 Hi, good evening. We'll get started in just a couple minutes waiting for everybody to log in from the waiting room. It is 6.03. We're going to get started. I'd like to say good evening and thank you for joining us for this first in our webinar series of addressing pediatric respiratory issues. Tonight's webinar focuses on the management of pediatric outpatient asthma in the COVID-19 era. I'm Cassie Pulse, physician liaison with the University of Maryland Children's Hospital. Before I introduce our speaker, I have a few housekeeping items that I'd like to go over. You may submit your questions at any time during the presentation using the chat box feature. Erin Rommel, our pediatric marketing manager, will be monitoring the chat box and Dr. Lasso will answer all of your questions at the end of the presentation. Please note that this seminar will be recorded and an email link on an email with the link to this recording will be sent out next week. Our speaker this evening is Dr. Anna Lasso. Dr. Lasso is an assistant professor of pediatrics for the University of Maryland School of Medicine and division head of pediatric pulmonology, allergy, and sleep. She went to medical school at the University of Panama School of Medicine and did her pediatric residency at Mama Medical Center in New Jersey. She went on to complete her pediatric pulmonary fellowship at St. Christopher's Hospital for Children in Philadelphia, Pennsylvania. Dr. Lasso has been with us at the University of Maryland Children's Hospital since 2006. Dr. Lasso, the floor is yours. Thank you. Good evening. I'm going to try my slides. I think I have control of the mouse. Yes. So this is a quick talk and I hope that I will give you enough information that you can review later. But really the idea was to touch on a topic that we all are very familiar with and give you an update in the current times. Hopefully a clinical update that can be useful in treating patients. I do not have anything to discuss for this lecture. We'll review quickly in the lecture some of the basics of asthma, the burden particularly for children, disparities, diagnostics, tools for assessment of asthma severity and treatment. And then we'll get a little bit more into the details of the 2020 focus updates to the asthma management guidelines and ending with a little bit of a conversation on asthma and COVID-19 in children and adolescents. So why are we talking about asthma? As we all know, asthma is extremely common. Many, many people have asthma. It is said that the children had asthma, pink has asthma, development, ghee, just to name a few. It's extremely common but we're still learning a lot about it and it's a condition that we really have to improve our ability to control because it causes so much disease and so much impairment. Globally, more than 300 million people have asthma based on 2016 data. It is the most common chronic childhood disease worldwide and it is not just a public health problem for high-income countries like we once thought. In fact, 80% of asthma deaths occur in low- to middle-income countries and globally we think that asthma is really under-diagnosed and under-treated, causing substantial burden to individuals and families worldwide. In the US, based on the same data base, about 25 million Americans have asthma, about 50 billion dollars are spent annually in hospitalizations and missed workdays, and about nine people die of asthma daily here in the United States. For pediatric patients, 9% of kids between 8 and 9% of kids are thought to have asthma. It is the most common chronic condition in children in the US as well and it is the third ranking cause of hospitalizations for US kids. It is also a condition that is affected by significant disparities and so we think that women, young adults, Black, Hispanics, less educated people and those with lower income tend to have a higher risk of disease and have more severe disease. Black adults are known to be more likely to die, two to three times more likely to die due to asthma, and it is said that one in four Blacks and one in seven Hispanic adults cannot afford their asthma medications. But what is it? You know, basically as we all know, the general definition is that it is a chronic inflammatory disease of the airways. However, the long-standing debate is whether asthma is a single disease or a disease that has variable precipitation, if you will, one disease with variable precipitation versus multiple diseases that have airway obstruction as their common feature. We personally and in pediatric pulmonary, I would say generally speaking think that asthma is really an umbrella term, that it is a complex disease, perhaps multiple complex diseases that present with recurrent episodes of bronchial obstruction and heightened airway reactivity that present in different, the cause by different molecular pathways, endotypes, it present with different clinical phenotypes. What do we know today about it? So, we do know, we still think that airway inflammation leads to hyperresponsiveness with increased response to triggers. I apologize because my errors are out of place, but the idea is that hyperresponsiveness causes obstruction that is usually reversible and that this is what causes symptoms, that symptoms that we know typically to be characteristic of asthma, like cough, wheezing, shortness of breath. One of the concepts that we explain and talk about is that we do think that symptoms are easily appreciated, but inflammation can occur prior to symptom development. So, it's something that we need to treat even in patients that are not having daily symptoms. We do know that asthma triggers are many, allergens, upper respiratory infections, changes in weather, cold air, exercise, irritants, even strong emotions can be a cause of an asthma flare. We also know that aesthetics can have chronic changes in their bronchial biopsies and to the upper right, you can see a biopsy of an individual without asthma versus asthma versus the biopsy of an asthmatic subject. One concept that's perhaps a little bit newer is that airway obstruction in asthma is perhaps not always reversible and that there is potentially a blow of disease that goes from