Diagnosis and Treatment of Asthma
What is the strongest identifiable predisposing factor for the development of asthma?
Atopy - genetic predisposition to respond to allergens
What are the four components of asthma care?
Assessment and monitoring Education for a partnership in care Control of environmental factors and co-morbid conditions that affect asthma medications
How do you categorize mild/moderate/severe respiratory distress?
Number of words patient is able to say in a sentence
What are Methylxanthines?
Old drug - not commonly used • Sustained-‐release theophylline is a mild to moderate bronchodilator - Used as alternative therapy for step 2 care - Or as adjunctive therapy with ICS in patients at least 5 years of age - May have mild anti-‐inflammatory effects - Monitoring of serum theophylline concentration is essential
What is in the medical history?
symptoms, patterns of symptoms, precipitating/aggravating factors, development of disease and treatment, family history, social history, history of exacerbations, impact of asthma on patient and family, assessment of patient and family's perception of the disease
What is control?
the degree to which the manifestations of asthma are minimized by therapeutic intervention and the goals of therapy are met • Responsiveness: - the ease with which asthma control is achieved by therapy
What is severity?
the intrinsic intensity of the disease process. Severity is most easily and directly measured in a patient who is not receiving long-term control therapy. Also measured, once asthma control is achieved, by the step of care - amount of medication required to maintain control
What is risk?
the likelihood of either asthma exacerbations, progressive decline in lung function or for children - reduced lung growth - or risk of adverse effects from medication
How should asthma exacerbations be managed at home?
• Patients should be instructed how to: - Use a written asthma action plan. - Recognize early indicators of an exacerbation, including worsening PEF. - Adjust their medications by increasing SABA and, in some cases, adding a short course of oral systemic corticosteroids. - Remove or withdraw from allergens or irritants in the environment that may contribute to the exacerbation. - Monitor response to treatment and promptly communicate with the clinician about any serious deterioration in symptoms or PEF or about decreased responsiveness to SABA treatment.
What else can be done to treat asthma exacerbations?
• Rapid reversal of airflow obstruction should be attempted by repetitive or continuous administration of an inhaled, short-‐acting beta-‐agonist and the early administration of systemic corticosteroids to patients with moderate to severe asthma exacerbations. • Frequent high-‐dose delivery of an inhaled short-‐acting beta agonist is indicated and is usually well tolerated in the setting of severe airway obstruction. • Some studies suggest that continuous therapy is more effective than intermittent administration of these same agents.
How is Peak flow used?
Peak expiratory flow - PEF meters are handheld devices designed as home monitoring tools. PEF monitoring can establish peak flow variability, quantify asthma severity, and provide both the patient and the clinician with objective measurements on which to base treatment decisions
What are the four most common asthma triggers?
cockroaches, dander, dust, feces
What should you think of if you see polyps in a child 6 or under?
cystic fibrosis
What is important to know about asthma treatments?
differentiate between acute or prophylactic use describe its mechanism of action understand its side effects and possible adverse reactions
What are examples of oral corticosteroids?
- Methylprednisolone - Prednisolone - Prednisone
What are risk factors for asthma-related death?
- Previous severe exacerbation - intubation or ICU admission for asthma - Two or more hospitalizaLons or >3 ED visits in the past year - Use of >2 canisters of SABA per month - Difficulty perceiving airway obstruction or the severity of worsening asthma - Low socioeconomic status or inner-‐city residence - Illicit drug use - Major psychosocial problems or psychiatric disease - Comorbidities, such as cardiovascular disease or other chronic lung disease
What should all asthma patients seen in the ER for exacerbation receive?
- Referral to follow-‐up asthma care within 1-4 weeks. - An ED asthma discharge plan - Review of inhaler technique - Consideration of initiating ICS
What is the DDX short list?
COPD Congestive heart failure Pulmonary embolism Mechanical obstruction of the airways pulmonary infiltration with eosinophilia cough secondary to drugs - ACE Vocal cord dysfunction - VCD GERD
What are characteristics of cromolyn sodium and nedocromil?
Cromolyn sodium and nedocromil: • Stabilize mast cells • Interfere with chloride channel function • Alternative for step 2 • May be used as preventative
What are characteristics of inhaled corticosteroids?
Improve asthma control more effectively in both children and adults than leukotriene receptor antagonists (LTRAs) or any other single, long-‐term control medication • Reduce impairment and risk of exacerbations • Do not appear to alter the progression or underlying severity of the disease in children
How have the NAEPP guidelines helped?
Improved scientific understanding of asthma has led to significant improvements in our ability to treat asthma New guidelines in 2007 emphasize attaining control by reducing impairment and risk
What is responsiveness?
The ease with which asthma control is achieved by therapy?
What are Leukotriene modifiers?
