Rob Steele, MD (Host): Welcome to the Children's Mercy Pediatrics in Practice. I'm Dr. Rob Steele, coming to you from Kansas City, and I have Dr. Jade Tam-Williams. I want to remind all our listeners to please remember to claim your CME credits after listening to our episode. Visit cmkc.link/cmepodcast and click the Claim CME to get your credits.

Dr. Jade Tam-Williams is the Medical Director of the Asthma Center, as well as the Medical Director of Advanced Asthma Interdisciplinary Respiratory Clinic, or the AAIR. She received her medical degree at University of Missouri School of Medicine and did her residency and fellowship at WashU at St. Louis Children's Hospital in St. Louis, where she has received her Pediatric Pulmonology certification and is also board-certified in Pediatrics. Dr. Tam-Williams, welcome.

Jade Tam-Williams, MD: Thank you, Dr. Steele. Thanks for having me.

Host: So, my understanding is that you were born and raised in Miami, Florida. Is that correct?

Jade Tam-Williams, MD: Yes, that is.

Host: How does one get from Miami, Florida to a pulmonologist and researcher in Kansas City, Missouri?

Jade Tam-Williams, MD: Typically, I think by way of marriage.

Host: I think we've all been there.

Jade Tam-Williams, MD: So, I went to college in Massachusetts and fell in love with a Missouri boy. And so, "He said, "I was born and raised in Kansas City, Missouri." And I said, "Is that where there's like an arch or something?"

Host: Yeah, yeah, we do have one of those in the state of Missouri. That's true.

Jade Tam-Williams, MD: Yeah. And so, subsequently, I've been all over Missouri. I've been in St. Louis, Columbia, and now finally in Kansas City.

Host: Very good. So, Dr. Tam-Williams' research is focused on collaborating with physicians from multiple specialties involved in asthma care here at Children's Mercy, Kansas City, to build a comprehensive guideline to asthma management and improve the care of children with asthma. I know you have other research interests, including interstitial lung disease, but I think we're going to focus mostly on asthma and asthma care.

Why don't we start with asthma in general? Do you find that it is difficult, particularly for the primary care pediatrician, to diagnose asthma to begin with?

Jade Tam-Williams, MD: Yeah. So despite the fact that asthma is one of our most common childhood disease processes, its diagnosis is actually very clinical. And I think what makes it difficult to diagnose in some cases is that it's very heterogeneous. It can manifest in many different ways for different children and sometimes it's super easy to figure out and then other times you can be kind of tricked into thinking something's asthma when it's not. Also, the presentation can be very variable. Triggers are very variable. For those of us who care for seasonal asthmatics, we know that a child during one time of year could be totally different than another time of year. So even within day-to-day presentations, this could be variable.

I think diagnosing it isn't as hard as it sometimes can be to treat it. And I think mainly the reason to why it's difficult to treat sometimes is that this is a disease in which the presentation and the control can be affected so much by extrinsic factors like the environment, tobacco smoke exposures, allergies or resource limitations like insurance or medicine access. And sometimes these are just things that we as physicians have maybe barriers to taking care of these patients or maybe feel like these are really hard things to change or make better.

Host: I mean, I can tell you as a primary care physician, all of those factors were impacting me as we were trying to do. You know, that child that is 18 months old that is on their second episode of wheezing, but it was during RSV season. And you're wondering, "Okay. Was this just simply two bad episodes or does this child actually have asthma?" Certainly, we've all kind of been at that place before. Can you talk a little bit more about the environmental factors and how they impact asthma?

Jade Tam-Williams, MD: Yes. So, that is a really good question. We know in asthma research that environmental factors impact asthma. It's both unfortunate and fascinating, and especially in Kansas City. I mean, we are in such an interesting space. We see children who are from the urban core with asthma triggers that are related to potentially indoor air quality issues. And then, we also see kids from rural areas who are exposed to maybe crop dusting, or spraying, or burning. And so, there's such a range of potential environmental factors impacting asthma, right?

But in addition to that, we all know of at least one patient who their asthma got so much better once they changed this or that within the home. So, there's that component of environmental factors. But now, even broader, we in the asthma research community recognize that environment is not just what's happening within the four walls of that child's home. It's now what's happening, like, next door, down the street, in their neighborhood. And when we think about environmental factors and its impact on asthma, we now think about air quality, but we also think about what the child is exposed to. So, for instance, you know, we now talk about the prevalence of asthma in neighborhoods that are prone to violence. So, knowing that even children who witness gun violence or witness abuse, they've also been shown to have an increased risk of poorly controlled asthma or increased asthma exacerbations compared to children who have not witnessed gun violence or abuse.

And there's even some interesting studies talking about one-time big events. So, I mean, I hate to refer to what recently happened within Kansas City here, but big events like a mass shooting can actually within a couple weeks after or increase the risk of asthma exacerbations within that community because of the level of stress. And if you live in an area with bad air quality, now that risk of asthma exacerbation is even compounded. So, it's really interesting what we're seeing when we think about environment and asthma now.

Host: Yeah. That is fascinating and probably underscores the importance of research. Because quite honestly, I don't know that I would have ever linked the two as being correlative. But when you think about the other environmental factors and that we've known for years to be implicated in exacerbating asthma, I guess it could make sense. You could see how those things could go hand in hand, but it's fascinating that the research has shown that. Tell me this, with respect to how parents and families deal with a child with asthma, what advice can you give to families to avoid asthma-related emergency room visits, for example?