what we traditionally consider asthma to more of a chronic bronchitis picture all the way down to a COPD-like disease that perhaps explains the COPD that we see in some non-smoking patients. We do know that there's many factors that affect asthma control, access to care, inhaler technique, environmental exposures, school movement conditions, adherence to medications, and of course socioeconomic factors. Let's get now a little bit more into the current asthma phenotypes or how we think of asthma today. I'll talk a little bit more in detail about each but basically we divide them in four, eosinophilic and eosinophilic type, a neutrophilic type, a posigermal cedic type, and a mixed inflammatory type. The eosinophilic type is what we traditionally consider allergic asthma. It's seen in about 40 to 60 percent of asthmatics. Patients with this type of asthma tend to have increased eosinophils in their sputum and also in their blood and tend to have a high level of nitric oxide in their breath. It is associated with type T2 inflammation and tends to respond to our standard therapy for asthma with inhaled corticosteroids. Neutrophilic asthma is less common, affecting about a quarter of asthmatics, tends to have a predominance of neutrophils in their induced sputum. There is no correlation in these issues between the degree of neutrophils in their sputum and their blood neutrophils. Unfortunately, this type of asthmatic doesn't tend to respond well to therapy with inhaled corticosteroids and tends to have more severe disease with worse control. There's then the type where basically there's less cells. It affects between 17 and 48 percent of asthmatics. It's called posigermal cedic because these patients have less than 61 percent neutrophil counts and less than two eosinophils per field. These patients tend to be easy to control. The last type is the more severe type that tends to have both cell types on sputum and tends to have more difficult disease, more difficult to control disease than simple cell types of them. When we think of asthma, the way I'd like to think of asthma is that we should focus on it as what do we do for those patients when they're in their outpatient settings where we should base our management and guidelines and then obviously the inpatient setting that should be pathway based and that has to address what to do with patients when they get to the emergency room or when they are admitted. This lecture focus is more on the outpatient setting and so that's what we'll do is talk a little bit more now about the guidelines and the focus updates that came out in publication in 2020. When we think of asthma guidelines, the first guidelines came out in 1991 with updates in 1997, 2002, and 2007. There has been also an international effort called the Google Initiative for Asthma that came out in 2015 with an update in 2020 and then now what we're going to focus most on this lecture the update 2020 to the expert panel report that included literature search with studies published by 2018. So what I'll mention now is going a little bit more into that. I wanted to remind everybody that as you know we have two types of asthma medications if you will. Our quick relief medications are used for as needed rescue use and our controller medications that tend to be preventive and anti-inflammatory. And there is now also new medications that are available for poorly controlled asthmatics that are not responding to standard therapy. We have a little list there but basically we have Omolysubeth, which is an anti-IGE monoclonal antibody. We have three anti-IL5 monoclonal antibody medications and we have Dupitlumab which is an anti-IL4 receptor antagonist which basically blocks IL4 and IL13th and is also approved for atopic dermatitis. Now as a reminder when we think of asthma management in the outpatient world we should remember that we have the option and should think of primary function when we have difficulty controller controlling the situation or for diagnosis. And we should also think of our questionnaires to assess symptomatology. Perhaps the most used the ACT or asthma control test that is available for different age groups and allows for patients and their caregivers to give us an idea in scores of their symptoms with a score of more than 19 being considered good control. Spacers, I just touched on this quickly. I wanted to remind you that spacers slow particle velocity and that minimizes the quantity of the drug that impacts the oropharynx. It also allows for particles that are too large for long delivery to settle out, minimizing the quantity of the drug that impacts the oropharynx and decreases basically the amount of medicine that swallowed. Most spacers also whistle when there is an excessive inhalational rate or patient is breathing too fast if you will so that reminds the patient to slow down the rate of inhalation decreasing the the position of the medicine on the oropharynx. When we think of spacers versus nebulizers basically we think that spacers are more effective in terms of decreasing hospitalization. They're also portable. They actually have been shown to improve the clinical score compared to nebulizers in the emergency room and they decrease side effects like increased respiratory rate and heart rate for patients on bronchodilators likely because of reduced swallowing. So the good news to summarize this section is that we have anti-inflammatory therapy and we still use it. The guidelines still recommended and basically they're good if you will for the majority of the patients. The only thing is that we don't think that therapy in asthma changes the natural course of the disease. So what we think happens is that we're controlling the situation where the patients take their medicines but it's not a long-term effect. So adherence is extremely important. As a reminder antibiotics do not have a role in asthma management and in fact if a patient is responding to antibiotics it is likely that the condition is another and we need to re-evaluate our diagnosis. Now let's get into more of the details of what the focus update brings to the picture. So this was published as I said in December of 2020. It is a large