Management of Asthma

Asthma is one of the most common chronic diseases and affects up to 7% of pregnancies. The recently validated “one-third rule” states that in pregnancies with asthma, a third of the patients will improve, a third will get worse, and a third will stay the same.

Asthma in two thirds of pregnant women will either worsen or show no improvement; the importance of treating all persistent asthmatics with inhaled corticosteroids must be emphasized. One large study showed that in women using inhaled corticosteroids prior to pregnancy, the number of emergency department visits for asthma remained unchanged, and the rate of physician visits for asthma actually decreased after pregnancy.

Despite worsening or unchanged asthma in two thirds of the patients, pregnant women in general report a decrease in asthma symptoms throughout the pregnancy, particularly in the last 4 weeks of pregnancy. This perceived improvement may be explained by hormonal changes or other factors and may lead to difficulties with medication adherence.

Adverse pregnancy outcomes for patients with asthma

Studies have shown that pregnant women with asthma are at increased risk for pregnancy-induced hypertension, preeclampsia, eclampsia, vaginal bleeding, perinatal mortalities, premature birth, low birth weights, and neonatal sepsis. For pregnancies complicated by moderate to severe asthma, studies report an increased incidence of Cesarean section deliveries. Pregnancies with poorly controlled asthma are at risk for intrauterine growth retardation.

Physiology

During pregnancy, many physiologic changes occur in the mother. Understanding these changes is important not only for the care of the pregnant patient with asthma but also for the fetus.

Maternal Respiratory Physiology

In early pregnancy, 60% to 70% of women feel dyspneic due to hyperventilation. The mechanism of the hyper-ventilation is progesterone mediated with a resultant increase in tidal volume. As pregnancy progresses, an up to 50% increase in minute volume occurs with a corresponding increase in oxygen consumption and carbon dioxide production. The increase in carbon dioxide production is partially blunted by an increase in renal excretion of bicarbonate (explaining the polyuria of early pregnancy), resulting in a mild compensatory respiratory alkalosis. During pregnancy, arterial blood gases typically have pH levels at 7.42 to 7.46, Pco₂ levels at 26 to 30 mm Hg, and Po₂ levels at 99 to 106 mm Hg.

The increased size and pressure of the uterus limits diaphragmatic excursion, lowering residual volume and functional residual capacity. Compensation occurs by increased mobility and flaring of the ribs, as well as by a progesterone-mediated relaxation of bronchial smooth muscle. The net result is that pulmonary function test results remain unchanged for forced expiratory volume in 1 second (FEVj), forced vital capacity, the forced expiratory volume in 1 second to forced vital capacity ratio (FEVj to forced vital capacity), and peak expiratory flow rate .

Maternal Cardiovascular Physiology

Although central venous pressure remains unchanged, there is a 40% increase in maternal cardiac volume and cardiac output with a marked increase in left ventricular mass, compliance, and end-diastolic volume. Total blood volume increases by 40%, but plasma volume increases more than red cell mass resulting in anemia of pregnancy or physiologic hemodilution.

Maternal Gastroesophageal Reflux

Gastroesophageal reflux during pregnancy is a common complaint and may exacerbate asthma. The increase in gastroesophageal reflux may be due to progesterone-mediated relaxation of smooth muscle of the esophagus with a resultant increase in intraabdominal pressure.

Table. Maternal respiratory physiology.

• 60-70% of patients have dyspnea of early pregnancy due to hyperventilation.

• Progesterone-related tidal volume increase.

• Minute ventilation increases up to 50% with increased O2 consumption and CO2 production.

• Compensatory respiratory alkalosis (pH 7.42-7.46, Pco2 26-30,and Po2 99-106).

• Increased size and pressure of uterus limits diaphragmatic excursion.

• Increased mobility and flaring of ribs.

• Progesterone may relax bronchial smooth muscle.

• Pulmonary function tests remain essentially unchanged.

Fetal Physiology

The fetus functions by aerobic metabolism, even though the Po₂ level of the fetus is one fourth of the Po2 level of the mother. Mechanisms allowing the fetus to thrive include an increase in hemoglobin content and the oxygen affinity of fetal hemoglobin, preferential blood flow to vital organs, high cardiac output, and leftward shift of the oxygen dissociation curve.

A low maternal Po2 is important to normal fetal acid-base balance. An increase in maternal Po2 may affect this balance and result in fetal acidosis, even with adequate oxygenation.

Asthma treatment during pregnancy

Exacerbations

Conclusion

Optimal asthma control during pregnancy is very important for both the mother and the fetus. To achieve this goal, thorough assessments and evaluations are critical, including monitoring with pulmonary function testing and peak-flow meters. Avoidance and control of common triggers needs to be addressed with an emphasis on smoking cessation. Effective treatment must include asthma education and reassurance that treatment is much safer for the fetus than maternal asthma exacerbations and symptoms. The obstetrical provider should be involved as part of the asthma care management team from the start of the pregnancy.

Evidence-based medicine

National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Asthma and Pregnancy Working Group. NAEPP expert panel report. Managing asthma during pregnancy: recommendations for pharmacologic treatment-2004 update. This paper is a systemic evidence-based review of phar-macologic treatment of pregnancy. Tables from this working paper are highlighted in the post. This is a very thorough, well-presented paper.

Table. Medications and dosages for asthma exacerbations during pregnancy and lactation.

