383 - Asthma Guidelines, Physical Activity and Mortality, EKGs in Children
Take 3 – Practical Practice Pointers©
From the National Heart, Lung and Blood Institute (NHLBI)
1) Updates to Asthma Guidelines
The NHLBI National Asthma Education and Prevention Program last released a comprehensive asthma guideline in 2007. This December 2020 update focuses on a handful of focused topics in the diagnosis and management of asthma. The expert panel that created the guidelines was interdisciplinary, included primary care, and solicited patient and family input. Importantly, the NAEPP used a systematic review commissioned from the Agency for Healthcare Research and Quality and used the well-established GRADE framework to develop their recommendation. The foreword of the guidelines laments the dearth of strong recommendations but notes that this is an expected consequence of a rigorous guideline methodology and a heterogeneous condition like asthma. The recommendations include:
Using intermittent inhaled corticosteroids
- Children aged 0-4 years with recurrent wheezing with URI only, short-course daily ICS at onset of infection and PRN short acting beta agonist (SABA). (conditional recommendation/high certainty of evidence (COE))
- With mild-moderate persistent asthma, ages 4 years and older and adherent to daily ICS doses, don’t use short-term increase in ICS dose for symptoms/decreased peak flow. (conditional/low COE).
- With moderate-severe persistent asthma, ages 4 years and older, use ICS+formoterol as BOTH daily therapy and reliever therapy (SMART – single maintenance and reliever therapy). (strong/high for >=12 years, mod 4-11 years)
- Formoterol has a more rapid onset of action than other long-acting beta-agonists (LABAs). Dose is 1-2 puffs 1-2 times per day (depending on severity) and 1-2 puffs PRN symptoms. No more than eight puffs/day.
- If current daily ICS + PRN SABA therapy is working, no need to change, but ICS+formoterol should be tried before increasing to next step in therapy.
- Don’t use ICS+formoterol for reliever if using ICS+salmeterol, just use SABA.
- With mild persistent asthma, aged > 12, use either: (conditional/moderate COE)
- daily low-dose ICS and PRN SABA, or
- ICS+SABA used together as needed only.
Using long-acting muscarinic antagonists (LAMAs) (both conditional/moderate COE)
- With uncontrolled persistent asthma, do not add a LAMA to ICS unless a preferred LABA cannot/will not be used.
- With uncontrolled persistent asthma on ICS/LABA, a LAMA can be added.
Indoor allergen mitigation
- With a history of sensitivity to specific allergens, multicomponent allergen-specific mitigation interventions are recommended. (conditional/low COE)
- With sensitivity to dust mites, recommend impermeable pillow/mattress covers. (conditional/moderate COE) along with other interventions.
- With a history of a sensitivity to pests (cockroaches, rodents), pest management is recommended. (conditional/low COE).
- Without a history of specific indoor allergen sensitivity, do not recommend allergen mitigation (conditional/low COE)
- Includes mite pesticides, carpet removal, HEPA filters, mattress/pillow covers, pest management, mold mitigation, pet removal, etc.
Role of subcutaneous and sublingual immunotherapy
- With mild-moderate allergic asthma worsened by specific allergens, ages 5 years and older, subcutaneous immunotherapy can be added. (conditional/moderate COE)
- Expect only small improvements in quality of life and symptom control.
- With persistent allergic asthma, sublingual immunotherapy is NOT recommended. (conditional/moderate COE).
Fractional exhaled nitric oxide (FeNO) in diagnosis and management of asthma
- FeNO testing can be added to diagnostic algorithm for age 5 years and older if there is still uncertainty about the diagnosis after history/physical, clinical course and spirometry. (conditional/moderate COE)
- FeNO is a measure of airway inflammation measured by breath test.
- FeNO can be hard to interpret due to common confounding conditions. A high result (> 50 ppb (or > 35 ppb in ages 5-12)) is most useful.
- The panel recommends that inhaled corticosteroids (ICS) NOT be withheld solely based on this test.
- FeNO can be used to monitor and adjust anti-inflammatory therapies in patients with asthma (conditional/low COE), but should not be used alone. (strong/low COE)
- FeNO should not be used to predict asthma in ages 0-4 years. (strong/low COE).
The panel notes that the very recent “explosion” of biologic therapies was not addressed in this update, as its inclusion would have delayed the guideline further.
It’s always interesting for me to read about a guideline group adapting to the GRADE framework and “realizing” the relatively fragile evidence-base on which previous recommendations have been made – placebo-controlled trials without comparative effectiveness studies, efficacy studies in homogenous populations, and the use disease-oriented or proxy outcomes. This was a well-done guideline and provides some good new information about these new directions for diagnosis and management. A helpful At-A-Glance version of these guidelines is HERE.
