Children’s Asthma Management Program: Improving the health of children with asthma
from Caring For Our Future, Summer 2006
By Diane Herrick, RRT, NPS, AE-C, Coordinator, The Children's Hospital Asthma Management Program
Asthma is the most common chronic disease of childhood and the No. 1 discharge diagnosis at The Children’s Hospital. Asthma has significant health, social and economic impact upon children, their families and society at large. In the past two decades, progress in assessment, diagnosis, control medications, education and monitoring haveresulted in substantial improvement in asthma control. The Children’s Hospital Asthma Management Program incorporates evidence-based Clinical Care Guidelines to provide coordinated, evidence-based systems of care.
Asthma Prevalence
According to the Centers for Disease Control (CDC), more than 150 million people throughout the world have asthma. In the U.S. , 14 to 15 million people, including more than 5 million children, have asthma. From 1980 to 1994, there was a 74 percent increase in asthma prevalence among children ages 5 to 14 and a 160 percent increase in children under the age of 4. Asthma continues to be more prevalent in African-Americans and in lower socioeconomic populations.
Morbidity and Mortality
Primary risk factors for morbidity and mortality include socioeconomic deprivation, urban dwelling, co-morbidity (chronic lung disease, cardiovascular disorder), environmental exposures and ethnicity. Additional mortality risk factors include: past history of sudden severe exacerbation; prior intubation for asthma; prior ICU admission; two or more hospitalizations within the last year; current use or recent withdrawal of systemic corticosteroids; difficulty perceiving airfl ow obstruction or severity of symptoms; serious psychiatric disease or psychosocial problems; and illicit drug use.
In 2000, Emergency-Department (ED) visits were 125 percent higher and hospitalization rates 220 percent higher among black non-Hispanics compared with white non-Hispanics, with death rates for asthma consistently highest among African-Americans aged 14-24 years. In 2000, 4,487 people died from asthma in the United States , or a rate of 1.6 per 100,000 people. Among children, asthma deaths were rare, with 223 children aged 0–17 dying from asthma, or 0.3 deaths per 100,000 children. The upward trend in deaths has flattened since that time. In 2002 among children 0 to 17 years, there were approximately 214,000 hospitalizations (30 per 10,000) and hospitalizations were highest among children 0–4 years (67 per 10,000). Overall, the number of children who access any acute outpatient care is nearly double that of adults. Social impact in the U.S. includes 14.5 million lost workdays and 14.0 million lost school days.
Economic Impact
In 2000, the calculated annual total cost of asthma (adults and children combined) to the U.S. economy was approximately $12.7 billion, with direct costs contributing $8.1 billion and indirect costs (loss of work, lost school days and mortality) contributing $4.6 billion. The annual estimated cost of asthma-related inpatient hospital care was more than $3.5 billion, and the annual estimated cost of asthma-related emergency room visits was more than $650 million. The burden of health-care costs for asthma treatment in the U.S. more than doubled between 1990 and 2000, from $6.2 billion to $12.7 billion.
The Children’s Hospital Asthma Management Program
Asthma has a significant impact at Children’s that is reflective of national data (See Table 1).
In 2002, a team made up of representatives from Respiratory Care, Pulmonary Medicine, Emergency Medicine, the Child Health Clinic and the Pharmacy convened to assess current asthma care at Children’s. Assessment revealed inconsistencies in diagnosis, assessment of severity, therapeutic interventions, education, monitoring and referral to asthma specialists. Subsequently, the team developed a strategic plan based upon available evidence and the National Institute for Health (NIH) Expert Panel 2 recommendations. The plan called for improvements and consistency in diagnosis, classification, treatment, education of health-care providers and families, monitoring, use of an Asthma Action Plan, and referral to an asthma specialist.
|
Principal Diagnosis 493XX |
Secondary Diagnosis 493XX |
Total |
| Inpatients |
415 |
371 |
786 |
| ED Patients |
1110 |
537 |
1647 |
| Outpatients |
3329 |
1508 |
4837 |
| Total |
4854 |
2416 |
7270 |
All patients of all ages discharged 1/1/03 - 12/31/03 with Asthma diagnosis codes.