• Interfere with the pathway of leukotriene mediators - LTRAs •Montelukast •zafirlukast •Alternative therapy for patients who require step 2 care •Can also be used as adjunctive therapy with ICSs •For youths 12 years of age and adults the addition of LABAs is preferred - 5-‐lipoxygenase inhibitor •Zileuton •Requires monitoring of LFTs • Zileuton (Zyflo) is a 5-‐lipoxygenase inhibitor that decreases leukotriene producLon. • Zafirlukast (Accolate) and montelukast (Singulair) work as leukotriene receptor antagonists
What are anti-cholinergics?
• Ipratropium bromide (Atrovent) is the most common agent. • Inhibit muscarinic cholinergic receptors • Reduce intrinsic vagal tone of the airway • Provides addiLve benefit to SABA in moderate or severe exacerbations in the emergency care setting • May be used as an alternative bronchodilator for patients who do not tolerate SABAs
What are the two general classes of medications?
• Long-‐term control medication and - Quick-‐relief medication. • Selection of medications includes consideration of the general mechanisms and role of the medication in therapy, delivery devices, and safety.
What are quick relief medications?
• Short-‐Acting Beta Agonists (SABAs) • Anticholinergics • Systemic corticosteroids
What are the NAEPP guidelines?
Intermittent - Mild Persistent - Moderate Persistent - Severe Persistent - Severe/Life Threatening
What do you need to teach regarding the role of medications?
Long-‐term control medications - Quick-‐relief medications
What is the epidemiology of asthma?
22 million Americans have active asthma Hospitalization rates are highest among blacks and children Death rates for asthma are highest among blacks ages 15-24 years
What are issues surrounding inhaled corticosteroids and linear growth in children?
Inhaled Corticosteroids and Linear Growth in Children: • The potenLal risks are well balanced by their benefits • Poorly controlled asthma may delay growth. • Short-‐term evaluaLon may not be predictive of final adult height attained • The potential for adverse effects on linear growth from ICS appear to be dose dependent
What is the DDx?
Allergic and environmental asthma alpha 1-antitrypsin deficincy Aspergillosis • Bronchiectasis • COPD Chronic sinusitis cystic fibrosis Foreign body aspiration Gastroesophageal reflux disease heart failure sarcoidosis upper respiratory infection Vocal cord dysfunction
What are clinical manifestations of atopy?
Allergic rhinitis asthma hay fever eczema
What are the concepts of severity and control of asthma?
Assess severity to initiate therapy Assess control to adjust therapy Assess responsiveness to therapy through ongoing patient assessment
What is asthma?
Chronic inflammatory disorder of the airways 3 components Inflammation of the airway bronchial hyperresponsiveness obstruction to airflow
What are important features of dietary and infectious factors?
Consider inactivated influenza vaccination for patients who have asthma. Dietary factors have an inconclusive role in asthma
What are important features of Component 3: Control of Environmental factors and comorbid conditions?
Evaluate the potential role of allergens - particularly inhalant allergens and irritants. • Advise patients who have asthma to reduce exposure to allergens and pollutants or irritants to which they are sensitive Consider subcutaneous allergen immunotherapy for patients who have persistent asthma when there is clear evidence of a relationship between symptoms and exposure to an allergen to which the patient is sensitive
What are other precipitants of asthma?
Exercise, upper respiratory infections, rhinitis, sinusitis, post-nasal drip, aspiration, gastroesophageal reflux, changes in the weather, cold air, and stress, exposure to environmental tobacco smoke
What symptoms worsen in asthma?
Exercise, viral infection, inhalant allergens, irritants, changes in weather, strong emotional expression, stress, menstrual cycles
What is impairment?
Frequency and intensity of symptoms and functional limitations the patient is currently experiencing or has recently experienced.
What is the zone system of an Asthma action plan?
Green Zone implies good control: The PEF >80%. The patient has no asthma symptoms and medications should be taken as usual. - Yellow Zone implies caution! The PEF is 50 to 80% The patient should use a short-acting inhaled beta-agonist - Red Zone implies medical alert! The PEF is <50%. The patient should use a short-acting inhaled beta-agonist and call the provider or go to the emergency department
What is included in a workup for asthma?
Includes spirometry - FEV1, FVC, FEV1/FVC - before and after the administration of a short-acting bronchodilator These measurements help determine the presence and extent of airflow obstruction, and whether it is immediately reversible Airflow obstruction is indicated by a reduced FEV1/FVC ratio - <70% Additional Pulmonary function studies • Bronchoprovacation • Chest X-‐ray • Biomarkers of inflammation
What is the progress of inflammation?
Inflammatory mediators precipitate the inflammatory cascade, which in turn causes airway hyper-responsiveness
What is important to teach about MDI technique?