Jade Tam-Williams, MD: Yes. So, we know as physicians how scary these visits can be for the child and their families. So for those who have a known asthma diagnosis, I really advocate prevention and preparedness. And really, the key here is asthma education. I believe that parents who understand their medications and how they work and when to use their medications are going to be much more successful in preventing an acute or life threatening episode.

And in the asthma world, we really circle our asthma education around the asthma action plan. And there's been some mixed data there with some folks feeling that asthma action plans are helpful, and some folks feeling like, "Eh, it may not be." I always say that if you make an asthma action plan and you just hand the piece of paper to a family, that's not useful. The asthma action plan really is an opportunity for the physician and the family to discuss what medications to use for prevention, but also how to escalate treatment. So, that's a point in time where you can have a conversation with your family and say, "How does your child's asthma exacerbation typically manifest? What are their pre-respiratory symptoms, for instance?" And being able to identify these things can actually help parents know when to act so that they can hopefully prevent an asthma-related emergency room visit.

Host: Yeah. That's fantastic advice. Over the course of years, the recommendations with regard to how a clinician treats a child with asthma, depending on just the severity and chronicity of that asthma, it seems to have changed quite a bit and maybe has even gotten pretty complicated in the past. So, do you have any advice or maybe tricks of the trade of how you take something that can be fairly complicated and translate that into an asthma action plan or even just discussing it with the family?

Jade Tam-Williams, MD: Yeah, I actually like to make my asthma plans in the room, right in front of the family, because then there's no confusion on how to do it. But you're correct. I mean, our asthma guidelines have really changed in the last four years, in particular with the new updated NHLBI Expert Panel Report, Guidelines and Updates in 2020. So, it has gotten more confusing, and now you have more options, too. So, the best thing, I think, for me, that has helped is to make these plans in the room with the family, and to really discuss, "Well, this is the plan," to tailor that plan to the family themselves.

Host: Yeah. I think that's really great advice of being able to do that right in front of the parents, that also engages them in the care of their child and get more buy in. So, I think that's great. Tell me when it then comes to the actual therapy, you know, there's number of ways of administering these medications, going from dry powder inhalers to other inhalers with extensions to allow for, you know, masks and whatnot, do you have any advice for the clinician as well as for the parents with regard to the options? Are there newer options that are on the horizon? Or how do you tailor your delivery mechanisms for the child?

Jade Tam-Williams, MD: Sure. So, for a very long time we, have had nebulizer treatments. But in addition, we have also what sometimes we say an HFA or hydrofluoroalkane or a metered-dose inhaler with a spacer. And most of us have moved to an HFA option for pediatrics. Your other option is a dry powder inhaler. And what we know is that if you use a metered-dose inhaler with a spacer, you get better deposition of medications compared to nebulized medications and studies show consistently 55-80% deposition of that medicine in the lungs using an inhaler with a spacer compared to 8-12% of deposition of medications using a nebulizer. I mean, this is the main reason to why when you buy budesonide, you buy it in milligrams. Whereas if you buy a fluticasone inhaler, it's sold in micrograms. And also the time. So, anyone who's been giving medicines to like a screaming toddler knows that time is of the essence, right? So, you know, having to sit them down for 20 minutes is really hard to do a daily controller.

And then, our other options are our dry powder inhalers. Now, dry powders can be pretty tough in kids. And so, what we know is dry powders need more inspiratory force to drag that medicine from the mouth down through the pharynx, through the vocal cords, into the lungs, and making sure none of it just lands in the mouth. So for me, I typically consider dry powder inhalers when they're over the age of 12. And I definitely don't use them if the child has any neuromuscular weakness or cannot follow multi-step commands or cannot hold their breath for more than 10 seconds.

And this has become an issue, in the United States in particular, in the last couple of months. We've had quite a bit of changes in our insurance coverages, especially in this area of what is going to be covered by most of our major insurance providers with quite a few of them moving away from HFAs. And so as a pediatrician, you're in a lurch really, because some of the options that are going to be covered are typically dry powders. And so for those kids, I usually do my quick screening and say, "You know, is this a kid who's actually going to be able to do a dry powder inhaler? Can they hold their breath for 10 seconds? Are they strong enough to do so? Can they follow multi-step commands?" And if I feel like this is a child who can't, then typically I will try my best to move them back to an inhaler with a spacer set up.

Host: Yeah. Great practical advice. That's great. Dr. Tam-Williams, I appreciate so much your time, your research, your passion for taking care of the kids and their families. I have one last question, and maybe it might be the most important question. In your opinion, who tolerates it better, the locals in Miami when it's 45 degrees or the Kansas City residents when it's -8?

Jade Tam-Williams, MD: I think the Kansas City folks do, because, I mean, when it hits 60 in Miami, yeah, there's a lot of whining at point, they're not used to that.

Host: We're pretty tough here, I think.

Jade Tam-Williams, MD: Yeah, I will say, tough and independent. I always say that about Kansas City.

Host: Yeah, very good. Dr. Tam-Williams, thank you so much. Again, the link for the CME is at cmkc.link/cmepodcast. Be sure and click the CME button to claim your CME credit. This is Dr. Rob Steele here with Children's Mercy, Kansas City. Thank you for listening.