document with 322 pages. It is very detailed but I'll try to give you an overview of what they talk about. So they rely on the previous guidelines where they helped us classify asthma severity based on the frequency if you will have symptoms and the risk or the impairment of the patient. So it is important to think of asthma the same way we used to think of it as intermittent or persistent and within the persistent category to think of it as mild, moderate or severe and this is based on symptoms and long function. As a reminder because I do think this is important and something that's helpful to me is to think that anybody who requires two or more courses of systemic steroids per year should be categorized as having persistent asthma and so I think this is useful because sometimes it's a little bit hard to get into the details of all the symptoms. Now this is a little bit more kind of perhaps a little bit easier to follow but basically the same idea that you classify patients as intermittent or persistent and within the persistent mild, moderate or severe. This slide is addressing the fact that if a patient is having symptoms that suggest poor control then you should think if they are taking their controller appropriately before you make any changes and if they're not to then go ahead and retrain the family if you will on how to do it properly. If they are then you consider stepping up their therapy and keeping them on that level for good two to three months before you reassess how they're doing. It is important in red here like we said what we're thinking of appropriate therapy to check adherence, their inhaler technique, is there new environmental factors or go more with conditions that might make the patient more difficult to control than before. Now the updates to the 2020 guidelines were basically six. They address phina use. This is the fraction of exhaled nitric oxide. They made recommendations regarding remediation of indoor allergens and asthma management. They talked about adjustable medication dosing. They recommend that they made recommendations on long-acting anti-moscarinic agents as add-on therapy. They talked about immunotherapy and they talked about bronchial thromoplasty in adult severe asthma. Now we'll go into each one of them but basically what they said is that this fractional exhaled nitric oxide measurement is not recommended for children 0 to 4. They also did not recommend it in isolation so it should not be used as a single test to assess asthma control or to predict exacerbations in the long term or even to assess severity so as a single test is not useful. They did suggest that it could be an adjunct to therapy and it could help also as an adjunct in terms of the evaluation of a patient particularly if the patient was difficult to assess and if the patient having symptoms that could be confused with other diseases and the table here gives us an idea of the levels that should be considered elevated. So I will leave the slides with you guys and you'll have access to them later as Cassie said with the link so I hope to go through them in a pretty quick fashion but then you can hopefully later recheck and pay attention to some of the details. So allergen mitigation was basically not recommended unless the individual was sensitized so it should not be recommended as a standard approach to asthma care so we should definitely not be recommending to remove carpets to cover pillows to cover mattresses unless the patients are known to be symptomatic when exposed to indoor allergens and that this is confirmed by history or allergy testing and it should not be used as a single approach if you will but it should really be part of a multi-component allergen mitigation intervention. Now this is the slide probably that's the most important for most of us clinicians because it also has most of the changes so here when they talk about inhale corticosteroids the first thing I will mention is that they talked about something that is been used but has not been approved before which is that you can start a patient on an inhale corticosteroid course for seven days at the beginning of symptoms that are known to cause a flare of the asthma. So for example if a patient is known to get in trouble with colds that you might start that patient on an inhale corticosteroid course for seven days at the first signs of a cold and that then you add a short acting broncholide later like albuterol if they develop symptoms and the degree of the evidence is pretty high for this and this is particular to the zero to four age group they talked about in patients' cold and older with mild persistent asthma that they may do either or they might either be recommended to be on a daily load dose of inhale corticosteroid or use as needed in inhale corticosteroids with a short acting broncholide later. So basically you either put your patient on a daily control like you normally would have or you might leave them on no daily medicine but add an inhale corticosteroid with a short acting broncholide later when they develop symptoms or they start with symptoms related to the trigger for example again with a cold. They sent that individuals for years in order they couldn't find enough data to support this so they recommended against short term increase corticosteroids for that group unless compliance was an issue. So like the other two groups where they actually recommended it in this group they did not recommend it unless they felt that you know compliance was an issue so that in that group then you could think about it but they didn't find that it was they had low confidence in that recommendation and another thing that I thought was really important and very different from what we have been doing is that individuals four years and older who have moderate to severe asthma can use an inhale corticosteroid with for motor oil. The commercial name for this is Symbolport or Denerix for this but basically that they could do this for daily control and as reliever therapy so that you could use the same medication for both for daily control or prevention and increasing the dose for acute flares so that you could use one medication for everything. Long-acting