Medications	Adult Dosages			Comments
Short-Acting Inhaled β2-Agonists
Albuterol
Nebulizer solution	2.5-5 mg q20min for 3 doses, then 2.5-10 mg q1-4h PRN,or 10-15 mg/h continuously			Only selective β2-agonists are recommended. For optimal delivery, dilute aerosols to minimum of 3 mLat gas flow of 6-8 L/min.
(5 mg/mL,
2.5 mg/3 mL,
1.25mg/3mL,
0.63 mg/3 mL)
HFA(90µg/puff)	4-8 puffs q20min up to 4 h, then q1-4h as needed			As effective as nebulized therapy if patient is able to coordinate.
Bitolterol
Nebulizer solution (2 mg/mL)	See albuterol dose			Has not been studied in severe asthma exacerbations. Do not mix with other drugs.
metered-dose inhaler (370 µg/puff)	See albuterol dose			Has not been studied in severe asthma exacerbations.
Levalbuterol (R-albuterol)
Nebulizer solution	1.25-2.5 mg q20min for three doses, then 1.25-5 mg q1-4h as needed, or 5-7.5 mg/h continuously			0.63 mg of levalbuterol is equivalent to 1.25 mg of racemic albuterol for both efficacy and side effects.
(0.63 mg/3 mL,
1.25 mg/3 mL)
HFA45µg/puff	See albuterol dose
Pirbuterol
metered-dose inhaler (200 µg/puff)	See albuterol dose			Has not been studied in severe asthma exacerbations.
Systemic (Injected) β2-Agonists
Epinephrine
1:1000(1 mg/mL)	0.3-0.5 mg q20min for three doses sq			No proven advantage of systemic therapy over aerosol.
Terbutaline (1 mg/mL)	0.25 mg q20min for three doses sq			No proven advantage of systemic therapy over aerosol.
Anticholinergics
Ipratropium bromide
Nebulizer solution (0.25 mg/mL)	0.5 mg q30min for three doses, then every 2-4 h as needed			May mix in same nebulizer with albuterol. Should not be used as first-line therapy; should be added to β2-agonist therapy.
HFA(17µg/puff)	4-8 puffs as needed
Ipratropium with albuterol
Nebulizer solution (each 3-mL vial contains 0.5 mg ipratropium bromide and 2.5 mg albuterol)		3 mL q30min for three doses, then every 2-4 h as needed.		Contains EDTA to prevent discoloration.This additive does not induce bronchospasms.
Ipratropium with albuterol
metered-dose inhaler (each puff contains 18 µg ipratropium bromide and 90µg albuterol)		4-8 puffs as needed
Systemic Corticosteroids (Dosages and comments apply to all three corticosteroids)
Prednisone			40-80 mg/d in 1 or 2 divided doses until peak expiratory flow reaches 70% of predicted or personal best			For outpatient”burst,”use 40-60 mg in 1 or 2 divided doses for 5-10 days in adults
Methylprednisolone
Prednisolone

The treatment goal for the pregnant asthma patient is to provide optimal therapy to maintain control of asthma for maternal health and quality of life as well as for normal fetal maturation, as per the National Asthma Education Prevention Program (NAEPP). Asthma control is defined as follows:

•   Minimal or no chronic symptoms day or night

•   Minimal or no exacerbations

•   No limitations on activities

•   Maintenance of normal or near-normal pulmonary function

•   Minimal use of short-acting inhaled β-antagonist

•   Minimal or no adverse effects from medications. Always consult latest NAEPP guidelines.

Table. Maternal cardiovascular physiology.

• Central venous pressure remains unchanged

• 40% increase in maternal cardiac volume

• 40% increase in cardiac output

• Increase in left ventricular mass,compliance,and end-diastolic volume

• Plasma volume increases more than red cell mass: anemia of pregnancy

Table. Fetal physiology.

• Fetus functions by aerobic metabolism

• Mechanisms allowing fetus to thrive

• Increase in hemoglobin content

• Increase in oxygen affinity of fetal hemoglobin

• Preferential blood flow to vital organs

• High cardiac output

• Leftward shift of oxygen dissociation curve

• Acid-base balance important

• Increase in maternal Pco2 may result in fetal acidosis, even with adequate oxygenation

Assessment of Asthma

Pregnant women with asthma should have a thorough assessment of their asthma control. Patients should be asked about their frequency of symptoms (particularly at night), how often symptoms interfere with normal activities, and the usage of short-acting P2-agonists for symptom relief (not for exercise-induced bronchospasm prevention). Validated questionnaires such as the ATAQ, ACQ and the ACT are particularly helpful in classifying the level of asthma control.

In addition, a complete assessment of asthma must include objective measurements. All patients should have pulmonary function testing at their initial evaluation to determine disease severity. Patients should be given a peak flow meter to monitor asthma variability. At subsequent office visits, repeat pulmonary function testing is preferable, but at a minimum, assessment of peak expiratory flow rates (PEFRs) should be checked.

Assessment of the Fetus

All pregnant women should be advised to be attentive to fetal activity. Serial ultrasound evaluations beginning at 32-week gestation may be considered for women with moderate to severe asthma and women with poorly controlled asthma. In addition, after a severe exacerbation, an ultrasound evaluation may be reassuring.

Table. Guide to asthma severity.

Category	Symptoms/day	Symptoms/night	FEV, or peak expiratory flow rate	peak expiratory flow rate Variability
Intermittent asthma	<2 d/wk	<2 nights/mo	>80%	<20%
Mild persistent	>2/wk<daily	>2 nights/mo	>80%	>20-30%
Moderate persistent	Daily	>1 night/wk	>60-<80%	>30%
Severe persistent	Continual	Frequent	<60%	>30%

Reassurance

Patients need to be reassured about the safety of asthma medications and advised that the risks of treatment are much less than the risks of untreated asthma. Concern about side effects in the fetus may interfere with medication adherence and lead to undertreatment of asthma.

Education

All pregnant women with asthma should receive asthma education emphasizing the important benefits of treatment and its impact on the fetus. Written and verbal instructions should be given on the proper use of medications, spacers, and peak-flow meters. Patients should be taught how to monitor inhaler usage to avoid running out of medication.

Smoking

Any patient who is smoking should be advised to quit and be referred to a smoking cessation program. Besides adversely affecting asthma, smoking has deleterious affects on the mother and the fetus.