- 2020 Focused Updates to the Asthma Management Guidelines | NHLBI, NIH. Accessed January 4, 2021. Link
From the Literature
2) Reducing Mortality by Increasing Physical Activity
The amount of time spent in sedentary behaviors - especially sitting - has increased dramatically over the past 15 years and for many, has been further exacerbated by the COVID-19 pandemic. High rates of sitting are associated with increased morbidity and mortality and, given the prevalence, it has been said that “sitting is the new smoking.”
Previous research has found regular moderate-to-vigorous physical activity to be effective in mitigating the adverse effects of sitting (particularly cardiovascular disease risk factors). However, the level of physical activity (minutes per day or per week) associated with these benefits is inconsistent in the literature and not all studies have shown similar results. In the majority of previous studies, activity level was self-reported by research subjects, which is prone to multiple biases.
A recent meta-analysis explored the relationship between differences in sitting and physical activity with overall mortality using accelerometer data from more than 44,000 adult subjects from the U.S., Norway, and Sweden followed for 4 – 14 years. This was a “harmonized” meta-analysis, in which the authors took pains to transform the result data from each of the included cohort studies to be as comparable as possible. Overall, they showed that the time spent in sedentary activity (sitting or reclining while awake) averaged 8.5 – 10.5 hours/day, while time spent in moderate-to-vigorous physical activity averaged 8 – 35 minutes/day. Approximately 30-40 minutes of daily or almost-daily moderate-to-vigorous physical activity was effective in mitigating much of the effect of sedentary behavior on mortality, even when controlling for age, sex, BMI, socioeconomic status, and smoking status. Further, subjects who were sedentary for 8 to 10 hours per day but participated in just 11 minutes of moderate-to-vigorous physical activity had lower mortality than those who did not.
Our thanks to our colleague Michelle Rockwell, PhD, RD, for taking the lead on writing this Pointer and Commentary. Michelle writes, “While we have a multitude of reasons for sitting during work and leisure time, focusing on just 11+ minutes of moderate-to-vigorous physical activity is very do-able! Fewer than 25% of adults achieve the DHHS Physical Activity Guidelines for Americans (150 to 300 minutes of aerobic activity plus two sessions of strength-building exercise weekly), so a focus on shorter bouts of more intense exercise can be an alternate approach to balancing out our sedentary lifestyles. The American College of Sports Medicine has provided a nice infographic for estimating physical activity intensity, and that is included as the 2nd reference.
A Twofer From the Choosing Wisely Campaign and the AAP
3) Screening EKGs in Healthy Pediatric Patients – Just Say No
The American Academy of Pediatrics (AAP) Section on Cardiology and Cardiac Surgery recently released a list of “things physicians and patients should question.” Two of the recommendations had to do with the use of screening EKGs. They include:
Do not routinely order a screening ECG as part of a sports preparticipation examination in asymptomatic, otherwise healthy patients with no personal or family history of cardiac disease.
Routine screening ECGs for preparticipation sports clearance are not currently recommended by the American Heart Association (AHA). Instead, it is recommended that the AHA’s 14-point screening guidelines, or the American Academy of Pediatrics’ “Preparticipation Physical Evaluation” be used in conjunction with a targeted personal history, family history, and thorough physical examination. The goal is to identify warning signs or signs that raise suspicion of cardiovascular diseases that place certain athletes at risk of sudden cardiac death. These individuals should be referred for further evaluation by a pediatric cardiologist who may order an ECG or an echocardiogram as part of the work-up.
Routine ECG screening of healthy pediatric patients with no personal or family history of cardiac disease has demonstrated a high false-positive rate and has not been found to reduce mortality from sudden cardiac death. In addition, it can also lead to unnecessary secondary evaluations. ECG screening should be performed in those patients with a strong family history of conditions likely to cause sudden cardiac arrest or death.
Do not order a screening ECG prior to initiation of attention-deficit/hyperactivity disorder (ADHD) therapy in asymptomatic, otherwise healthy pediatric patients with no personal or family history of cardiac disease.
Many clinicians obtain ECGs in healthy patients with no personal or family history* of cardiac disease prior to initiating stimulant therapy for ADHD out of fear of triggering an adverse cardiovascular event or worsening a previously undiagnosed cardiovascular disease. However, the probability that such screening will lead to the diagnosis of cardiac disease is low. Furthermore, when ECG abnormalities are identified, they rarely warrant a change in planned ADHD therapy. As a result, obtaining the ECG increases health care costs and can increase stress for both the patient and family.
If there is concern based on the history and physical examination, then a pediatric cardiology referral is a reasonable consideration.
This is a good reminder that asymptomatic testing is not a benign intervention. HOWEVER, please note that the AAP recently released an updated interim guidance for returning to sports for children who have had COVID. An EKG and referral to pediatric cardiology is recommended for those who have had mild disease but have a concerning history or physical exam, and for all those who have had moderate or severe disease. See the 2nd reference below for further details.
Mark and John
Carilion Clinic Department of Family and Community Medicine
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