Dr. Sarah Gubara (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Sarah Gubara. And today, I'm joined by Dr. Jade Tam-Williams, Division Director of Allergy, Immunology, Pulmonary, and Sleep Medicine. Today, we're discussing clinical management of asthma. Dr. Tam-Williams, thank you for joining us today.

Dr. Jade Tam-Williams: Thank you for having me.

Host: Dr. Tam-Williams, when you think about day-to-day asthma care in pediatrics, what are the most common management gaps you see in primary care, and how can pediatricians address them early?

Dr. Jade Tam-Williams: So, one of the most common gaps that I see as a pediatric pulmonologist for children with asthma is a reliance still on short-acting beta agonists, such as albuterol, before adding in inhaled corticosteroids.

For about seven years now, the guideline has included the use of inhaled corticosteroids along with a reliever therapy for children with asthma. We often still see children coming to the pediatric pulmonology office who have only ever tried albuterol and receiving oral corticosteroids with illnesses.

Now, the guidelines say essentially that, yes, you can actually add in inhaled corticosteroids, whether it's in the yellow zone or what we call concomitantly using inhaled corticosteroids with albuterol every four to six hours as needed during an illness, or using ICS with a formoterol platform, such as a single maintenance and reliever therapy, sort of a plan or an ICS with formoterol as needed.

All of these treatment plans allow for the use of anti-inflammatory inhaled corticosteroids during an exacerbation, and it has not been completely picked up in the practice yet. We recognize, as those of us who do asthma, that the patient or the family may not immediately see the benefit of inhaled corticosteroid during illness or during exacerbations. But the goal overall is to prevent worsening of flares, and to sort of take a population-based approach for this. And I think that is one big gap that we still are seeing in general pediatrics.

I think the other thing is there's still a gap in the feeling of how do we convey education on asthma and overall prognosis? This has continued to be difficult for children with asthma as we still hear out in the community phrases such as reactive airways disease, for instance, which is not an actual disease process. There is such a thing as reactive airways dysfunction, for instance. But reactive airways disease is sort of one of the ways that people have been disguising asthma—is another way that I think about it.

Host: When you think about stepwise therapy in children whose symptoms don't fit neatly into mild or moderate asthma, what should prompt pediatricians to escalate or reassess treatment?

Dr. Jade Tam-Williams: I still personally use the rule of twos. I think it's a very easy rule. I think it's easy to explain to families. And so, the rule of two is still symptoms, cough, wheezing, shortness of breath, or use of your albuterol or ICS formoterol, some sort of rescue inhaler use more than two days per week; waking up at night coughing, wheezing, or short of breath more than two times out of a month; and more than two exacerbations a year that require steroids.

And I think the rule of twos allows families to really understand control. I think a lot of families are so "used to" their child who coughs all the time or wheezes all the time, they don't recognize what is actually normal, so to speak. And whenever I provide education in my clinic, I always talk about, "Hey, well, you know, I'm glad you feel like your child is well controlled. Tell me, how many times out of a week does your child cough or wheeze?" And then sometimes they say, "Oh, sometimes," or, "A little bit." And then, I'll actually push it and say, "Is it more than two times in a week? Or do you think they're waking up at night more than two times in a month?" And that's when really the families have this kind of eye-opening, "Oh, well, wait. That's a lot, more than two?"

And when I use that rule, it allows me to then say, "Okay, we need to escalate our symptoms up." And I explain to them, what we don't want is we don't want to under-treat. We don't want to over-treat either, but we don't want to under-treat your child. And I think giving them a context with using the rule of twos really helps me convey that.

 After you then assess, okay, how much is the control? Are they well controlled or are they not well controlled? And yes, we should escalate. After that point, then my suggestion and the guidelines suggest to continue to follow up at least every quarter and every six to 12 months for maintenance.

After good control, then comes the time for when you can step down. All of us as pediatricians know of the kid that struggles all winter, but then has a wonderful summer, for instance. And so, sometimes getting them in more frequently over the wintertime and then maybe giving them the summer holidays a break or a holiday break off of their medications could be done if you're seeing them that frequently.

Host: Thank you for sharing about that. In your experience, what role do adherence, inhaler technique, environmental triggers play in asthma that appears refractory to standard treatments?

Dr. Jade Tam-Williams: So as part of my clinical work, I specifically manage severe refractory asthmatics, and I would say a good number of severe refractory asthmatics have difficult-to-control asthma because of medication nonadherence. Many of the issues around medication nonadherence unfortunately surround the mythology around medications. But sometimes it's about access to medications from a financial perspective, from an insurance, or maybe even from a transportation perspective.

So, medication nonadherence does play a pretty big role in so-called refractory asthmatics. There are definitely some children who are truly, truly refractory. They are definitely taking all of their medications, yet they continue to have exacerbations and flares and poor control. Another place that I do see problems is definitely in inhaler or spacer technique.