Triggers

An assessment of common triggers with instructions on avoidance and control should be part of all patient evaluations. Patients should be educated on ways to minimize exposure to dust mites, cockroaches, pets, pollens, irritants, and odors. Studies reporting that high levels of either total serum immunoglobulin E (IgE) or cockroach-specific IgE are associated with worsening asthma underscore the importance of such environmental controls. Patients with exposure to secondary smoke, including wood-burning stoves and fireplaces, should also be counseled on the importance of avoidance.

Viral infections are the most common triggers causing severe exacerbations. Influenza vaccines and frequent handwashing are recommended, particularly during the so-called flu season. In nonpregnant patients, increased body weight and high-panic-fear state can worsen asthma and complicate treatment. Although studies are conflicting in pregnancy, increased body weight and high-panic-fear state should still be considered potential triggers.

Treatment Plans

Together with the patient, providers should develop medication regimens that are effective and easy to follow. Providers need to be aware that pregnant patients with asthma may have difficulty following complicated treatment regimens.

All patients should receive a written self-management plan. The plan should emphasize home management of exacerbations, including instructions on when to start oral steroids and when and where to call for help. Ideally, these plans should be based on both symptoms and peak-flow meter.

In addition, it is important to include the obstetrical provider from the beginning. The obstetrical provider will be assessing the patient more regularly, and their involvement in the asthma care team is critical, particularly in reassuring the patient on the safety of the medications.

Medications

Inhaled Short-Acting P2-Agonists

Inhaled short-acting P₂-agonists are one of the mainstays of therapy and should be administered only as needed. The preferred medication is albuterol, based on more published data on safety.

Inhaled Long-Acting P2-Agonists

Inhaled long-acting P2-agonists have a profile similar to the inhaled short-acting P2-agonists with the exception that these drugs are retained longer in the lungs. The preferred medication is salmeterol (Serevent), due to the longer availability of the drug in the United States.

There has been a recent controversy about inhaled long-acting   P2-agonists  paradoxically  increasing  the risks of hospitalization and death in asthmatics. It would be prudent to use inhaled long-acting P2-agonists only as add-on therapy to medium- or high-dose inhaled corticosteroids, if asthma remains poorly controlled.

Table. Summary of control measures for environmental factors that can make asthma worse.

Allergens

Reduce or eliminate exposure to the allergen(s) the patient is sensitive to, including:

• Animal dander: Remove animal from house, or,at the minimum, keep animal out of patient’s bedroom and seal or cover with a filter the air ducts that lead to the bedroom.

• House dust mites:

• Essential: Encase mattress in an allergen-impermeable cover; encase pillow in an allergen-impermeable cover or wash it weekly; wash sheets and blankets on the patient’s bed in hot water weekly (water temperature of >130°F is necessary for killing mites).

• Desirable: Reduce indoor humidity to less than 50%; remove carpets from the bedroom; avoid sleeping or lying on upholstered furniture; remove carpets that are laid on concrete.

• Cockroaches: Use poison bait or traps to control. Do not leave food or garbage exposed.

• Pollens (from trees, grass, or weeds) and outdoor molds:To avoid exposure, adults should stay indoors, especially during the afternoon, with the windows closed during the season in which they have problems with outdoor allergens.

• Indoor mold: Fix all leaks and eliminate water sources associated with mold growth; clean moldy surfaces. Consider reducing indoor humidity to less than 50%.

Tobacco Smoke

Advise patients and others in the home who smoke to stop smoking or to smoke outside the home. Discuss ways to reduce exposure to other sources of tobacco smoke, such as from child care providers and the workplace.

Indoor/Outdoor Pollutants and Irritants

Discuss ways to reduce exposures to the following:

• Wood-burning stoves or fireplaces

• Unvented stoves or heaters

• Other irritants (e.g., perfumes, cleaning agents, sprays)

Inhaled Corticosteroids

Inhaled corticosteroids are the cornerstone of therapy for the pregnant woman with persistent asthma. Multiple studies have emphasized the decrease in asthma exacerbations and the improvement in FEVj with the use of inhaled corticosteroids. Even studies in large birth registries have failed to relate the use of inhaled corticosteroids to any unfavorable perinatal outcome, including increased incidence of congenital malformations. The preferred medication is budesonide (Pulmicort), based on more recently published data.

Oral Corticosteroids

Studies have shown that oral corticosteroid use has been associated with a decrease in birth weight of approximately 200 g, although without an increased incidence of small for gestational age infants. In addition, there is an association with an increased incidence of isolated cleft lip (without cleft palate) especially when taken during the first trimester (0.3% vs. 0.1% in the general population). The preferred drugs are prednisone and prednisolone because they have limited placental transfer. Oral corticosteroids are used in the treatment of poorly controlled severe persistent asthma or for the treatment of asthma exacerbations. On occasion, a short course of oral corticosteroids may be necessary to gain control of asthma.

Cromolyn Sodium

Cromolyn sodium is safe for pregnancy. It is considered an alternative but not a preferred option for mild persistent asthma.

Theophylline

Theophylline is safe for pregnancy in the usual therapeutic serum level range of 5 to 12 µg/mL. However, theophylline has many side effects and drug-drug interactions. Studies have shown that women treated with theophylline have a high rate of discontinuance of the drug, and there is an increase in the proportion of women with FEVj less than 80% of predicted. Oral theophylline is an alternative but not a preferred option for mild, moderate, or severe persistent asthma.

Table. Usual dosages for long-term-control medications during pregnancy and lactation.

