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Indian Pediatr 2016;53: 154 -158 |
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Airway Diseases Education and Expertise (ADEX
) in Pediatrics: Adaptation for Clinical Practice in India
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H Paramesh, K Nagaraju, TU Sukumaran, Sharad
Agarkhedkar, Santanu Bhakta, Raj Tilak, Vijayasekaran D, Varsha
Narayanan, Amey Mane, Abhay Phansalkar and Ganesh Kadhe
From ADEX working group, Indian Academy of Pediatrics
Allergy and Applied Imunology Chapter, Indian Academy of Pediatrics,
India.
Correspondence to: Dr H Paramesh, Sirona Center for
Health Promotion, Bengaluru 560094, Karnataka, India.
Email: [email protected]
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Justification: Asthma and allergic rhinitis together are part of the
concept of one airway, one disease or united airway disease. The
management of allergic airway diseases should address this united
concept and manage the issue by educating the patients and their parents
and health care providers, along with environmental control measures,
pharmacotherapy and immunotherapy. Here, we present recommendations from
the module of Airway Diseases Education and Expertise (ADEX) that
focused on allergic rhinitis, asthma and sleep disorder breathing as a
single entity or Allergic Airway Disease.
Process: A working committee was formed by the
collaboration of Pediatric Allergy Association of India (PAAI) and
Indian Academy of Pediatrics (IAP) Allergy and Applied Immunology
chapter to develop a training module on united airway disease.
Objectives: To increase awareness, understanding
and acceptance of the concept of "United Airway disease" and to educate
the primary health care providers for children and public health
officials, in the management of united airway diseases.
Recommendations: Recommendations for diagnosis,
management and follow-up of Allergic airway disease are presented in
this document. A better compliance by linking education of child,
parent, grandparents and other health care providers, and scientific
progress by collaboration between practitioners, academicians,
researchers and pharmaceutical companies is suggested.
Keywords: Allergic rhinitis, Asthma, Education, Guidelines,
Management
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A
sthma and allergic rhinitis frequently occur
together [1], and are major public health problem, [2]. Owing to close
association between asthma and rhinitis, they are often referred to as
"one airway, one disease" or "diseases of the integrated airway" or
"united airway diseases" [2-5]. Upto 40% patients with alergic rhinitis
may have asthma, and around 80% patients of asthma can have alergic
rhinitis. Alergic rhinitisis also known to adversely affect asthma and
its response to treatment, and therefore, should also be evaluated and
treated [6,7].
Allergic airway diseases are the most common cause
for sleep disordered breathing (SDB) and obstructive sleep apnea
syndrome (OSAS) [8,9]. Similarly, OSAS is common in patients with
asthma, but it is poorly investigated. If OSAS is left untreated, it can
lead to worsening of asthma symptoms [9]. The severity of OSAS can be
reduced through adequate treatment of AR [8].
Though allergic rhinitis and asthma are common in
children [10], difficulty in diagnosis, management and lack of
knowledge/education among parents of the affected children make the
situation more challenging. Further, there is a need of diagnostic and
prognostic markers for asthma and/or specific phonotypes [11]. To
highlight the current thinking and increase awareness, understand and
accept the concept of United Airway disease and bridge the knowledge gap
in awareness, diagnosis, management and referral of airway diseases at
the basic general practitioner level specifically in India; we developed
a module on Airway Diseases Education and Expertise (ADEX) in pediatrics
that focused on allergic rhinitis, and asthma as an integrated approach.
A working committee (Annexure I) was formed by
the collaboration of Pediatric Allergy Association of India (PAAI) and
Indian Academy of Pediatrics (IAP) Allergy and Applied Immunology
chapter to develop a training module on united airway disease (ADEX).
The scientific, technical and financial support was provided by
Wockhardt Pvt. Ltd. A literature search was done for the period
1993-2014 using PubMed and Google scholar with keywords for allergic
airway diseases. A total of 584 publications were obtained till January
2014. The abstracts of the articles were reviewed by the panel members.
The full text articles of 49 potentially relevant articles were read to
consider the article for inclusion in ADEX training module. The articles
published during last two decades, pertaining to allergic rhinitis,
asthma and SDB in children were included; while the articles pertaining
to airway diseases in adults, with poor sample size and ambiguous
results were excluded.
All discussions, suggestions and panel consensus were
compiled into a presentation module which was then reviewed by
international experts.