muscarinic antagonists were recommended as part of this guideline update as an additional drug for individuals 12 and older who are already on an inhale corticosteroid with a long-acting bronchodilator so for patients who are already on combination therapy they did not recommend it for patients who are on inhale corticosteroids alone so LAMA should not be added instead of a long-acting bronchodilator but in addition to immunotherapy or allergy shots as we know them were recommended in the subcutaneous form for individuals five years and above who have mild to moderate allergic asthma that's already controlled so the patient it has low controlled asthma and but for the topic immunotherapy in the subcutaneous form was recommended in addition to their other therapy they did not recommend the silk lingual form of immunotherapy and bronchial thermoplasty that I'm not sure if you guys are familiar with because it's not something we tend to recommend in pediatrics it's sometimes recommended in the adult world overall basically was not recommended in this guidelines they did say that in some cases with very severe asthma where the patients were interested in kind of short-term benefit that it could be considered but they warned that very little was known in terms of the long-term effects of this therapy on the airway so as a general statement they did not recommend it now the next three slides are basically putting kind of what I talked about into the context of how to treat patients based on the guidelines and it goes 0 to 4 5 to 11 and more than 12 like you guys should know this therapy tends to be hard to memorize it's best to in my view to get back to it later and perhaps even take a picture of each one of the three slides so that you can have them for your reference because basically the idea is that once you know where your patient is you know is your patient an intermittent patient or is your patient a patient with persistent symptoms that has to be labeled as persistent asthma and then based on that kind of assessment then you decide what therapy to do and then the guidelines gave you then what they suggest so like I said for example just an example here before we would have said in this step just PRN albuterol or PRN short-acting brokodylid now they're saying that plus to consider the addition of an inhaled corticosteroid for seven days at the start of symptoms so there's a little bit of a change of approach perhaps we're a little bit more proactive at treating with inhaled corticosteroids than we were before and there's data to support that so like I said I'm not going to go into each one of the steps but each one of the three three groups age groups has one of the stable that incorporates what the update gave us into the stepwise approach to asthma care and this is 12 years and older so now I definitely want to remind everybody that when we think of effectiveness for medication we need to think of really the factors that affect appearance because effectiveness is the combination of efficacy and appearance and appearance is impacted by many factors for example is an indication oral or inhaled the dosing frequency the side effects the cost of the medicine patient education onset of action inhaler technique all of those can make a big impact on how much a patient takes their medicine and of course if the patient doesn't take the medicine then obviously that will impact how effective the medicine is now switching to our last topic so we have some time for questions this is just giving you a little bit of background on COVID-19 burden in the U.S. recently in children so this is data from just the last month basically where we can see that about 13% of all U.S. cases of COVID have been pediatric patients there's been about 14,000 hospitalizations for kids and 292 deaths so it's important to realize that this data might be underreported but it is important to think of this as COVID causing definitely some pediatric disease that is significant when we think of asthma and COVID in particular and we now focus on that there is really not much on the topic the CDC stated looking at 345 cases where they saw that 11% of the children that had chronic conditions had chronic lung diseases including asthma so basically lumping all chronic lung disease in one category so we don't know enough about how much asthma has been the predisposing factor for admissions to the hospital for this kids and in a new hospital report they talked about a quarter of their kids with COVID admissions for COVID having asthma well we do know and think right now is that asthma during the pandemic has been behaving differently than it has in other years and overall we're seeing just less asthma admissions and I think you all will agree on that that we're just not having the number of admissions that we normally would have during the winter or now springtime and perhaps this is due to multiple factors but some might need more study but kind of at a glance what we think is that perhaps kids are less exposed schools have been close for a very long time many schools have been um pieces have been less exposed to other patients to other people they have been in general less exposed to the outdoors until more recently perhaps we're well opening a little bit more but for a long time people have been less exposed there's been less physical activity um there's been perhaps more indoor air exposure and allergens exposure that way for indoor allergens um there's been different different a different kind of mode if you will for how we live so lots of different um triggers and less triggers in some areas than others um the other thing that is potentially impacting what we're doing is that we're doing also a lot of telehealth and perhaps that is helping us manage our patients somewhat better than before um so there's been decreased outpatient visits but also decreased emergency visits for asthma to finish basically I wanted to give you an overview that we should definitely think of it in health care to go to it's still today as the preferred controller medication that management should be individualized and it's a partnership between the family and the health care provider