Asthma in Pediatric Patients

Abstract

Asthma is a leading chronic condition in the pediatric population within the United States. The prevalence of asthma has increased in modern times likely due to an increase in air pollutants in the environment. Asthma also has an economic burden associated with an increased number of missed school days per year and high emergency department admission rates. Genetic and lifestyle factors have been shown to predispose people to the development of asthma. A tertiary prevention program that involves the comprehensive use of the Asthma Action Plan, developed by the American Lung Association, can help gain better control of a patient's asthma and reduce the number of asthma related emergency department visits. This plan requires the cooperation of school nurses, physicians and parents in order reach its maximum potential. This program can also help patients and their families gain more control of their health at a relatively low personal and economic cost.

Epidemiology of Asthma in the Pediatric Population

Asthma is the most common chronic disease in childhood in resource-rich countries, including the United States (Sawicki, & Haver, 2018). It is estimated that 14 million days of school are missed due to asthma in the United States each year (Sawicki, & Haver, 2018). The prevalence of asthma can be contributed to a genetic component in addition to several environmental factors. These environmental factors include: diet, air quality, smoking, antibiotic use, and allergies (Patel, Henderson, Jeffreys, Davey, Smith, & Galobardes, 2012). If asthma is left uncontrolled, this disease can become costly due to the potential for life-threatening symptoms that may require admission to an emergency department or hospital. By implementing a structured program with coordination from the patients, parents, school and provider, these costs can be minimized. Epidemiologic Parameters and Significance of Disease (Shafer) Asthma has been an increasing problem in the United States over the last two decades, particularly in children under 18 years old. According to the Center of Disease Control and Prevention, asthma rates of the total population increased by 12.3% from 2001-2009, making the prevalence of asthma in the United States 8.2% (2011, p. 547). The prevalence of asthma in children jumped and then plateaued (Sawicki & Haver, 2018). Data collected by the Center of Disease Control and Prevention between 2001-2009 showed that the prevalence of asthma in children was at 9.6%, which was increase from previous years (2011, p. 547). With increased awareness and intervention, the prevalence of asthma in children did show a decrease to 8.3% from 2013-2016, especially in children under the age of 5 (Sawicki & Haver, 2018).

Asthma is a serious, chronic disease that comes with a lifetime need for medical treatment. Poor asthma management can result in hospitalization and sometimes death. According to the American Lung Association, asthma is the third leading cause of hospitalization among children under the age of 15 years (2018, para. 7). Although asthma-related death is rare in children, there were 169 children who died in 2016 due to complications of asthma (Asthma and Children Fact Sheet, 2018). The American Lung Association also reported that in 2010 there were approximately 640,000 emergency room visits due to asthma in those under 15 years of age (2018, para. 8). Asthma continues to be a prevalent chronic disease in the United States, particularly in the pediatric population. Due to its multifactorial development, additional research must be conducted to better understand the pathophysiology of the disease. Genetic Markers of Asthma (Hubacek) Asthma is a common disease that is known to develop due to genetic and environmental factors. Many studies have been completed and further research is still being done to determine which genes are responsible for genetic inheritance of asthma. Asthma does not follow a typical Mendelian path of inheritance, instead the asthma phenotype is expressed non-linearly and is highly variable so it is more difficult to make predictions of the rate at which it is passed down to offspring (Thomsen, 2015, para. 2). Important factors for determining the inheritance of asthma include: degree of genetic relation to the relatives with asthma and the severity of the asthma and the age at which the relative developed asthma (Thomsen, 2015). The recurrence risk of asthma in children with one affected parent is around 25%, whereas the risk if both parents are affected is around 50% (Thomsen, 2015, para. 3). Ober & Yao found that asthma has significant genetic contributions, with heritability estimates varying between 35% and 95% (2011, p. 10). Thomsen brings to light that twin studies have shown there is an increased chance of developing asthma if someone who has very similar genetic composition has the condition (2015). For example, the risk of asthma in both identical twins is much higher than that of fraternal twins (Thomsen, 2015). At this point in time, there are several genes that have been found to correlate to the inheritance of asthma. In 2010, the largest study regarding the genetics of asthma was conducted genotyping 26,475 participants, over half of which had asthma (Thomsen, 2015). This study revealed 9 genes that are responsible for the asthma phenotype. The genetic markers involved in the inheritance of asthma include: the gene for nonmuscle isoform of myosin light chain kinase (nmMLCK), ADAM33 on chromosome 20p13, ILIRL1 and IL18R1 on chromosome 2, HLA-DQ on chromosome 6, IL33 on chromosome 9, SMAD3 on chromosome 15, ORMDL3 and GSDMB on chromosome 17, and IL2RB on chromosome 22 (Ober & Yao, 2011; Zhou, Wang, & Garcia, 2015; Thomsen, 2015). The study conducted by Zhou, Wang, & Garcia demonstrated nmMYLK dependent gene expression differentiates the severity of asthma in patients (2015). The ADAM33 gene has been specifically linked to the bronchial hyperresponsiveness in asthma in addition to airway remodeling (Thomsen, 2015). The ORMDL3 gene, in particular, was associated with childhood onset, whereas the HLA-DQ gene was related to later-onset asthma. Further, the results showed that 38% of all cases of childhood-onset asthma were attributable to a combination of the identified genes (Thomsen, 2015, para. 11). The extent of research completed thus far does indicate that genes are responsible for the development of asthma. However, additional research still needs to be done in order to better predict the inheritance pattern of asthma. Family Genogram of Asthma (Hubacek) This genogram illustrates there is an increased probability of developing asthma if a close family member has asthma. This is seen as both twins inherited asthma from their mother, likely due to their similar genetic makeup. In addition, this genogram demonstrates with Aimee and Jerome's children that there is a 25% recurrence rate of asthma when one parent is affected. Environmental and Lifestyle Factors (Shafer)