There was one study that showed almost 50% of people out there are using their inhalers incorrectly. In children, we've really pushed, through our asthma education program the importance of using a spacer or a valved holding chamber with all of your MDI inhalers. And that has been good. But now, unfortunately, there's this sense of, "Well, I only need to use it if I'm a kid. I don't need to use it once I've hit a certain age because I'm 'old enough to figure out how to do that.'" And that's just not true. Using a spacer increases the amount of medications that you get.

Once you get into the "severe refractory asthmatic" though, you now get a number of different types of inhaled medications. So, as an example, a level five asthmatic might be on a Dulera, that is an HFA that uses a valved holding chamber, and a Spiriva Respimat that does not need a valved holding chamber and has a different modality of delivering medication, or a Spiriva Handihaler, which is a dry powder that you have to actually put a pill in, and then you puncture the pill, and then you inhale it. They may also have Digihaler that maybe keeps track of how many puffs they take.

So, the field has gotten ever more complicated, because there are so many different ways to deliver these medications, and oftentimes families might get confused, or patients might get confused to what they need to use an inhaler with, and what they don't.

Host: I appreciate the recommendation on inhaler technique. I'm a proud user of my spacer. So, thank you for validating that.

Dr. Jade Tam-Williams: I tell all of my patients that Dr. Jade is still using a spacer, and I'm much older than you.

Host: Dr. Tam-Williams, what clinical or historical red flags should signal the need for referral to allergy, immunology, or pulmonology?

Dr. Jade Tam-Williams: Let's go first with signs and symptoms, and then we'll go with physical exam. So for example, signs and symptoms that would make me really nervous, the patient's not growing, not gaining weight well, having failure to thrive. That would be one big one that would make, say, parents, like, "Hey, they eat and they eat and they eat, but they just don't put on weight." That's a red flag. A chronic runny nose every single day, chronic wet cough every single day. And sometimes I clarify this because we get some families who, you know, moms who are maybe a little overwrought and very anxious who say, "Oh no, it never goes away." But you have to really push them and say, "Really? Every single day the kid has a runny nose?" That would be a concern. Every single day, the kid has a chronic wet cough. Yes, that's a concern. Any kind of GI symptomatology automatically makes me think, "Okay, is there some cystic fibrosis here I'm missing? Some kind of immunodeficiency?" Need for antibiotics, not just need for steroids. Lots of high doses of steroids, more than two, again, going back to that rule of two would be another kind of history thing that would make me nervous.

New onset wheezing at an older age, right? So, a kid who never wheezed before, never had problems with illnesses, and now suddenly at the age of 10 or 12, suddenly has localized wheezing that doesn't respond to albuterol. That's just weird. That doesn't fit. So, those things in the history would make me say, "Hey, maybe let's think a little bit more, push a little bit harder on an evaluation."

On exam, definitely clubbing would make me say, "Yep, that's different." Any kind of cyanosis, hemoptysis, any of those things would be of concern, too. I look a lot at growth charts. I'm kind of obsessive about them at this point for a number of reasons. One because I always want to make sure I'm not missing some kind of genetic condition like such as cystic fibrosis.

But the other is also that I'm always looking to make sure that the number of steroids the child is on hasn't caused iatrogenic adrenal insufficiency. And that can be hard because we oftentimes think about steroids leading to weight gain and whatnot, but we also need to think about a kid who's not gaining height. I think every year I catch a couple of iatrogenic adrenal insufficiency kids just by looking at their growth chart, and then sending them to endocrinology. Those would all be things that I'd say, "Hey, why don't you get assessed, you know, by a subspecialist?" And then, definitely indications of high mortality risk.

A child who's ever been to the ICU is more likely to die of asthma. If they've needed a non-invasive ventilation like BiPAP, again, more likely to die of asthma. Frequent ER visits, frequent, steroids, again, more likely to die of asthma than another child. Those would be other red flags that says, "Hey, you need to come on in and get checked out by a subspecialist."

Host: I appreciate the clinical and red flags that you've shared. Is there an ideal workup that would be most helpful to you before getting that referral?

Dr. Jade Tam-Williams: Sure. If you put the child on an inhaler, make sure they're doing it correctly. Does the kid have a valved holding chamber? Does the kid actually know how to do it properly? Can they demonstrate appropriate technique for you? And just to put a plug in, we have lots of great resources on our Children's Mercy website on how to use aerochambers and educational pieces. And for every inhaled asthma medication out there, I have how you are supposed to do it correctly with a QR code linking to videos. Those are all on the website should you ever need it.

The other thing is if you have access to spirometry, that definitely is very helpful. Because if you can confirm reversible airflow obstruction, well, that is helpful for a diagnosis of asthma.

