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When to Refer: Pediatric Asthma Red Flags Every Hospitalist Should Know · Pediatrics in Practice: A CME Podcast

• 0:03
  Dr. Sarah Gubara (Host):
• 0:03
  Welcome to Pediatrics in Practice, a CME podcast.
• 0:07
  I'm Dr.
• 0:07
  Sarah Gubara.
• 0:09
  And today, I'm joined by Dr.
• 0:11
  Jade Tam-Williams, Division Director of Allergy, Immunology,
• 0:16
  Pulmonary, and Sleep Medicine.
• 0:19
  Today, we're discussing clinical management of asthma.
• 0:23
  Dr.
• 0:23
  Tam-Williams, thank you for joining us today.
• 0:26
  Dr. Jade Tam-Williams:
• 0:26
  Thank you for having me.
• 0:28
  Host: Dr.
• 0:28
  Tam-Williams, when you think about day-to-day asthma care in pediatrics,
• 0:33
  what are the most common management gaps you see in primary care, and how
• 0:37
  can pediatricians address them early?
• 0:40
  Dr. Jade Tam-Williams:
• 0:40
  So, one of the most common gaps that I see as a pediatric pulmonologist
• 0:45
  for children with asthma is a reliance still on short-acting beta
• 0:51
  agonists, such as albuterol, before adding in inhaled corticosteroids.
• 0:57
  For about seven years now, the guideline has included the use of inhaled
• 1:04
  corticosteroids along with a reliever therapy for children with asthma.
• 1:11
  We often still see children coming to the pediatric pulmonology office who have
• 1:17
  only ever tried albuterol and receiving oral corticosteroids with illnesses.
• 1:23
  Now, the guidelines say essentially that, yes, you can actually add in
• 1:28
  inhaled corticosteroids, whether it's in the yellow zone or what we
• 1:32
  call concomitantly using inhaled corticosteroids with albuterol every
• 1:38
  four to six hours as needed during an illness, or using ICS with a formoterol
• 1:44
  platform, such as a single maintenance and reliever therapy, sort of a plan
• 1:50
  or an ICS with formoterol as needed.
• 1:54
  All of these treatment plans allow for the use of anti-inflammatory
• 1:59
  inhaled corticosteroids during an exacerbation, and it has not been
• 2:04
  completely picked up in the practice yet.
• 2:07
  We recognize, as those of us who do asthma, that the patient or the family
• 2:13
  may not immediately see the benefit of inhaled corticosteroid during
• 2:17
  illness or during exacerbations.
• 2:20
  But the goal overall is to prevent worsening of flares, and to sort of take
• 2:27
  a population-based approach for this.
• 2:30
  And I think that is one big gap that we still are seeing in general pediatrics.
• 2:37
  I think the other thing is there's still a gap in the feeling of how do we convey
• 2:46
  education on asthma and overall prognosis?
• 2:50
  This has continued to be difficult for children with asthma as we still hear
• 2:55
  out in the community phrases such as reactive airways disease, for instance,
• 3:01
  which is not an actual disease process.
• 3:07
  There is such a thing as reactive airways dysfunction, for instance.
• 3:10
  But reactive airways disease is sort of one of the ways that people
• 3:15
  have been disguising asthma—is another way that I think about it.
• 3:21
  Host: When you think about stepwise therapy in children whose symptoms
• 3:25
  don't fit neatly into mild or moderate asthma, what should prompt pediatricians
• 3:31
  to escalate or reassess treatment?
• 3:34
  Dr. Jade Tam-Williams:
• 3:34
  I still personally use the rule of twos.
• 3:37
  I think it's a very easy rule.
• 3:40
  I think it's easy to explain to families.
• 3:43
  And so, the rule of two is still symptoms, cough, wheezing, shortness of breath, or
• 3:49
  use of your albuterol or ICS formoterol, some sort of rescue inhaler use more
• 3:55
  than two days per week; waking up at night coughing, wheezing, or short of
• 4:00
  breath more than two times out of a month; and more than two exacerbations
• 4:06
  a year that require steroids.
• 4:08
  And I think the rule of twos allows families to really understand control.
