Anxiety, Toxic Stress, and Reactive Airway Disease in Children

Educational Objectives

The goal of this program is to improve the management of reactive airway disease in patients experiencing stress or anxiety. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize the relationship between asthma and reactive airway disease and psychological distress.
2. Appropriately treat patients who are experiencing a stress or anxiety response.

Summary

Adverse childhood experiences (ACEs): adversity affects psychological well-being; ACEs can cause toxic stress; ACEs fall into 3 categories of abuse, neglect, and household challenges; stress reactions have maladaptive consequences; a linear relationship exists between the number of ACEs and the degree to which they cause psychological and physical difficulties; maladaptive consequences include emotional reactivity, anger outbursts, and dissociative episodes

Stress and reactive airway disease: ACEs affect physical well-being; a study showed that ACEs increase the risk for asthma onset; ACEs have respiratory sequelae and cardiovascular, endocrine, neuroendocrine, and immune consequences; the physiologic sequelae are termed toxic stress; describes longer-term changes in physiology as a result of long-term dysregulation of the stress response; a common presentation is the toxic stress triad of asthma, atopy, and obesity, which is thought to be due to immune dysregulation and inflammation; toxic stress can cause several disorders in children and becomes more problematic as children age

Anxiety and reactive airway disease: stress is the behavioral and physiologic response to fearful or threatening stimuli; anxiety is a diffuse cognitive response in anticipation of fearful or threatening stimuli; stress is a physiologic reaction to fear whereas anxiety is the anticipation of fear; anxiety does not cause reactive airway disease but the relationship is bidirectional; anxiety is associated with poorer asthma outcomes; managing anxiety could be helpful in managing asthma; behavior therapies can focus on mitigating sensitivity to anxiety and the avoidance of distressing physical sensations associated with reactive airway disease; optimizing the doses of anxiolytic medications can reduce the risk for severe asthma exacerbations; targeting interventions to psychological well-being can make a difference in symptoms of reactive airway disease; decreasing the baseline of symptoms may reduce the number of exacerbations and asthma attacks

Nonpharmacologic interventions for stress response: sleep interventions include encouraging bedtime routines (eg, consistent bedtime) and sleep hygiene (eg, having a wind-down time before bed); physical fitness interventions include relaxation exercises, mindfulness, and yoga; nutrition can be helpful in promoting physical fitness and decreasing the toxic effects of stress; interventions for affective symptoms include focusing on relationships and cognitive behavioral therapy (CBT)

Pharmacologic interventions for stress response: centrally acting adrenergic agents may be used; peripherally acting agents tend to be contraindicated in children with asthma; clonidine acts at the α2A-, α2B-, and α2C-adrenergic receptors; has a short half-life; an immediate-release formulation requires frequent dosing; extended-release formulation allows once-daily dosing; clonidine has a higher likelihood of adverse effects (eg, sedation, hypotension, rebound hypertension) after missed doses; guanfacine is more selective and acts only at the α2A receptor and has a better adverse effect profile; can be associated with hypotension and associated dizziness and lightheadedness; is also associated with constipation; these adverse effects can be mitigated by good hydration

Nonpharmacologic interventions for anxiety: include psychosocial supports (eg, psychoeducation), breathing exercises when reactive airway crisis is not occurring, progressive muscle relaxation, biofeedback or neurofeedback (involves working with other clinicians), and CBT to improve tolerance to distress

Pharmacologic interventions for anxiety: first-line medications include selective serotonin reuptake inhibitors (SSRIs; eg, escitalopram, citalopram, fluoxetine); SSRIs are good anxiolytic and antidepressant agents that target serotonin, which underlies the anxiety response; serotonin-norepinephrine reuptake inhibitors (SNRIs; eg, duloxetine, venlafaxine) are also useful; mirtazapine is a serotoninergic medication that acts at serotonin receptors rather than by inhibiting reuptake; provides anxiolytic and antidepressant effects and helps with sleep and gastrointestinal symptoms; has more adverse effects than SSRIs and SNRIs, requires blood work for laboratory monitoring, and is associated with metabolic syndrome and rarely agranulocytosis but is useful; non-first-line treatments include bupropion, which is a nonserotonergic dopamine-norepinephrine reuptake inhibitor helpful in younger children with anxiety; gabapentin and pregabalin, which are voltage-gated calcium channel blockers, can be used as scheduled medications and as needed; monoamine oxidase inhibitors and tricyclic antidepressants are not appropriate because they may interact with oral-inhaled asthma medications; benzodiazepines mask anxiety rather than treat it and are not recommended

Readings

Belkin M and Schwartz TL. Alpha-2 receptor agonists for the treatment of posttraumatic stress disorder. Drugs Context. 2015 Aug 14;4:212286. doi:10.7573/dic.212286; Gilgoff R et al. Adverse childhood experiences, outcomes, and interventions. Pediatr Clin North Am. 2020;67(2):259-273. doi:10.1016/j.pcl.2019.12.001; McKelvey LM et al. Adverse childhood experiences in infancy and toddlerhood predict obesity and health outcomes in middle childhood. Child Obes. 2019;15(3):206-215. doi:10.1089/chi.2018.0225; Mrakotsky C et al. Prospective open-label pilot trial of mirtazapine in children and adolescents with social phobia. J Anxiety Disord. 2008;22(1):88-97. doi:10.1016/j.janxdis.2007.01.005; Rippe JM. Lifestyle Medicine: the health promoting power of daily habits and practices. Am J Lifestyle Med. 2018 Jul 20;12(6):499-512. doi:10.1177/1559827618785554.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Ihle was recorded at the 54th Annual Advances and Controversies in Clinical Pediatrics, held May 12-15, 2021, and presented by the University of California, San Francisco, School of Medicine, and its Office of Continuing Medical Education. For information on future CME activities from this presenter, please visit www.ucsfcme.com. Audio Digest thanks the speakers and the University of California, San Francisco, School of Medicine for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PD673802

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.