But if you confirm that the obstruction is not reversible, that is also helpful for me to think about other disease causes. Other things could include like a complete blood count to check for eosinophilia would be helpful.

I personally, as a pediatric subspecialist, I actually enjoy getting immunization records. I like to see what the child has ever been immunized for, because maybe one thing could be that they have a very mild case of specific antibody deficiency, for instance. And actually, that's why they're really struggling with their asthma. So, that's another thing that is really helpful for me.

And then, anytime that you have a suspicion for cystic fibrosis, I say you never go wrong with ordering a sweat test for me. And then, I always tell all the trainees, "You never go wrong ordering a chest X-ray for me to look at." That just makes my job a little bit easier when I first meet them

Host: Let's end on innovation. So with all the newer therapies such as biologics and evolving guideline recommendations, what should general pediatricians understand about managing severe or difficult-to-control asthma today?

Dr. Jade Tam-Williams: So, what we know now about severe refractory asthma in the age of biologics is far and beyond what when I started out doing this could have ever imagined. We are now talking about pediatric remission from asthma, because of biologics, which is something that when I first started training, we didn't think about, right? We just said, "You have asthma, you'll probably have asthma your entire life. It'll probably wane. You know, maybe you'll have periods of your life where it won't be that bad. But then, it'll probably come back if you get older or smoke," et cetera, et cetera.

 Now, we're talking about with on therapy, getting to the point where a child or an adult could be without exacerbation, normalizing lung function. And I mean, so if this kind of puts into perspective how far we've gotten in the last 20 years with biologics. And then, for those of you who don't know, biologics are injectable medications that specifically target cytokines or antibodies that severe asthmatics may have more of.

So, the most commonly known is omalizumab, which is anti-IgE. And then, after that, we have mepolizumab, which is an anti-IL-5. We also have anti-IL-5 receptor with fasenra, and then anti-IL-4 receptors with dupilumab. And then, now even we're moving beyond the TH2 biologic or the only TH2 biologic into tezepelumab, which is anti-TSLP biologics. And these biologics essentially target these inflammatory pathways and turn them down.

So from a general pediatric point of view, I would say what really helps in helping to take care of these kids. So, we can start with just initiation. Oftentimes where we are in Kansas City, we are taking care of kids who come from a very, very far away distance. So, the community pediatricians that I work with that can help me initiate biologics, God, I love them, because it really helps the family from not having to drive four, five hours just to get an injection. So, that's to start. I've really relied on quite a bit of my far off community pediatricians with helping me start the process of actually doing the biologics, training the patients for biologics, and then the follow-up part.

So, the other follow-up things could include sometimes patients get so good with their biologic that it's like they forgot what to do when they have asthma. They're so good, they haven't had a flare in like a year. And so, the subsequent year, they get a flare, and they forget the basics, you know?

So as the community pediatrician, that's really helpful, is that in these kids, biologics really help a lot, but that doesn't mean that they might not never get a flare. And so, they might still get a flare, you know, every so often. And if they do, reminding these families of "Well, did you actually take the inhalers?" And so, I actually had to do that conversation with one of my families just recently and say, "Yes, I know you've been great, but did you remember to do the albuterol with the Flovent and with your Dulera? Did you remember?" And they're like, "Oh yeah, we just haven't done it in so long. We've lost our asthma action plan."

So, I think that's another space where it's really helpful, recognizing they could still have flares. And for some kids who are so refractory, unfortunately, there are still some kids out there that they continue to have flares even on the highest dose of medications. And really, that communication back to the pediatric subspecialist is so beneficial, because oftentimes we might not know that this family is still out there struggling despite, getting, you know, three, four different medications for their asthma.

I think those kind of things are really helpful to help coordinate care. And there are things that definitely a beloved family practitioner or a beloved long-term pediatrician, they know about their families that I, as somebody who sees them, you know, every four to six months or maybe every six months, I don't get that relationship as much as our general pediatricians do, who know the community they're living in, know the family dynamics, et cetera.

So, any of those things are really helpful, I think, for me as a pediatric subspecialist, because sometimes there's some insight there to why the asthma is so uncontrolled despite using biologics. That's really kind of what I call, like, Pediatrics 101. But I didn't get that, because I don't have that same relationship. So, I think those are pieces of asthma in primary care that helps me as the subspecialist.

Host: Thank you so much, Dr. Jade Tam-Williams, for sharing all about clinical management of asthma with us today. And as a reminder to our audience, claim your CME credits after listening to this fascinating episode today. You could do so by visiting cmkc.link/cmepodcast, and then click the Claim CME button.

If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm Dr. Sarah Gubara. And this has been Pediatrics in Practice, a CME podcast.