Medication	Dosage form	Adult Dose
Inhaled Corticosteroids
Systemic Corticosteroids (Applies to all three corticosteroids.)
Methylprednisolone	2-,4-,8-, 16-, 32-mg tablets	7.5-60 mg daily in a single dose in am or qod as needed for control Short-course”burst”to achieve control:40-60 mg/d as single dose or two divided doses for 3-10 d
Prednisolone	5-mg tablets, 5 mg/5 mL, 15 mg/5 mL
Prednisone	1 -, 2.5-, 5-, 10-, 20-, 50-mg tablets 5 mg/mL, 5 mg/5 mL
Long-Acting Inhaled inhaled β2-Agonists (Note: Should not be used for symptom relief or for exacerbations. Use with corticosteroi ids.)
Salmeterol	DPI 50 µg/blister		1 blister q12h
Formoterol	DP112 µg/single-use capsule		1 capsule q12h
Combined Medication
Fluticasone/	DPI 100,250, or	1 inhalation bid; dose depends on severity of asthma. 2 puffs bid; dose depends on severity of asthma
Salmeterol	500µg/50µg,HFA45, 115or230µg/21µg
Budesonide/	HFA MDI 80mg or	2 inhalations bid; dose depends on severity of asthma
Formoterol	160 mcg/4.5 meg puff
Cromolyn
Cromolyn	metered-dose inhaler 800 u/puff	2-4 puffs tid-qid
	Nebulizer 20 mg/ampule	1 ampule tid-qid
Leukotriene Receptoir Antagonists
Montelukast	10-mg tablet	10 mg qhs
Zafirlukast	20-mg tablet	40 mg daily (20-mg tablet bid)
Methylxanthines (Serum monitoring is important [serum concentration of 5-12 µg/mL at steady state].)
Theophylline	Liquids, sustained-release tablets,and capsules	Starting dose, 10 mg/kg/d up to 300 mg max; usual max 800 mg/d

Leukotriene Receptor Antagonists

There are limited studies on leukotriene receptor antagonists available for review, but they appear to be safe in pregnancy. Consequently, leukotriene receptor antagonists would be an alternative but not preferred option for the treatment of mild or moderate persistent asthma.

Ipratropium

Although there are reassuring animal studies for ipratropium (Atrovent, Atrovent HFA), it should only be used in the treatment of severe asthma exacerbations. In the emergency department, usage is indicated only when the FEVj is less than 50% or there is impending respiratory arrest.

Table. Estimated comparative daily dosages for inhaled corticosteroid.

Drug	Low Daily Dose Adult	Medium Daily Dose Adult	High Daily Dose Adult
Beclomethasone HFA 40 or 80 ng/puff	80-240 µg	> 240-480 µg	>480 µg
Budesonide DPI 90 or 180 µg/inhalation	180-540 µg	>540-1080µg	>1080µg
Flunisolide 250 µg/puff	500-1000 µg	1000-2000 µg	>2000 µg
Fluticasone metered-dose inhaler:44,110,or220µg/puff DPI: 50,100, or 250 µg/inhalation	88-264 µg 100-300 µg	264-440 µg 300-500 µg	>440 µg >500 µg
Triamcinolone acetonide 75 µg/puff	300-750 µg	750-1500 µg	>1500µg
Mometasone DPI 220µg/inhalation	220 µg	440 µg	>440 µg

Treatment Guidelines

The NAEPP has proposed a pharmacologic treatment approach for pregnant women with asthma based on stepwise asthma care. This approach follows established guidelines for intermittent asthma and mild, moderate, and severe persistent asthma. It recommends controller medications for all levels of persistent asthma. These guidelines may be modified to fit the needs of individual patients.

Intermittent Asthma

Patients with intermittent asthma should be treated with inhaled short-acting P₂-agonists, preferably albuterol, as needed. However, it is important to note that even patients with intermittent asthma can experience life-threatening exacerbations and should have treatment plans for exacerbations that include oral corticosteroids .

Mild Persistent Asthma

Patients with mild persistent asthma should be treated with low-dose inhaled corticosteroids, preferably budesonide (Pulmicort), with inhaled short-acting β2-agonists, preferably albuterol, used as needed.

Alternative but less-preferable treatments include cromolyn, leukotriene receptor antagonists, and sustained-release theophylline.

Moderate Persistent Asthma

Patients with moderate persistent asthma should be treated with medium-dose inhaled corticosteroids, preferably budesonide (Pulmicort). If control is difficult or cannot be achieved, inhaled corticosteroids can be supplemented with an inhaled long-acting β2-agonist, preferably salmeterol (Serevent). Inhaled short-acting β2-agonists, preferably albuterol, should be added as needed. Alternative, but-less preferable treatments include either low-dose or medium-dose inhaled corticosteroids with the addition of sustained-release theophylline or leukotriene receptor antagonist therapy.

Severe Persistent Asthma

For patients with severe persistent asthma, the treatment of choice is high-dose inhaled corticosteroid therapy, preferably budesonide (Pulmicort), and an inhaled long-acting β2-agonist, preferably salmeterol (Serevent). Inhakd short-acting β2-agonists, preferably albuterol, should be added as needed. Alternative but less-preferable treatment would be high-dose inhaled corticosteroids with  sustained-release theophylline. If control cannot be achieved with these drugs, oral corti-costeroids should be added, as needed, to maintain control.

Assignment of Severity Step

All patients should be assigned to the highest step, in which any single feature occurs. For example, nighttime symptoms twice a week will increase the severity assignment to moderate persistent asthma, even if all other symptoms and objective measures are in the mild persistent asthma category.

Overuse of Albuterol

Patients need to be specifically asked about their use of albuterol or other inhaled short-acting bronchodilators. Overuse of albuterol indicates inadequate asthma control and the need to increase the asthma severity assignment to a higher level. Pharmacy records, if available, can be invaluable in analyzing refill patterns and determining if patients are refilling their inhaled short-acting β2-agonists too frequently.

The extent of albuterol overuse can be easily estimated by multiplying the number of canisters used by 200 (puffs per canister) and dividing the result by the number of days between refills. Even the use of one canister, every 2 months, indicates an average of more than 3 puffs of albuterol per day, suggesting suboptimal control that should be evaluated.

Patients often experience worsening of asthma symptoms during exercise. These patients may require albuterol use prior to exercise. In some cases, alteration of medication regimens may be required to allow for exercise.

