogenetic testing may enable physicians to understand why patients react differently to various drugs and to make better decisions about therapy. Ultimately, this understanding may shift the medical paradigm to highly individualized therapeutic regimens.
ABSTRACT: Gastroesophageal reflux disease typically manifests as heartburn and regurgitation, but it may also present with atypical or extraesophageal symptoms, including asthma, chronic cough, laryngitis, hoarseness, chronic sore throat, dental erosions, and noncardiac chest pain. Diagnosing atypical manifestations of gastroesophageal reflux disease is often a challenge because heartburn and regurgitation may be absent, making it difficult to prove a cause-and-effect relationship. Upper endoscopy and 24-hour pH monitoring are insensitive and not useful for many patients as initial diagnostic modalities for evaluation of atypical symptoms. In patients with gastroesophageal reflux disease who have atypical or extraesophageal symptoms, aggressive acid suppression using proton pump inhibitors twice daily before meals for three to four months is the standard treatment, although some studies have failed to show a significant benefit in symptomatic improvement. If these symptoms improve or resolve, patients may step down to a minimal dose of antisecretory therapy over the following three to six months. Surgical intervention via Nissen fundoplication is an option for patients who are unresponsive to aggressive antisecretory therapy. However, long-term studies have shown that some patients still require antisecretory therapy and are more likely to develop dysphagia, rectal flatulence, and the inability to belch or vomit.