that we need to keep regular follow-up and assessment of our patients and that in this new world telemedicine might have a significant role in this um condition that we need to step up care when needed but to wait at least three months before we step down to make sure patients are controlled that we need to always write our action plans our instructions for our patients and keep on going education and utilize data local resources for asthma if we don't ask medication and patient care and in the year of covid virginia guidelines or google initiative guidelines that we continue our patients under controllers um that we keep them if they're on biologics under biologics that if they're on steroids we keep them under steroids that treat exacerbations of asthma as we normally would including using systemic stereotypes needed and that we refer parents and hopefully children soon for covid vaccination um in fact I just heard a lecture today that there may be availability of the vaccine for pediatric patients as early as this summer so with that I will leave you for questions and hope that this summary and the overview is helpful um in that if you any questions um thank you thank you dr lasso now we will go to Aaron for questions in the chat box okay great thank you please enter your questions now and dr lasso will answer them we do have one comment from dr lala so um hi dr lasso you see a lot of my patients from dr lala it's it's very nice too it's a little weird I will say that I can't see anybody so I'm glad that you said hi great all right um we don't seem to have any questions at this time please submit them right now okay I guess there are no questions um well thank you dr lasso for your time um and please oh here we go I take that back um this is again from dr lala um if I understand it clearly those with intermittent intermittent asthma less than four years um those with intermittent asthma less than four years you should give ICS for seven days should get ICS for can you read that part of course if I understand clearly those with intermittent intermittent asthma less than four years we should give ICS for seven days right yes I think that that's actually one of the biggest the two things that I took from this update that were very different from my practice is that yes if a patient they said that they found enough data to support this approach in kids less than four and over 12 that kids between 11 5 and 11 they didn't find enough data but that doesn't mean that it doesn't work for them it just means that there wasn't enough data for them to recommend it so um but for the groups where they found enough data which are zero to four and more than 12 they uh recommended use of seven days of in inhale steroid um they proposed somewhere in the in the 322 pages that you could do something like you deconide one gram twice a day for seven days so that would be nebulized um you deconide I personally don't use a lot of nebulized steroids so I personally would do something like to take a zone or supplement a zone which is q bar but the point is that you can give them an inhale steroid at the beginning of their symptoms before they develop symptoms meaning if they have a congested nose for example from a cold that you could start right then and then give them seven days of that if they develop symptoms you add albuterol if that if that makes sense and then the other thing I forgot to say that the other thing that I thought was very different from what I've been doing is the use of um some record basically or it's generic as a daily medicine plus a PRN medicine so that you could keep your mother to see charismatic this medicine and then when developing symptoms escalating the frequency of the dose so that they can also use it as a rescue medicine thank you dr lasso is that also correct for children between the ages of four and twelve so the guidelines tend to to divide their their patients in zero to four five to eleven and more than twelve so what they said the problem with this type of guideline is that they won't commit if they don't find enough data so they were able to to give us pretty good data for less than four and more than 12 so it's up to you guys to decide what to do with the grouping between so if you ask me I think I would say that I'm going to use this mode for everybody you know I think that clinically clearly there isn't enough data for the five to eleven um but you know logically speaking it kind of makes sense that if you are able to do it for less than four and over 12 that you know that's going to be my practice starting now thank you can you speak a little bit about um simba court and the dosage for simba court as you guys know is two plus twice a day um and we use it with a spacer so in this in this form you'd be doing that for daily use but then you would be increasing the dose during flares so you'd be doing something like q six hours so two plus q six or something like that I personally need to kind of um I haven't done this before so I I don't have experience with it I've never used it like that it's been actually proposed by the GNA guidelines as well so the international guidelines are the same thing so both guidelines that came out in 2020 um are saying the same thing um my concern I will tell you is that I don't know if insurances will pay for this form of use um because simba court has been marketed as a medication that has enough puffs for daily use but if you start having somebody do PRN use you're going to use their inhalers quicker um so I guess you know with forethought um I think we might run into a little bit of trouble getting insurance coverage for this approach um but hopefully we can convince them that I mean it's definitely great thank you are there any more questions already well again dr lasso thank you so much for presenting this this evening um this will will conclude our webinar thank you all for joining us and we hope that you will be able to join us for our next webinar on thursday may 13th at 6 p.m when dr lasso will be discussing obstructive sleep apnea in children when is snoring a problem thank you again for attending and have a great rest of your evening good night thank you