Table. Stepwise approach for managing asthma during pregnancy and lactation: treatment.

Classify Severity: Clinical Features Before Treatment or Adequate Control			Medications Required to Maintain Long-Term Control
	Symptoms/Day	PFEForFEV, Symptoms/Night         peak expiratory flow Variability	Daily Medications
Step 4 Severe Persistent	Continual                     Frequent	<60% >30%	•   Preferred treatment: •  High-dose inhaled corticosteroid AND •  Long-acting inhaled β2-agonist AND, if needed, •  Corticosteroid tablets or syrup long term (2 mg/kg/d, generally not to exceed 60 mg per day). (Make repeat attempts to reduce systemic corticosteroid and maintain control with high-dose inhaled corticosteroid.) •  Alternative treatment: •  High-dose inhaled corticosteroid AND •  Sustained-release theophylline to serum concentration of 5-12 µg/mL.
Step 3 Moderate Persistent	Daily                        >1 night/wk	>60%-<80% >30%	•   Preferred treatment: •  Medium-dose inhaled corticosteroid If needed (particularly in patients with recurring severe exacerbations): •  Medium-dose inhaled corticosteroid and long-acting inhaled β2-agonist. •  Alternative treatment: •  Low-dose inhaled corticosteroid and either theophylline or leukotriene receptor antagonist. If needed: •  Medium-dose inhaled corticosteroid and either theophylline or leukotriene receptor antagonist.
Step 2 Mild Persistent	>2d/wk but<daily         >2 nights/mo	>80% >20-30%	•   Preferred treatment: • Low-dose inhaled corticosteroid •  Alternative treatment (listed alphabetically): cromolyn, leukotriene receptor antagonist, OR sustained-release theophylline to serum concentration of 5-12 µg/mL.
Step 1 Mild Intermittent	<2 d/wk                     <2 nights/mo	>80% <20%	•   No daily medication needed. •  Severe exacerbations may occur, separated by long periods of normal lung function and no symptoms. A course of systemic corticosteroid is recommended.

Gaining Control of Asthma

Most asthma specialists start a patient at a higher dose of medication to gain control quickly and even consider a short course of oral steroids. Once control is gained, the dosage should be lowered to the minimal medication needed to maintain good control. Reassessment should occur frequently to determine if control can be maintained at a lower dose of medications.

Specialty Care

The NAEPP Guidelines recommends that pregnant women with asthma be referred to an asthma specialist if there is difficulty controlling their asthma. The guidelines specifically advise that patients with severe persistent asthma or those requiring step 4 treatment be referred to an asthma clinic or to a specialist. Patients with moderate persistent asthma or who require step 3 treatment may also be considered for referral.

During the course of their pregnancy, studies show that 20% of asthma patients have exacerbations severe enough to seek urgent medical care. Approximately 6% require hospital admissions. Severe exacerbations such as those requiring hospital admission, urgent physician visits, or systemic corticosteroids are significantly more likely to occur with severe asthma.

Exacerbations are most common in the late second trimester to early third trimester. The most common reasons for exacerbations are viral infections and non-compliance of inhaled corticosteroid treatment. The importance of regular usage of inhaled corticosteroids for persistent asthma cannot be overemphasized. Studies show that for patients using inhaled corticosteroids before pregnancy, the rate of asthma-related physician visits decreased and the number of emergency department visits was unchanged after pregnancy.

Management of Exacerbations

The management of the pregnant woman having an asthma exacerbation is set forth in the NAEPP Guidelines. Treatment depends on the severity of the exacerbation with nebulized albuterol and oral steroids used as the primary treatment, particularly at home. For pregnant women with severe exacerbations in the emergency department, nebulized ipratropium can be added to the nebulized albuterol.

The usual Pco2 in pregnancy is in the range of 26 to 30 mm Hg. For pregnant women presenting with a severe acute asthma exacerbation, a Pco2 of 40 signifies impending respiratory arrest.

Mechanical Ventilation

Fortunately, it is rare for a pregnant woman to require intubation and mechanical ventilation. If needed, intubation should be oral instead of nasal due to airway narrowing. Preoxygenation with 100% oxygen prior to intubation is important to avoid a precipitous drop in oxygen that may occur after even a short period of apnea. Studies show that it is important to maintain cricoid pressure before and after intubation to avoid aspiration and gastric insufflation.

Studies show that patients should be ventilated with respiratory rates of 8 to 12 breaths per minute, tidal volumes of 6 to 8 ml/kg, and high-inspiratory flow rates of 100 to 120 per minute. Hyperventilation should be avoided because a respiratory alkalosis may decrease uterine blood flow and impair oxygenation of the fetus. In addition, it is important to avoid volutrauma and barotrauma.

Earlier posts have offered information about understanding, controlling, and treating your child’s asthma. But as parents of children with chronic diseases know all too well, there’s more to caring for a child than giving medicine and getting to doctors’ appointments. There’s also a sea of bureaucracy — the “health care system” of insurance forms, referrals, specialists, bills, copays, deductibles, prescriptions, medical devices. . . .

Caring for a child with asthma may sometimes feel like a journey across unfamiliar waters. Your primary care provider’s office may serve as a home base, but other important ports of call may include subspe-cialists, visiting nurses, medical supply companies, and other providers. Unfortunately, the coordinates for this journey are not mapped out clearly for you in advance. Our health care system is complex and ever changing. Financial and bureaucratic obstacles still prevent many children from receiving the care they need.

Social workers can help families work through these challenges. You are fortunate if a social worker is playing an active role on your child’s team. If not, an experienced social worker has contributed information to this post that will give you insight into successfully navigating the health care system. You can use this information to help create a team that includes your child’s doctor and other health care professionals. Parents should not have to carry the burden alone.