• 4:14
  I think a lot of families are so "used to" their child who coughs all the time or
• 4:21
  wheezes all the time, they don't recognize what is actually normal, so to speak.
• 4:27
  And whenever I provide education in my clinic, I always talk about, "Hey,
• 4:33
  well, you know, I'm glad you feel like your child is well controlled.
• 4:36
  Tell me, how many times out of a week does your child cough or wheeze?"
• 4:42
  And then sometimes they say, "Oh, sometimes," or, "A little bit."
• 4:47
  And then, I'll actually push it and say, "Is it more than two times in a week?
• 4:51
  Or do you think they're waking up at night more than two times in a month?"
• 4:55
  And that's when really the families have this kind of eye-opening, "Oh, well, wait.
• 5:00
  That's a lot, more than two?"
• 5:02
  And when I use that rule, it allows me to then say, "Okay, we
• 5:08
  need to escalate our symptoms up."
• 5:10
  And I explain to them, what we don't want is we don't want to under-treat.
• 5:14
  We don't want to over-treat either, but we don't want to under-treat your child.
• 5:18
  And I think giving them a context with using the rule of twos
• 5:23
  really helps me convey that.
• 5:26
  After you then assess, okay, how much is the control?
• 5:29
  Are they well controlled or are they not well controlled?
• 5:32
  And yes, we should escalate.
• 5:33
  After that point, then my suggestion and the guidelines suggest to continue
• 5:38
  to follow up at least every quarter and every six to 12 months for maintenance.
• 5:45
  After good control, then comes the time for when you can step down.
• 5:50
  All of us as pediatricians know of the kid that struggles all winter, but then
• 5:56
  has a wonderful summer, for instance.
• 5:58
  And so, sometimes getting them in more frequently over the wintertime
• 6:03
  and then maybe giving them the summer holidays a break or a holiday break
• 6:08
  off of their medications could be done if you're seeing them that frequently.
• 6:14
  Host: Thank you for sharing about that.
• 6:17
  In your experience, what role do adherence, inhaler technique,
• 6:21
  environmental triggers play in asthma that appears refractory to standard treatments?
• 6:27
  Dr. Jade Tam-Williams:
• 6:27
  So as part of my clinical work, I specifically manage severe refractory
• 6:33
  asthmatics, and I would say a good number of severe refractory asthmatics
• 6:39
  have difficult-to-control asthma because of medication nonadherence.
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  Many of the issues around medication nonadherence unfortunately surround
• 6:49
  the mythology around medications.
• 6:52
  But sometimes it's about access to medications from a financial perspective,
• 6:59
  from an insurance, or maybe even from a transportation perspective.
• 7:03
  So, medication nonadherence does play a pretty big role in
• 7:07
  so-called refractory asthmatics.
• 7:09
  There are definitely some children who are truly, truly refractory.
• 7:14
  They are definitely taking all of their medications, yet they continue to have
• 7:20
  exacerbations and flares and poor control.
• 7:23
  Another place that I do see problems is definitely in inhaler or spacer technique.
• 7:29
  There was one study that showed almost 50% of people out there are
• 7:33
  using their inhalers incorrectly.
• 7:36
  In children, we've really pushed, through our asthma education
• 7:41
  program the importance of using a spacer or a valved holding chamber
• 7:46
  with all of your MDI inhalers.
• 7:50
  And that has been good.
• 7:51
  But now, unfortunately, there's this sense of, "Well, I only
• 7:55
  need to use it if I'm a kid.
• 7:57
  I don't need to use it once I've hit a certain age because I'm 'old
• 8:02
  enough to figure out how to do that.'"
• 8:04
  And that's just not true.
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  Using a spacer increases the amount of medications that you get.
• 8:10
  Once you get into the "severe refractory asthmatic" though, you now get a number
• 8:17
  of different types of inhaled medications.
• 8:20
  So, as an example, a level five asthmatic might be on a Dulera, that is an HFA
• 8:29
  that uses a valved holding chamber, and a Spiriva Respimat that does not
• 8:35
  need a valved holding chamber and has a different modality of delivering
• 8:40
  medication, or a Spiriva Handihaler, which is a dry powder that you have to
• 8:46
  actually put a pill in, and then you puncture the pill, and then you inhale it.