Asthma is a multifactorial disease that is affected by genetics, environmental factors and lifestyle choices. There are a multitude of environmental factors that are said to exacerbate asthma, including diet, air quality and pollution, smoking, antibiotic use and exposure to different allergens (Patel, Henderson, Jeffreys, Davey Smith, & Galobardes, 2012). According to Kravitz-Wirtz et al., there is evidence showing that exposure to air pollutants in utero and in the postnatal years can have an effect on the development of asthma later in life (2018). The fetal lungs begin to develop in the later trimesters of pregnancy and continue to mature until 3 years of age (Kravitz-Wirtz et al., 2018). The lungs are highly susceptible to environmental toxins due to the permeability of cells lining the respiratory tract (Kravitz-Wirtz et al., 2018). The absorption of toxins via the respiratory tract endothelium seems to contribute to the development of asthma later in life (Kravitz-Wirtz et al., 2018). There is also a correlation of the development of asthma in children with lower socioeconomic status (Kravitz-Wirtz et al., 2018). According to Kravitz-Wirtz et al., children in under-resourced neighborhoods lack access to proper health care, therefore increasing their stress levels, contributing to poorer nutrition status and exposing them to more air pollutants (2018, para. 6). The combination of these lifestyle and environmental factors seem to have an increased risk of asthma in children across the United States (Kravitz-Wirtz et al., 2018). Another significant risk factor for developing asthma is obesity (Asthma Risk Factors, 2018, para. 7). Reasons for this correlation are still unknown, but inflammation is suspected to play a key role (Asthma Risk Factors, 2018, para. 7). According to the American Lung Association, obese patients often use more medications, suffer worse symptoms and are less able to control their asthma than patients in a healthy weight range (2018, para. 7). The growing obesity rates in the United States, especially in pediatric patients, put more children at risk for developing asthma.

Tertiary Prevention Program for Asthma

At this point in time, asthma is a well-known diagnosis among the pediatric community. However, many pediatric patients suffer from uncontrolled asthma. Uncontrolled asthma increases the number of emergency department visits and hospital admissions, costing families thousands of dollars yearly. We would like to implement a tertiary prevention program to ensure better control of asthma in pediatric patients. This would reduce the number of asthma related emergency department visits and hospital admissions. The American Lung Association has created an Asthma Action Plan to be used for all patients with an asthma diagnosis. This plan includes three zones (green, yellow, red) to guide patients with their home asthma care when their symptoms are controlled, moderately uncontrolled, and severely uncontrolled, respectively (American Lung Association, 2018). In order for this plan to be effective, patients must receive education on how to use a peak flow meter, what the results mean, and how often they should test their lung function using this device at home. Upon diagnosis, providers should review this information with the patient and parents and have them demonstrate before the end of the appointment. Providers should also review when patients should return for a follow up appointment. The current form recommends following up within 24 hours of reaching the yellow zone (American Lung Association, 2018). This tool is not being widely used among pediatric patients with asthma. We would like to fully implement the use of the Asthma Action Plan form, Figure 2, within pediatrician offices and schools. This requires full cooperation of school nurses, patients, parents and the provider. Patients with asthma who attend public school will be required to have a follow up visit regarding their asthma treatment before the school year starts. The school will require the Asthma Action Plan to be completed and signed by the parent and provider. Spirometry should also be completed at this follow up visit to monitor lung function and determine whether or not the current treatment plan is effective for the patient to use during the school year. Two peak flow meters will be given to the patient to keep one at home and one at school along with duplicate controller and rescue medications. If the patient's asthma is not well controlled, they should follow up monthly and update their Asthma Action Plan until their symptoms consistently stay within the green zone. When a patient remains in the green zone, they should plan to follow up every 6 months.