Recommendations
Diagnostic Tests and Modalities for Allergic Airway
disease (Fig. 1)
The association between allergic rhinitis and asthma
increases the importance of accurate diagnosis of allergic rhinitis. The
diagnosis of allergic diseases is based on history of typical allergic
symptoms and supported by laboratory tests and investigations (Fig.
1).
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Fig. 1 Diagnostic tests for various
allergic airway diseases.
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ADEX Recommendations
Diagnosis of allergic airway diseases
Good clinical history supported by physical
examination is the cornerstone for diagnosing allergic airway
diseases. Laboratory tests are only complementary.
Where available, spirometry is recommended for
all patients suspected to have asthma for confirming the diagnosis,
assessing severity of airflow obstruction and monitoring of asthma
control. However, normal spirometry does not rule out asthma.
Forced expiratory flow between 25% and 75% of
vital capacity (FEF[25%-75%]) is an early marker of bronchial
involvement in patients with AR.
Peak expiratory flow rate (PEFR) measurement is
inexpensive and to be used in clinic set up for monitoring of
asthma. Self-monitoring of PEF by patients is recommended for better
asthma control.
Other tests like FENO, and impulse oscillometry
are not recommended routinely.
Tests for bronchial hyper-responsiveness are to
be performed in specialized centers only, where facilities are
available and not routinely recommended.
Skin prick test (SPT) is a useful tool for
detection of sensitization by specific allergen/allergens. This test
can be done by pediatricians trained in SPT, by using 10-12 common
standardized antigens, for purpose of allergen avoidance, and
whenever planning for specific immunotherapy.
In vitro testing of serum specific IgE
is very expensive and not recommended routinely. However, when we
suspect a particular allergen is the cause, it can be done for
purpose of allergen avoidance.
Quantification of eosinophil count in nasal
smear (>5/HPF) by Hansels stain is easy to do, has good accuracy
and cheap. It can be done by the practitioners in their clinics.
Quantification of eosinophil count in sputum in children is not
recommended.
Total IgE, absolute eosinophil count and
peripheral smear for eosinophil count are routinely not recommended
for the diagnosis, as elevated levels are seen in other conditions
also. It may be normal in 30% cases of respiratory allergies.
X-ray of neck (lateral view) for
visualization of adenoid enlargement is not recommended, as adenoid
size never correlates with X-ray.
X-ray PNS is not recommended as in only
40% of patients with allergic rhinitis, mucosal thickening is seen
in routine X-ray PNS.
X-ray chest is not routinely recommended
for patients suspected to have asthma; however; it can be done to
rule out alternate diagnosis, and whenever complications of asthma
are suspected.
Nasal endoscopy in AR patients is not routinely
recommended. It can be done with ENT specialist whenever anatomical
abnormalities are suspected, for knowing the size of adenoids, and
the status of osteomeatal complex.
Computed tomography (CT) of para nasal sinuses
are not routinely recommended. It is indicated only when maximum
medical treatment has failed, when surgery is planned or when there
are complications of sinusitis.
Management of Allergic Airway Disease
The management of allergic airway diseases is based
on education of the patients, parents, and healthcare providers,
environmental control measures, pharmaco-therapy and specific
immunotherapy (Fig. 2) [11-13]. A sequential approach to
the therapy of pediatric asthma is presented in Fig. 3.
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Fig. 2 Allergic rhinitis disease
management.
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Fig. 3 Sequential approach to therapy
for pediatric asthma.
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ADEX Recommendations
Goals of management of respiratory allergies
include relief of patients current symptoms, prevention of further
disease progression, good lung function and ability to perform his/
her normal daily activities.
Combination of patient education,
self-monitoring, and regular physician visits, avoidance of triggers
along with pharmacotherapy is the corner stone in the management.
Allergen and irritant avoidance along with
patient education is the first step in the treatment of respiratory
allergic diseases.
Second generation antihistamines are to be used
instead of first generation because of better safety and efficacy
ratio.
All second generation antihistamines are
equally effective; however, cetirizine can cause mild sedation in
certain children while Fexofenadine and Levocetrizine cross blood
brain barrier minimally and therefore are non-sedating, effective
and safe.
Intranasal antihistamines are not recommended
in children, due to their bitter taste and mild somnolence.