Private Health Insurance

Public Insurance

If you do not have private insurance, several options are available for public insurance. These programs use funds from the federal government but are organized differently in each state. You can learn the specific rules for your area by calling your local county Board of Assistance. Medical Assistance (also known as Medicaid) offers coverage to children under the age of nineteen based on income, residency, and other requirements. Many state Medicaid programs involve managed care plans that have rules about specialty care similar to private insurance plans.

In 1997, the federal government established the Children’s Health Insurance Program (CHIP) to expand the availability of health insurance coverage to working families beyond what Medicaid provides. The federal government funds the states to help pay for this program. Since the program is administered by each state, the specific rules may vary in your area. In most states, children from a family of four, with earnings up to $34,100 per year (in 2002), are eligible. More information about the CHIP program can be obtained by calling 1-877-KIDS-NOW.

Some children with chronic diseases like asthma may be eligible for Supplemental Security Income (SSI) as determined by financial and medical criteria. There are strict guidelines, but an eligible child may receive cash assistance as well as medical insurance. Information about SSI can be obtained through the Social Security Administration at 1-800-772-1213 or through your local Social Security office.

PRIMARY CARE

SPECIALTY CARE

Asthma Care in the Home

Home care is a growing area of medicine that is very applicable to asthma. In addition to teaching about asthma in the comfort of a child’s usual setting, home care staff can check asthma equipment, such as nebulizers, and assess the condition of the home. Eliminating allergens and improving the air quality of a home can dramatically improve asthma symptoms for some children, as discussed in chapter 10. Some health insurers recognize the value of home visits and may provide these services in selected cases. If you feel that a home visit would be helpful for your child, discuss this possibility with your primary care provider.

Making the System Work for Your Child

Many different types of health services are available for children with asthma. Most children will do well with simple interventions, but if your child is having difficulty, it is important to ask about what else can be done. Obtaining additional services may require approvals from your primary care provider or insurance company. Well-run insurance companies have recognized that although these services cost money, in the long run they may prevent expensive emergency visits and hospital care. Since asthma is such a common condition, many insurance companies have developed asthma programs that attempt to identify children who are not doing well and link them with services such as home nursing visits, asthma education classes and printed materials, and asthma specialists. A case manager, often a nurse or social worker with experience in asthma, may be assigned to your child to help make sure that appropriate services are provided. You may want to ask your insurance company about the availability of such a person. If not, don’t hesitate to advocate for your child and take on this role with the help of your primary care provider.

Although caring for a child with asthma can be a daunting journey, many supports and services are available to help families along the way. Viewing asthma care as a team approach — your family, your primary care doctor, nurse practitioner, office staff, and others as needed — will help make treating asthma smooth sailing for your child.

Asthma care and medicines are expensive, and obtaining the right health insurance is an important first step in accessing the health care system. Recent changes in the law provide the opportunity for virtually every child in every state to qualify for some form of health insurance. The rules and steps involved are complex, however, and may leave many gaps in the care that is provided. Gone are the days when parents could assume that any type of health insurance would pay for all the care that a child with asthma requires.

If your child has private insurance through your employer, you need to explore what it covers. Inpatient (in-hospital) and outpatient (office) benefits may be treated differently and may include copays and deductibles that come out of your pocket before the insurance coverage starts to pay. Some insurance plans provide full payment only to providers who are within the plan’s own “network.” If this is the case, it’s important to be sure that the network includes your child’s primary care doctor or pediatrician, nurse practitioner, and other health care professionals. A referral from your primary care provider may be needed for the insurance plan to cover fully any specialists, such as allergy or pulmonary doctors.

With the increasing costs of medicines, most insurance companies have cut back on prescription plans. Many plans include copays, prior authorization, or require the use of a mail-order prescription company. Generic forms of some asthma medicines are available and may result in lower costs if prescribed by your doctor or nurse practitioner. By and large, generic drugs for asthma work just as well as name brands.

If your insurance does not cover prescriptions, there are other options to consider. Some pharmaceutical companies offer assistance plans; information can be obtained by contacting the individual company directly. Clinical research trials also will sometimes cover the cost of medicines. Information about clinical trials can be obtained through drug companies, your physician, or through an Internet site set up by the National Institutes of Health (www.ClinicalTrials.gov). Durable medical equipment, such as nebulizers and other home care needs, are covered differently by insurance plans. Some forms of equipment, such as spacers, can be ordered at low cost from organizations such as the Allergy & Asthma Network: Mothers of Asthmatics (www.aanma.org or 1-800-878-4403).

Every child should have a primary care provider for well-child checkups and immunizations. With a chronic disease like asthma, it is particularly important to see consistently the same physician, nurse practitioner, or other professional over time so the primary care provider can get to know your child well. This primary care provider will play the lead role in assessing your child’s asthma, prescribing medicines, and making referrals for other services or specialty care if needed.

Primary care providers differ in many ways, including their training background (for example: family medicine, pediatrics, and nurse practitioner programs), the structure of their offices (private office, hospital, or public clinic), and the size of their practice (a single provider or a large group).

Choosing a primary care provider is a personal decision, but several factors are important to consider when your child has asthma.

•   Experience with young asthma patients: The provider should be familiar with treating asthma in the pediatric age range. Children have many unique needs that require a treatment approach different from that for adults.

•   Access: Since asthma flares can occur at unpredictable times, you should always be able to reach someone for advice. Many offices are open for evening and weekend hours, which can be very convenient for working parents.

•   Support systems: Last but certainly not least, the other staff and support services are important. A friendly, accessible office staff and a well-organized system for teaching about asthma, refilling prescriptions, and following through on patients’ needs can add a great deal to your child’s care. Some offices may have specifically trained staff, such as social workers or case managers, available to

help with obtaining services. A team approach to primary care has the most to offer.