Ethical and Cost-Benefit Considerations (Hubacek)

Monitoring asthma in previously diagnosed patients is fairly cost effective and non-invasive. There are not any ethical conflicts in our proposed tertiary prevention program for asthma due to its necessary and non-invasive nature. Asthma is most commonly tracked with the use of lung function tests such as peak flow and spirometry in order to determine the patient's baseline lung function and reevaluate the effectiveness of their prescribed treatments. According to Alliance Tech Medical, the typical cost of a peak flow meter for CPT code A4614 is $21.95 (2018). The cost may amount to even less depending on insurance coverage. Once a patient pays for a peak flow meter, they are able to reuse this device to evaluate their lung function at home and school. The use of this device outside of the medical office can help the patient determine whether or not their asthma is well controlled and help the patient decide if they need to make additional appointments to follow up. Spirometry is also another non-invasive procedure that has the ability to diagnose asthma and determine the effectiveness of asthma medications, particularly inhaled corticosteroids, with repeat tests. Alliance Tech Medical also suggests that this is an affordable test with a cost of $35 for CPT code 94010 and $65 for CPT code 94060 (2018). Compared to the cost of most tests in health care, these tests are fairly affordable and essential for managing asthma treatment.

The Asthma Action Plan forms from the American Lung Association can be downloaded for free to be filled out by a healthcare provider. Most common diagnostic methods and repeat follow ups are covered by insurance due to the high prevalence of this disease. The cost of purchasing a peak flow meter, asthma medications, and follow up appointments can add up, but they are necessary to prevent life threatening asthma attacks. Overall, the benefits of appropriately maintaining control of the patient's condition outweigh the cost of the associated medical fees.

Conclusion

Asthma is a serious and life-threatening disease that affects the population on a global scale. In 2016, the prevalence of asthma in children under 18 years old was 8.3% (Sawicki & Haver, 2018). Asthma is prevalent in highly developed countries and accounts for hundreds of emergency department visits, hospital admissions and missed school days (Sawicki & Haver, 2018). Parents diagnosed with asthma have a high chance of producing children with asthma, suggesting a genetic correlation (Thomsen, 2015). Some of the known genetic markers include ADAM33, ORMDL3, and HLA-DQ (Thomsen, 2015). Environmental factors and lifestyle choices also play a role in the development of asthma. Air pollutants, smoking, diet, antibiotic use and exposure to allergens have been shown exacerbate or trigger the development of asthma (Patel et al., 2012). Early life exposure to environmental toxins, low socioeconomic status, and childhood obesity put children at greater risk for becoming asthmatic (Kravitz-Wirtz et al., 2018; "Asthma Risk Factors" 2018). We chose to implement a tertiary prevention program using the Asthma Action Plan, an existing screening tool developed by the American Lung Association (2018). The Asthma Action Plan includes three zones (green, yellow, red) that correlate with the level to which the patient's asthma is currently controlled (American Lung Association, 2018). Our goal is to increase education and use of the Asthma Action Plan in primary care clinics. We also would require all public-school children diagnosed with asthma to have a clinic visit before the start of the school year, where they can fill out their Asthma Action Plan and receive extra medications and supplies. Our goal is to prevent severe asthma attacks and the costs associated with them. We identified that there are several major benefits of implementing this tertiary prevention program, including reduction of emergency department visits and hospital admissions, reduction of missed school days and earlier detection of asthma exacerbations. We did not identify any ethical dilemmas associated with this intervention. Asthma continues to be an ongoing problem in our country. It is imperative to control asthma at an early age to prevent complications. Implementation of the Asthma Action Plan could be extremely beneficial to help patients and parents manage asthma at home. Proper asthma management will reduce hospital admissions, emergency department visits, and the nationwide cost associated with asthma.

Cite this page