Asthma Clinical Care Guidelines (CCG) were implemented in 2003. Ongoing analysis of new evidence, methods and trends, in addition to trouble-shooting of the existing CCG, are incorporated into annual reviews and revisions by the Asthma Management Team and Children’s Outcomes Committee. The following are descriptions and rationale for key components of the Asthma CCG.
NIH guidelines for acute and ongoing asthma management strongly support accurate diagnosis and the use of care pathways. Accurate diagnosis results in more appropriate standardized acute and long-term care; lower morbidity and mortality rates; improved quality of life; and decreased utilization of acute care services. Identifying the disease to families, patients and health-care providers facilitates better acute and home management and outcomes (See Table 2).
At Children’s, a retrospective review of coding for children who met inclusion criteria revealed significant inconsistencies in diagnosis, including Reactive Airways Disease (RAD), pneumonitis, pneumonia, bronchiolitis and multiple sub-codes for asthma. Although RAD never had an assigned International Classes of Diseases (ICD) code, it continues to be documented and coded as a misnomer for asthma. Children who meet inclusion criteria are now assigned the diagnosis of asthma exacerbation as part of pre-printed orders, significantly improving the accuracy of diagnosis and consistency in care.
The asthma CCG uses the NIH classification system to facilitate appropriate long-term control. Assessment includes baseline symptoms, exercise tolerance, night symptoms and utilization of beta agonists. Patients already on everyday control medications are assessed for level of control using the same criteria. Control medications, with inhaled corticosteroids as the fi rst choice, are initiated shortly after admission so families can learn their purpose and correct administration.
| Inclusion |
Exclusion |
| Age 2 years or older with history of asthma |
Age less than 2 years old |
| Episodic symptoms of airflow obstruction such as recurrent cough and/or wheeze |
ICU admission |
| Airway obstruction at least partially reversible with Beta-2 agonist therapy |
Chronic lung disease, BPD, aspiration, cystic fibrosis |
| Includes first time episode |
Airway anomalies (e.g. tracheomalacia, subglottic stenosis) |
|
Bronchiolitis |
|
Croup/stridor |
|
Cardiac disease |
|
Neurological disorders |
Eligibility for inclusion is determined by the ED or inpatient admitting physicians.
Management of Acute Exacerbation
The NIH defines asthma exacerbation as episodes of progressively worsening shortness of breath, coughing, wheezing, accessory muscle use, chest tightness or some combination of these symptoms, characterized by decreases in expiratory airflow that can be quantified objectively.
Objective measures are more reliable indicators of obstruction than symptoms, but are often difficult to obtain in children. Symptoms often present for days to weeks and often are not recognized as asthma, especially in infants and younger children. Typically, patients present with a gradual increase in symptoms with increased use of quick relief medications over 5-7 days prior to exacerbation, followed by more rapid rise in the immediate 2- to 3-day period prior to admission. The Asthma CCG incorporates the Pediatric Asthma Score (PAS) for assessment and acute management (See Table 3).
Inhaled beta agonist therapy is the most effective means of rapidly reversing airflow obstruction, making it the first-line treatment for an acute exacerbation. Beta agonists can be delivered intermittently by small-volume nebulizer or with Metered-Dose Inhalers (MDIs)/valved holding chamber, or continuously by nebulizer. The degree of improvement is a function of the dose delivered. Factors impacting delivery include respiratory rate, breathing patterns, posture (upright position best), delivery (ideal mouthpiece or snug-fitting mask—NO BLOWBY) and correct device technique. The above factors should be considered since less than 20 percent of medication is delivered in ideal conditions, with less in children.