Specialty care for asthma can be confusing because each type of provider may have a different focus. Pediatric allergists specialize in the reactions of the immune system to common environmental allergens, such as pollens, dust mites, or pet dander, that can play a key role in asthma. Allergists use skin tests to detect allergies and may, in some cases, treat allergies by giving repeated small doses of the allergen. Pediatric pulmonary medicine physicians (also known as pulmonologists) specialize in lung diseases in children. These physicians perform lung function tests and procedures such as bronchoscopy, where a small camera is used to look inside the lung. Both allergists and pulmonologists treat asthma with the conventional medicines that have been described in this book. In specific cases, however, they may have a somewhat different approach to diagnosis and management of asthma.

Whether your child needs to see a specialist is an individual question to be discussed with your primary care provider. In most cases, mild asthma can be managed successfully by your regular physician or pediatrician. But a specialist can be very helpful if your child does not seem to be responding well to treatment or if your primary care provider has specific concerns and suggests that further testing may be needed. Beyond having added experience and training, specialists usually schedule extra time to delve into the specifics of more difficult cases. Since they focus on asthma, they may also have educational material, support staff, and other resources that can be very useful to you and your child.

Visiting a specialist may pose some potential problems. With more than one provider now treating your child, there is the potential for confusion and miscommunication. It’s important to make sure that information flows well between the specialist and your primary care provider, who will continue to prescribe your child’s medicines and see your child for acute illnesses.

Specialty care is expensive and can pose financial hardship if not covered by insurance, so it’s important to make sure that referrals and other needed forms are completed before seeing a specialist.

Families are spending more and more time away from home. Infants and toddlers leave the house for day care. Older children and teens are busy with school, sports, and after-school activities. On weekends and vacations, families pack up for trips to relatives’ homes, campsites, the beach, Disney World. . . . Everyone’s on the go.

Children with a chronic condition like asthma should not be kept at home or restricted from any activity that other children enjoy. They should be able to go to school and camp and go on sleepovers, field trips, and family vacations. Yet parents need to be prepared for the unexpected when children with asthma are away from home. Even if your child’s asthma is well controlled and she has no symptoms, it’s best to plan ahead, use common sense, and be prepared so that experiences away from home will be enjoyable for your child and stress-free for you. In this chapter, you can walk through various away-from-home settings and consider how to manage your child’s asthma effectively in each one.

At Day Care and School

School Policies on Medicines

Some schools don’t have a full-time school nurse, so ask the principal or your child’s teacher who will be responsible for giving medicine when the nurse is not in school. Policies about children carrying and taking their own medicine vary, depending on state and school regulations, so it’s important to learn your local policies and plan ahead before a crisis arises.

The use of medicine in school can be controversial. Health experts agree that children with asthma should have ready, easy access to their quick-relief medicines. But medicine is included in many schools’ “zero tolerance” drug policies, so students are not permitted to keep medicine in their pockets, bookbags, or lockers. Although it is very rare, prohibiting students from carrying medicine with them has had fatal results. The worst possible result, reported by the New York Times in 2002, was the death of a child who developed asthma symptoms in school but had not been allowed to carry his quick-relief medicine with him. By the time he received any medicine, it was too late.

This rare tragedy highlights the need for parents to be proactive and educate not only their child’s teachers but also school administrators about asthma and its consequences. Parents can make a difference by becoming involved when school boards make policies that could be a matter of life and death.

Triggers at School

Sleepovers

Camp

Dylan went to camp for the first time last summer. His parents did everything right. They organized all his medicines, sent an extra spacer, got him a special backpack to hold his medicines for day outings, and gave the camp nurse a copy of his asthma management plan. So what could possibly go wrong?

Dylan loved camp. He made new friends in his bunk, learned to swim, and showed no asthma symptoms — until the third week of camp, when his group went horseback riding. Dylan excitedly climbed on his horse and within a few minutes his eyes started to itch and water. His nose got congested, and he started sneezing. An alert counselor took him back to the infirmary where the camp nurse treated his allergic reaction, gave him a dose of albuterol, and Dylan quickly improved. The nurse then called Dylan’s parents to notify them of his allergic reaction to the horse, report that he was fine again, and suggested that they have him evaluated by an allergist. Everything worked smoothly for Dylan in this case, but his parents learned that they must make sure they know ahead of time how medical emergencies will be handled. If you’re planning to send your child to day or overnight camp, ask about the camp’s policies and procedures for emergencies and what medical personnel will be available to handle them.

Whenever Someone Else Is in Charge

Common sense and planning are essential when children with asthma go away from home without a parent. You need to communicate with anyone who will be taking care of your child. This includes relatives, baby-sitters, day care personnel, teachers, coaches, school nurses, friends’ parents, camp counselors, and other adults who will be responsible when you aren’t with your child. Keep in mind that many people don’t have an accurate understanding of asthma. A lot of old myths about asthma are floating around that people still believe are true.

Here is a basic list of what other adults need to know:

•   Names of your child’s medicines

•   When to give them (daily and/or when symptoms occur)

•   How to give the medicine

•   What symptoms indicate a problem

•   What to expect from the medicine (for example, they shouldn’t expect immediate relief from a long-term controller medicine but should from a quick-relief medicine)

•   What to do if the child doesn’t improve or gets worse after taking a quick-relief medicine

•   Who to call in an emergency (parents’ work/cellular numbers, backup person if parents aren’t reachable, child’s physician, ambulance, nearest hospital)

Much of the above will be listed in your child’s written asthma management plan, a copy of which should be given to those who are caring for your child.

If you don’t know the answers to all these points, sit down with your child’s physician or nurse practitioner and come up with a list together. Request prescriptions that you need now or in the near future, especially if you’re planning a trip. Do you need an extra spacer, inhaler, or nebulizer that will stay at day care, school, camp, or Grandma’s house? It’s just a matter of being prepared.