Oral decongestants are not recommended in
children, due to their systemic side effects, like irritability,
dizziness, headache, tremor and insomnia as well as tachycardia and
hypertension.
Intranasal decongestants are not recommended in
children. Prolonged use >10 days) can cause rhinitis medicamentosa.
Intranasal anticholinergic agent (Ipatropium
bromide) is not routinely recommended.
Inhaled corticosteroids (ICS)/inhaled nasal
steroids (INS) are the controller medications of choice.
All ICS/INS are equally efficacious when used
in equipotent doses.
Choose an INS/ICS with low systemic
bioavailability like Mometasone or Fluticasone furoate at a minimum
dose required to achieve symptom control.
Adverse effects of INS are negligible (Minor
nasal bleed, throat discomfort), and they arise mainly due to faulty
technique.
Prescription of the device should be
individualized according to patients ability to use, preference and
cost. Technique of INS/ICS should be evaluated during each visit.
Most of the clinical benefit from INS/ICS is
obtained at low to moderate doses.
Always use spacer with metered dose inhaler
(MDI). In children younger than three years, and non co-operative
patients, use face mask along with spacer with MDI.
When prescribing inhaled steroids for rhinitis
and asthma together, the total dose of steroid should not exceed the
recommended levels.
Long acting beta agonist (LABA) monotherapy
should not be used.
ICS+LABA is a preferred choice when symptoms
are uncontrolled despite ICS monotherapy in children older than 5
years.
Montelukast monotherapy is inferior to ICS/INS.
Short acting beta2 agonist (SABA) is the drug
of choice for rescue medication during acute episode of asthma.
Combination of ipatropium bromide with
salbutamol provides better bronchodilatation compared to either drug
alone.
Oxygen
saturation to be measured by pulse oxymetry whenever
possible in all cases of acute attack of wheeze (asthma).
If allergic rhinitis is predominant, INS with
Montelukast is the choice
If Asthma is predominant, ICS with Montelukast
is the choice.
Antihistamines and bronchodilators are to be
used on need basis.
Allergen specific immunotherapy
(Desensitization) is recommended in respiratory allergy patients
with definite but unavoidable specific one or two allergens and
patients not responding to maximum pharmacotherapy by a trained
specialist. Patients with severe asthma with FEV 1
<65% are contraindicated.
Sublingual Immunotherapy (SLIT) is preferred
over subcutaneous immunotherapy (SCIT) due to better safety.
Nasal irrigation may be used as adjuvant
therapy.
Anti IgE is not recommended due to its cost.
The treatment of allergic airway disease is
represented in Fig. 4.
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Fig. 4 Treatment of allergic airway
disease.
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Monitoring and Follow-up
Regular monitoring of the child is vital for
success of therapy.
Monitoring should be initially once in a month
until good control is achieved and thereafter once in 3 months
Upper and lower airway symptom score to be done
in every visit.
Dosage of drugs is to be adjusted (decreased or
increased) according to the control of the disease.
Withdraw the last added drug during step down
therapy.
Maintain minimal or low dose of ICS/INS to keep
patient symptom free (under control).
Encourage patient to perform PEFR twice daily
and maintain a record.
Check the inhalation technique during every
visit.
Encourage children to lead a normal life at
school, and participate in games.
Advise on yoga, pranayama etc. maybe given.
Conclusions
This module aims to meet the local needs of the
health care resources. Most aspects of allergic rhinitis and asthma have
been reviewed that will help in better understanding and management of
the airway allergies by the primary health care providers for children
and the public health officials. It is hoped that this module serves as
a basis for treatment and management of the united allergic airway
disease for primary care providers in children. It is advised that the
judgment of the management should be based on the diagnostic and
treatment choices available as well as on social determinants like
acceptability, availability, affordability and accountability.
Acknowledgements: Knowledge Isotopes Pvt.
Ltd. (www. knowledgeisotopes.com) for the medical writing
support.
Funding: None; Competing interests: None
stated.
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Annexure: ADEX Working Group
Chairperson: H Paramesh; Convener:
K Nagaraju; Participants: TU Sukumaran; Sharad
Agarkhedkar, Santanu Bhakta, Raj Tilak, Vijayasekaran, Varsha Narayanan,
Amey Mane, Abhay Phansalkar, Ganesh Kadhe.
International reviewers: Nicos Papadopoulus and PK Vedanthan.
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