• 8:50
  They may also have Digihaler that maybe keeps track of how many puffs they take.
• 8:58
  So, the field has gotten ever more complicated, because there are so
• 9:03
  many different ways to deliver these medications, and oftentimes families
• 9:08
  might get confused, or patients might get confused to what they need to use
• 9:13
  an inhaler with, and what they don't.
• 9:15
  Host: I appreciate the recommendation on inhaler technique.
• 9:19
  I'm a proud user of my spacer.
• 9:21
  So, thank you for validating that.
• 9:23
  Dr. Jade Tam-Williams:
• 9:23
  I tell all of my patients that Dr.
• 9:28
  Jade is still using a spacer, and I'm much older than you.
• 9:33
  Host: Dr.
• 9:34
  Tam-Williams, what clinical or historical red flags should signal
• 9:38
  the need for referral to allergy, immunology, or pulmonology?
• 9:43
  Dr. Jade Tam-Williams:
• 9:43
  Let's go first with signs and symptoms, and then we'll go with physical exam.
• 9:47
  So for example, signs and symptoms that would make me really nervous,
• 9:52
  the patient's not growing, not gaining weight well, having failure to thrive.
• 9:57
  That would be one big one that would make, say, parents, like, "Hey,
• 10:01
  they eat and they eat and they eat, but they just don't put on weight."
• 10:05
  That's a red flag.
• 10:07
  A chronic runny nose every single day, chronic wet cough every single day.
• 10:12
  And sometimes I clarify this because we get some families who, you
• 10:16
  know, moms who are maybe a little overwrought and very anxious who
• 10:20
  say, "Oh no, it never goes away."
• 10:21
  But you have to really push them and say, "Really?
• 10:24
  Every single day the kid has a runny nose?"
• 10:27
  That would be a concern.
• 10:28
  Every single day, the kid has a chronic wet cough.
• 10:31
  Yes, that's a concern.
• 10:33
  Any kind of GI symptomatology automatically makes me think,
• 10:37
  "Okay, is there some cystic fibrosis here I'm missing?
• 10:40
  Some kind of immunodeficiency?"
• 10:42
  Need for antibiotics, not just need for steroids.
• 10:46
  Lots of high doses of steroids, more than two, again, going back to that
• 10:50
  rule of two would be another kind of history thing that would make me nervous.
• 10:55
  New onset wheezing at an older age, right?
• 10:59
  So, a kid who never wheezed before, never had problems with illnesses,
• 11:05
  and now suddenly at the age of 10 or 12, suddenly has localized wheezing
• 11:13
  that doesn't respond to albuterol.
• 11:15
  That's just weird.
• 11:16
  That doesn't fit.
• 11:18
  So, those things in the history would make me say, "Hey, maybe let's
• 11:23
  think a little bit more, push a little bit harder on an evaluation."
• 11:27
  On exam, definitely clubbing would make me say, "Yep, that's different."
• 11:33
  Any kind of cyanosis, hemoptysis, any of those things would be of concern, too.
• 11:39
  I look a lot at growth charts.
• 11:41
  I'm kind of obsessive about them at this point for a number of reasons.
• 11:46
  One because I always want to make sure I'm not missing some kind of genetic
• 11:50
  condition like such as cystic fibrosis.
• 11:53
  But the other is also that I'm always looking to make sure that the number
• 11:58
  of steroids the child is on hasn't caused iatrogenic adrenal insufficiency.
• 12:03
  And that can be hard because we oftentimes think about steroids
• 12:06
  leading to weight gain and whatnot, but we also need to think about
• 12:11
  a kid who's not gaining height.
• 12:14
  I think every year I catch a couple of iatrogenic adrenal insufficiency kids
• 12:19
  just by looking at their growth chart, and then sending them to endocrinology.
• 12:24
  Those would all be things that I'd say, "Hey, why don't you get assessed,
• 12:27
  you know, by a subspecialist?"
• 12:30
  And then, definitely indications of high mortality risk.
• 12:34
  A child who's ever been to the ICU is more likely to die of asthma.
