Asthma in adolescents: Why new specific recommendations?

Lille, France – This is the first, submitted to French Pediatric Society Conference (1-3 June, night) [1] : Recommendations for the management of adolescents with asthma have just been published by pulmonologists, under the auspices of French Respiratory Society (Sudan People’s Liberation Front) and Pediatric Society of Respiratory Diseases and Allergy (SP2A) [2]. An expected text when we know that the prevalence of asthma among adolescents is increasing. Here are the highlights.

Adapting to adolescence

Since the adolescent no longer speaks strictly of a child, nor yet of an adult, it was necessary to make specific recommendations, taking into account the characteristics of this particular period of life: physical, emotional (anxiety), cognitive, social and respiratory changes such as vocal cord dyskinesia Secretive or hyperventilation syndrome, initiation of smoking and other addictions, concern about professional guidance, etc. Moreover, physiological developments at this age do not help the young person to integrate that asthma is a chronic disease that may be subject to daily treatment.

Adolescent death is always directly related to a defect in the care pathway

Most often, and particularly in the previous SPLF recommendations published in 2016, expert recommendations for adolescents were combined with those of adults. The recommendations for pediatrics strictly speaking are dated from 2009 (Recommendations of the Research Group on Advances in Pediatric Pulmonology – GRAPP).

“It seems important to us, as pulmonologists, to regard adolescence as a continuum from childhood, and thus, to associate adolescence with pediatrics, Dr. Antoine Deschielder (Department of Pediatric Pulmonology and Allergy, Hospital Jean de Flandre, Lille University Hospital), Coordinator of the Pediatric Pulmonology Group. Our goal was to issue clear messages, regarding goals and treatment, applicable to all players – GP, pediatrician, specialist – a prerequisite to following them. Because hospitalization in adolescents with asthma is not reduced, and the risk of death is not zero. However, the death of an adolescent is always directly related to a defect in the course of care.”

Very common disease, with more deaths associated with severe asthma

Asthma is the most common chronic disease among adolescents. In 2016-2017, 12% of 9th grade adolescents had at least one asthma attack or had asthma treated during the year (Public Health France), compared to 8.6% in 2003-2004 and 9,7% in 2008-2009. About 10% of hospitalizations occur among adolescents aged 10 to 19 (2015) with a total of 5,600 in 2015. Adolescents today still die of severe asthma. 13 deaths were recorded in 2016.

Control symptoms, prevent attacks

Good control of asthma symptoms is essential, and the central goal of management. By “good control,” experts mean (within the past 4 weeks), fewer than two daytime offerings per week, no asthma-related nighttime awakenings, less than two rescue medication per week, and no restricted activities due to asthma. asthma. If one or two items are not present, the control is partial.

Don’t compromise on asthma control in teens and keep your goals high

Moreover, poor asthma control is evident. Dr. Decheldry warns that “the night speaks very loudly, because nocturnal symptoms are generally a symptom of poor asthma control. On the other hand, when an adolescent declares that their asthma is having an effect on their physical activity, it is necessary to distinguish true asthma from exercise (which usually appears after a certain time or even after exercise and responds or is prevented by taking it. A short-acting bronchodilator), uncontrolled asthma (immediate symptoms – cough, wheezing, discomfort) or poor adaptation to exertion (especially when sedentary and/or overweight adolescents).

Experts encourage the use of control scores, especially the 5-question ACT score [3] Which explores daily discomfort, shortness of breath, typical symptoms, use of rescue medication, and subjective assessment.

Antoine Deschilder asserts that “an ACT score greater than or equal to 20 confirms controlled asthma, but in adolescents we suggest seeking a higher score, at least 22”. Conversely, a score of 15 or less is an alert indicating uncontrolled asthma. We should not compromise control of asthma in adolescents and maintain high goals, which we share with him by identifying times or activities when his asthma is bothering him.”

Beware of prescribing only long-acting bronchodilators without inhaled corticosteroids, as their excessive use is the open door to severe asthma leading to intensive care.

In addition to monitoring follow-up, Antoine Descheldry identifies, it is necessary to pay attention to the exacerbation of the disease, and to prevent it thanks to treatment by identifying the factors associated with the risk of an asthma ‘attack’, a term considered more appropriate than exacerbations because it is better understood by adolescents and their parents.