Traveling With a Child Who Has Asthma

Medicine When Traveling

Special Considerations for Flying

Two special circumstances apply to airplane travel and asthma. First, air inside a plane cabin is recycled. Second, air in a plane is thinner, or has less oxygen. If your child’s asthma is not under control before getting on the plane, your child may have increased symptoms. Consider postponing travel if your child is having a difficult-to-control flare. Planes are diverted to the nearest airport only in a life-or-death medical emergency, but otherwise they continue to the planned destination. If your child has a flare that becomes worse on board, the flight will seem painfully long for everyone involved. The best advice is to get your child’s flare under control before you fly.

Going Abroad

International travel makes planning even more complicated. These trips absolutely require that all medicines be properly labeled. Make sure that you take along enough medicine to last the entire trip because the exact same medicine may not be available in the country you’re visiting. You should also keep a copy of your child’s asthma management plan with the medicine.

Plug adapters may also be needed if you are going to use a nebulizer because electrical outlets abroad may differ from those in the United States. Adapters for different countries are available where luggage is sold. If you’re visiting a country where you don’t speak the language, make sure that you identify hospitals in advance.

Asthma and its treatment should not be any more burdensome while traveling than it is at home if you use common sense, plan ahead, and prepare to have a safe and enjoyable trip. Bon voyage!

Kia’s asthma was diagnosed when she was a year old, only a few months after she started attending a day care program. Her parents gave copies of her asthma management plan to the day care director and Kia’s teacher. They reviewed the plan to be certain that everyone could recognize symptoms and give Kia quick-relief medicine when necessary. At home, her parents gave her controller medicine each morning and evening. Except when triggered by occasional colds — which seem to make perpetual rounds of day care centers — Kia’s asthma was well controlled for the four years she attended day care. When she began elementary school, her parents again made her teachers and other school personnel aware of her asthma, gave them copies of her management plan, and made sure they understood how to implement it.

By the time Kia started middle school, her asthma was so well controlled that her parents let down their guard. Kia was now old enough to recognize symptoms herself, and she always carried a quick-relief inhaler and spacer in her backpack. Her parents didn’t bother to contact the middle school personnel about her asthma. But after a few months in middle school, which was an older building, Kia’s symptoms appeared more frequently. She still used a controller medicine at home, but her parents noticed that she was coughing more at night and often seemed short of breath.

With a little gentle prodding, her parents discovered that Kia had been using her quick-relief medicine much more often. They took her to the doctor who did a spirometry breathing test, reviewed the technique for administering her metered dose inhaler and spacer, and wrote new prescriptions with refills. In the end, they agreed that Kia’s recent problems were probably related to triggers at school.

Her parents called the school nurse and told her of Kia’s condition. They said they would send in a copy of Kia’s asthma management plan and asked the nurse to review it with Kia’s teachers. The nurse said she was happy to cooperate and mentioned, almost as an aside, that since she had started working at this middle school a few years ago, she was seeing a lot more students with asthma.

Kia’s story had a happy ending. The school nurse and her teachers kept an eye on her, watched for symptoms, and quietly reminded Kia when to use her inhaler and spacer without making a big deal of it or drawing attention to her. More importantly, the school nurse took the lead in alerting the principal and faculty to the growing incidence of asthma at their school. By the end of the year, the old building had been thoroughly cleaned — air ducts, vents, radiators, shelves, ceiling tiles. As a school community, the PTA and staff made it a priority to be better informed about asthma and to keep triggers to a minimum. One of the primary goals of successful asthma control is for children to be able to attend and participate in all day care and school activities. Since parents cannot guarantee this goal entirely on their own, the best way to achieve it is to work cooperatively with school and day care personnel. Some suggestions for doing that include:

•    At the beginning of each school year, contact your child’s teacher, school nurse, and any other personnel who are in contact with your child and inform them that she has asthma.

•    Provide written instructions for your child’s medicines and devices (nebulizer, metered dose inhaler/spacer, dry powder inhaler, or peak flow meter) to make sure your child doesn’t miss any doses of medicine.

•    Ask your child’s doctor or nurse practitioner to fill out the necessary paperwork well ahead of time so your child won’t miss any doses of medicine.

•    Fill out school forms at the start of every school year. If your child’s school has it own form with instructions for administering medicine, fill it out completely and be sure that your physician completes and signs the appropriate part. Attach a copy of your child’s asthma management plan to the forms.

•    When a permission slip comes home for a class trip to a zoo, farm, or other destination where your child might encounter asthma triggers, attach a note to remind the teacher to look over your child’s asthma management plan and take along contact information (for you and your child’s doctor or nurse practitioner) in the event a flare occurs.

The risk of exposure to triggers is another important consideration at day care or school. You may have done everything necessary to remove asthma triggers from your home, but your child spends six or more hours each day in school or day care. Take a look around that environment. In Kia’s old middle school building, triggers were easy to spot. But most schools — whether the building is new or old — contain a slew of asthma triggers: dust in carpeting or from chalk; class pets (those cute gerbils, hamsters, and rabbits); cockroaches; strong odors and chemicals used in science, art, or other classes and for cleaning the school; and smoke. Although smoking should be banned in schools, it still occurs.

As an individual parent, you can influence some positive changes if you discuss asthma triggers with school personnel. You can request that animals be removed from the classroom and moved elsewhere. If your child is bothered by chalk dust, he could be seated farther away from the blackboard. If he naps at day care or school, provide his own pillow with a protective covering. Suggest to the school principal that cockroaches are reduced by thorough cleaning, especially in the kitchen and cafeteria areas and through regular exterminating treatments and use of traps. Exterminating, cleaning with chemicals, or maintaining the grounds (mowing the grass or playing fields) should be done before or after school hours.

If you don’t want to stand out as a solitary critic, find other parents of children with asthma and approach school administrators as a small group to make these recommendations. At home, you work hard to keep your child’s asthma under control, so don’t hesitate to ask others to make a collective effort to protect all children with asthma from triggers at day care and school. Children shouldn’t miss school because of this disease. They should be able to pay attention to their schoolwork, participate in all activities, and rarely need to take quick-relief medicine if triggers are eliminated.