• 12:38
  If they've needed a non-invasive ventilation like BiPAP, again,
• 12:42
  more likely to die of asthma.
• 12:44
  Frequent ER visits, frequent, steroids, again, more likely to
• 12:48
  die of asthma than another child.
• 12:51
  Those would be other red flags that says, "Hey, you need to come on in and
• 12:56
  get checked out by a subspecialist."
• 12:58
  Host: I appreciate the clinical and red flags that you've shared.
• 13:01
  Is there an ideal workup that would be most helpful to you
• 13:06
  before getting that referral?
• 13:07
  Dr. Jade Tam-Williams:
• 13:07
  Sure.
• 13:08
  If you put the child on an inhaler, make sure they're doing it correctly.
• 13:13
  Does the kid have a valved holding chamber?
• 13:15
  Does the kid actually know how to do it properly?
• 13:18
  Can they demonstrate appropriate technique for you?
• 13:21
  And just to put a plug in, we have lots of great resources on our
• 13:25
  Children's Mercy website on how to use aerochambers and educational pieces.
• 13:32
  And for every inhaled asthma medication out there, I have how
• 13:37
  you are supposed to do it correctly with a QR code linking to videos.
• 13:41
  Those are all on the website should you ever need it.
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  The other thing is if you have access to spirometry, that
• 13:47
  definitely is very helpful.
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  Because if you can confirm reversible airflow obstruction, well, that is
• 13:55
  helpful for a diagnosis of asthma.
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  But if you confirm that the obstruction is not reversible, that is also helpful for
• 14:02
  me to think about other disease causes.
• 14:04
  Other things could include like a complete blood count to check
• 14:08
  for eosinophilia would be helpful.
• 14:10
  I personally, as a pediatric subspecialist, I actually enjoy
• 14:15
  getting immunization records.
• 14:16
  I like to see what the child has ever been immunized for, because
• 14:21
  maybe one thing could be that they have a very mild case of specific
• 14:26
  antibody deficiency, for instance.
• 14:28
  And actually, that's why they're really struggling with their asthma.
• 14:32
  So, that's another thing that is really helpful for me.
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  And then, anytime that you have a suspicion for cystic fibrosis,
• 14:40
  I say you never go wrong with ordering a sweat test for me.
• 14:44
  And then, I always tell all the trainees, "You never go wrong ordering
• 14:47
  a chest X-ray for me to look at."
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  That just makes my job a little bit easier when I first meet them
• 14:54
  Host: Let's end on innovation.
• 14:56
  So with all the newer therapies such as biologics and evolving
• 15:00
  guideline recommendations, what should general pediatricians
• 15:04
  understand about managing severe or difficult-to-control asthma today?
• 15:10
  Dr. Jade Tam-Williams:
• 15:10
  So, what we know now about severe refractory asthma in the age of biologics
• 15:20
  is far and beyond what when I started out doing this could have ever imagined.
• 15:27
  We are now talking about pediatric remission from asthma, because of
• 15:35
  biologics, which is something that when I first started training,
• 15:40
  we didn't think about, right?
• 15:41
  We just said, "You have asthma, you'll probably have asthma your entire life.
• 15:44
  It'll probably wane.
• 15:45
  You know, maybe you'll have periods of your life where it won't be that bad.
• 15:50
  But then, it'll probably come back if you get older or smoke," et cetera, et cetera.
• 15:54
  Now, we're talking about with on therapy, getting to the point where
• 15:59
  a child or an adult could be without exacerbation, normalizing lung function.
• 16:07
  And I mean, so if this kind of puts into perspective how far we've gotten
• 16:14
  in the last 20 years with biologics.
• 16:17
  And then, for those of you who don't know, biologics are injectable
• 16:21
  medications that specifically target cytokines or antibodies that
• 16:29
  severe asthmatics may have more of.
• 16:32
  So, the most commonly known is omalizumab, which is anti-IgE.
• 16:37
  And then, after that, we have mepolizumab, which is an anti-IL-5.
• 16:41
  We also have anti-IL-5 receptor with fasenra, and then anti-IL-4
• 16:47
  receptors with dupilumab.