Chief among these criteria is the occurrence of one or more episodes in the past 12 months. Poor compliance or incorrect inhalation technique (very common), heavy use of rescue medication showing poor control (except for one short-acting bronchodilation device every 1-2 months) are other risk factors. Adolescents with frequent exacerbations (>one attack per year) will require special care. “Beware of prescribing only long-acting bronchodilators, without inhaled corticosteroids, because their excessive use is the open door for severe asthma that leads to intensive care,” emphasizes Antoine Descheldry. It is also necessary to pay attention to the observance of basic treatment at its inception or after a crisis, through Planning to consult with the teen for evaluation. »

Standards maintained by experts to determine normal environmental flow requirements

“The main goal of care is to get the adolescent to reach adulthood with normal or optimal function, hence respiratory function tests (EFR) at diagnosis and then follow-up regularly, with periodic adjustments to the level of asthma severity. Standards maintained by experts who determine A normal EFR in adolescents with asthma is a pre-bronchodilator FEV1/forced vital capacity (FVC) ratio greater than -1.64 z-score and absence of reversal (difference between post-bronchodilator and pre-bronchodilator measurement), the latter determined by a difference At FEV1 and/or a difference in forced vital capacity (FVC) ≥12% and 200 ml”, explains Professor Antoine Decheldry.

Inhaled corticosteroid therapy, the cornerstone of treatment in adolescents

The severity of asthma is determined by the treatment needed to control symptoms. As in adults, levels 1 and 2 reflect mild asthma, levels 3 and 4 moderate asthma and level 5 severe asthma that requires specialist advice (read the new recommendations: Step-by-step treatment of teenage asthma).

Broadly, as recommended for adults, first-line disease-modifying therapy, given the highest level of evidence, is treatment with an inhaled corticosteroid, combined if necessary with a second drug treatment, preferably a long-acting bronchodilator. An alternative, but with a much lower level of proof, is the use of leukotriene antagonists, the neurological effects of which must be carefully monitored. For emergency treatment, priority is given to on-demand short-acting bronchodilators, whatever the level stipulated in the action plan.

Daily doses of inhaled corticosteroids in adolescents with asthma (12 years) are considered to be as high as 500 mcg/day of fluticasone propionate or equivalent (at least 800 mcg/day of budesonide). Efficacy of ICS above 200-250 mcg fluticasone propionate equivalent rapidly plateaus, resulting in modest benefit (on symptoms such as respiratory function) at higher doses, while the risk of adverse effects increases. Dr. Deschilder assures us: “Low to moderate doses are sufficient for most adolescents with asthma.”

Low to moderate doses are sufficient for most teens with asthma

Moreover, controlling the environment is important, in terms of allergens, exposure to tobacco, indoor pollution, humidity…. In addition, sublingual allergen (ITA) immunotherapy (house dust mite and pollen) may be offered as an additional treatment for asthmatic adolescents who are allergic to house dust mites and/or pollen also present as allergic rhinitis.

Finally, it is recommended to systematically investigate active smoking and/or vaping, other addictions, recurrent anxiety and depressive disorders in asthmatic adolescents and the origin of the effect on asthma and quality of life.

Reduce therapeutic pressure if control continues

Therapeutic levels are not constant, with a bidirectional therapeutic dynamic, which is an increase but also a decrease in therapeutic pressure depending on the control, EFR score, and crisis risk factors. It should be borne in mind that at least two-thirds of adolescents with asthma have an illness that is described as “mild”.

What don’t you do for fear of being bothered by breathing difficulties?

Connect with the young man

“Many adolescents with asthma fall through the cracks, neglecting symptoms because they are old or insignificant, considers Dr. Antoine Descheldry. A doctor should go to them, and speak to them directly, in order to fully understand their respiratory symptoms and their impact (“What not to do for fear of to be bothered by breathing difficulties?”; “What would you like to achieve but prevent yourself from doing because you know you would be embarrassed?”) These questions allow you to identify the connection point in the young man’s life, here and now (exercise …), to talk to him About treatment and the benefit it can derive from good asthma control.

Although the evaluation (EFR, etc.) is within the purview of the pulmonologist, follow-up by the GP is critical (continuation of treatment and adaptation, management of potential crises, identification of adolescent-specific problems, etc.) in a partnership context A specialist specialist and close follow-up of the adolescent coincides with his interests. It’s easy to lose a teen while tracking asthma. In addition, care should be comprehensive and include remedial education for the child and his parents. Older adolescents should benefit from regulation of transmission taking into account the severity of their asthma. »

Declaration of links of interest by Dr. Antoine Deschielder: Incidental interventions or participation in scientific boards: ALK, Stallergènes-Greer, Astra Zeneca, GSK, Novartis, Sanofi, Regeneron, DBV Technologies, Aimmune, Nestlé Health Science, Nutricia.

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