Recommendations are a high dose initially, then titration per severity assessment and FEV1/PEFR (forced expiratory volume in 1 second/peak expiratory flow rate). There does not seem to be any advantage in giving larger or more frequent quantities once pulmonary mechanics approach lower limit of normal. The Asthma CCG utilizes Bronchodilator Weaning Protocols that incorporate the PAS and algorithms specifi c to the ED and Inpatient settings. (See Asthma CCG). Patients may be managed off the Bronchodilator Weaning Protocols if they fail to respond in a straightforward manner or are worsening despite intensification of therapy.
Studies of ipratropium bromide (Atrovent) combined with beta2-agonist therapy demonstrate improved lung function, reduced admissions, decreased treatment duration and shorter length of ED stay more than beta2-agonists alone for moderate to severe asthma exacerbations. There were no significant benefits from single dose controls or in the Inpatient setting. The Asthma CCG includes it only in the first 24 hours for patients requiring beta agonists every two hours or more.
Systemic corticosteroids also are essential first-line medications for an acute asthma exacerbation and are most effective if begun early in treatment after initiating beta2-agonist therapy. Beneficial effects are seen within 6 to 12 hours, and oral or parenteral are equally effective. The loading dose of prednisone or solumedrol is 2mg/kg, then 1mg/kg BID. Patients typically receive a five- to seven-day burst, but may need longer depending upon severity and course of illness or prior use.
Assessment of oxygenation is also key, with supplemental oxygen for SpO2 less than 90 percent on room air or for any child in moderate to severe distress. SpO2 is the percentage of oxygen saturation (sometimes called oxygen saturation or O2 saturation). Hypoxia in children is associated with an FEV1 of less than 40 percent to 50 percent, indicating a high degree of obstruction. In Denver , a SpO2 of less than 90 percent on room air is a good predictor for an extended ED stay or hospitalization in young children. SpO2 may drop after delivery of beta agonists and is more pronounced with pneumonia and/or atelectasis.
The Asthma CCG recommends monitoring of airflow obstruction and response to beta agonists for patients 5 years or older via peak flow measurements on admission and before and after bronchodilator therapy, with spirometry prior to inpatient discharge.
Chest X-rays are not routinely indicated but may be considered in cases of first-time wheezing episodes, high fever, history of choking and/or foreign body aspiration, delayed resolution of symptoms including hypoxia, and persistent asymmetric lung exam. Arterial blood gases are not routinely indicated but may be considered in the presence of altered mental state, progressive fatigue, severe symptoms persisting after initial treatment and assessment of ventilation after intubation. Respiratory drive is typically elevated, and a relatively “normal” PCO2 (blood carbon dioxide level) of 40-42 mm hg indicates severe airfl ow obstruction and heightened risk of respiratory failure in children.
Whenever possible, unassigned patients should be assigned to the Pulmonary Team, although in-house consultations also can be ordered by the attending physician. Follow-up care with the PCP should be arranged for one to three days after discharge. Consultation with an asthma specialist is recommended for patients with moderate or severe persistent asthma and for all hospitalizations, and also should be considered for patients with mild persistent asthma. Outpatient follow-up with an asthma specialist includes allergy and skin testing; management of persistent asthma; and spirometry or additional pulmonary function testing.
Patient and family education combined with an Asthma Action Plan are instrumental for long-term management of asthma. Key messages include basic facts about asthma; description of quick relief vs. control medications; device techniques; environmental control measures including tobacco-exposure reduction; monitoring of peak flow and symptoms; and when and how to take rescue actions. Consistent education and reinforcement of the key messages should be provided throughout the patient’s stay, and the family must demonstrate understanding and proficiency in all key components and agree with the Asthma Action Plan prior to discharge.
Measurement of Outcomes
Due to inconsistencies in measurement systems, practices and outcomes prior to implementation of the Asthma CCG are not well-defined, making it difficult to compare it with data after implementation. Future implications include retrospective review of patient charts and prospective measuring of provider adherence and overall patient outcomes.