• 16:49
  And then, now even we're moving beyond the TH2 biologic or the only TH2 biologic into
• 16:58
  tezepelumab, which is anti-TSLP biologics.
• 17:02
  And these biologics essentially target these inflammatory
• 17:06
  pathways and turn them down.
• 17:08
  So from a general pediatric point of view, I would say what really helps
• 17:14
  in helping to take care of these kids.
• 17:17
  So, we can start with just initiation.
• 17:20
  Oftentimes where we are in Kansas City, we are taking care of kids who come
• 17:26
  from a very, very far away distance.
• 17:29
  So, the community pediatricians that I work with that can help me
• 17:34
  initiate biologics, God, I love them, because it really helps the family
• 17:39
  from not having to drive four, five hours just to get an injection.
• 17:44
  So, that's to start.
• 17:46
  I've really relied on quite a bit of my far off community pediatricians
• 17:50
  with helping me start the process of actually doing the biologics,
• 17:55
  training the patients for biologics, and then the follow-up part.
• 18:00
  So, the other follow-up things could include sometimes patients get so good
• 18:06
  with their biologic that it's like they forgot what to do when they have asthma.
• 18:12
  They're so good, they haven't had a flare in like a year.
• 18:16
  And so, the subsequent year, they get a flare, and they
• 18:21
  forget the basics, you know?
• 18:23
  So as the community pediatrician, that's really helpful, is that in
• 18:27
  these kids, biologics really help a lot, but that doesn't mean that
• 18:31
  they might not never get a flare.
• 18:33
  And so, they might still get a flare, you know, every so often.
• 18:36
  And if they do, reminding these families of "Well, did you
• 18:40
  actually take the inhalers?"
• 18:42
  And so, I actually had to do that conversation with one of my families
• 18:46
  just recently and say, "Yes, I know you've been great, but did you
• 18:49
  remember to do the albuterol with the Flovent and with your Dulera?
• 18:54
  Did you remember?"
• 18:55
  And they're like, "Oh yeah, we just haven't done it in so long.
• 18:58
  We've lost our asthma action plan."
• 19:01
  So, I think that's another space where it's really helpful, recognizing
• 19:05
  they could still have flares.
• 19:07
  And for some kids who are so refractory, unfortunately, there
• 19:10
  are still some kids out there that they continue to have flares even
• 19:15
  on the highest dose of medications.
• 19:17
  And really, that communication back to the pediatric subspecialist is so beneficial,
• 19:24
  because oftentimes we might not know that this family is still out there struggling
• 19:31
  despite, getting, you know, three, four different medications for their asthma.
• 19:36
  I think those kind of things are really helpful to help coordinate care.
• 19:41
  And there are things that definitely a beloved family practitioner or a beloved
• 19:45
  long-term pediatrician, they know about their families that I, as somebody
• 19:52
  who sees them, you know, every four to six months or maybe every six months,
• 19:56
  I don't get that relationship as much as our general pediatricians do, who
• 20:02
  know the community they're living in, know the family dynamics, et cetera.
• 20:06
  So, any of those things are really helpful, I think, for me as a pediatric
• 20:10
  subspecialist, because sometimes there's some insight there to why the asthma is
• 20:15
  so uncontrolled despite using biologics.
• 20:18
  That's really kind of what I call, like, Pediatrics 101.
• 20:23
  But I didn't get that, because I don't have that same relationship.
• 20:27
  So, I think those are pieces of asthma in primary care that
• 20:32
  helps me as the subspecialist.
• 20:37
  Host: Thank you so much, Dr.
• 20:38
  Jade Tam-Williams, for sharing all about clinical management
• 20:42
  of asthma with us today.
• 20:44
  And as a reminder to our audience, claim your CME credits after listening
• 20:49
  to this fascinating episode today.
• 20:51
  You could do so by visiting cmkc.link/cmepodcast,
• 20:54
  and then click the Claim CME button.
• 21:01
  If you enjoyed this podcast, please share it on your social channels
• 21:05
  and check out the entire podcast library for topics of interest to you.
• 21:10
  I'm Dr.
• 21:10
  Sarah Gubara.
• 21:11
  And this has been Pediatrics in Practice, a CME podcast.