Proper MDI technique and the use of an inhalation chamber - spacer - to improve drug delivery to the lung and decrease oropharyngeal deposition
What does inflammation cause?
Recurrent episodes of coughing - night and early in the morning wheezing breathlessness chest tightness Episodes usually associated with: Widespread airflow obstruction usually reversible
What is the goal of asthma treatment?
Reduce impairment Reduce risk
What is an SVN machine?
SVN Machine produces a mist of the medication Used for small children or for severe asthma episodes • No evidence that it is more effective than an inhaler used with a spacer
How do you use spirometry measurements?
Significant reversibility of airflow obstruction is defined by an increase of >12% and 200 mL in FEV1 or >/= 15% and 200 mL in FVC after administration of a short-acting bronchodilator
What are common allergens?
Strong odors, chalk dust, animal saliva - cats - house dust mites, cockroaches, mold, and seasonal pollens
What is the key educational message?
TEACH and reinforce at every opportunity The difference between airways of a person who has and a person who does not have asthma - have parents breathe through a straw to understand what if feels like The role of inflammation What happens to the airways during an asthma attack
What patient skills need to be taught?
Taking medications correctly Demonstrate inhaler technique, and have patient imitate the demonstration - Use of devices, as prescribed - valved holding chamber - VHC - or spacer, nebulizer • Identifying and avoiding environmental exposures that worsen the patient's asthma - allergens, irritants, tobacco smoke. • Self-‐monitoring - Assess level of asthma control Monitor symptoms and, if prescribed, PEF measures - Recognize early signs and symptoms of worsening asthma. Using a written asthma action plan to know when and how to: - Take daily actions to control asthma - Adjust medication in response to signs of worsening asthma • Seeking medical care as appropriate
How is asthma severity classified?
The National Asthma Education and Prevention Program - NAEPP - has developed asthma classification scheme to identify patients at high risk of having a life-threatening asthma attack
What are systemic corticosteroids?
• Systemic corticosteroids, either oral or parenteral, are most effective in achieving prompt control of asthma during exacerbations, or when initiatng long-‐term asthma therapy. • Burst therapy is a very common dosing method because it does not require tapering the dose • Abrupt discontinuation of systemic corticosteroids after long-‐ term use may precipitate adrenal insufficiency.
What are the PE findings?
Upper respiratory tract - increased nasal secretion, mucosal swelling, nasal polyp Chest - wheezing during normal breathing, prolonged phase of forced exhalation hyperexpansion of the thorax use of accessory muscles appearance of hunched shoulders chest deformity - increased JAP diameter Skin atopic dermatitis - eczema
How does the asthmatic present?
Wheezing - although a lack of and a normal chest examination do not exclude asthma History of any of the following: cough - worse at night recurrent wheeze recurrent difficulty in breathing recurrent chest tightness
How do patients record peak flow readings?
morning and night - best of three attempts
What are important long-term medications?
• Taken daily to maintain control of persistent asthma • Include the following: - Corticosteroids - Cromolyn sodium and nedocromil - Immunomodulators. - Leukotriene modifiers - LABAs
What are principles of the stepwise approach?
• A stepwise approach to managing asthma is recommended to gain and maintain control of asthma in both the impairment and risk domains. • The stepwise approach incorporates all four components of care: - Assessment of severity to initiate therapy or assessment of control to monitor and adjust therapy; - Patient education - Environmental control measures, and management of comorbid conditions at every step - Selection of medication.
How is asthma managed in Urgent Care and/or Hospital settings?
• Administer supplemental oxygen to correct significant hypoxemia in moderate or severe exacerbations. • Administer repetitive or continuous administration of SABA to reverse airflow obstruction rapidly. • Administer oral systemic corticosteroids to decrease airway inflammation in moderate or severe exacerbations or for patients who fail to respond promptly and completely to SABA treatment. • Monitor response to therapy with serial assessments
What are Combination ICS/LABA medications?
• Advair (fluLcasone propionate/salmeterol)
How do Albuterol and Levalbuterol compare?
• Albuterol is a racemic drug and has an "R" isomer and an "S" isomer. • Levalbuterol (Xopenex) is composed entirely of the "R" isomer of albuterol.
What are cormorbid conditions with asthma?
• Allergic Bronchopulmonary Aspergillosis (ABPA) • Gastroesophageal Reflux (GERD) • Obesity or overweight • Obstructive Sleep Apnea (OSA) • Rhinitis or sinusitis • Stress and depression
In summary, what are the most important points regarding asthma?
• Asthma continues to be a growing public health issue in the United States and Worldwide • The goal of therapy is asthma control • The Four Components of Asthma Care o Assessment and monitoring o Education for a partnership in care, o Control of environmental factors and comorbid conditions that affect asthma o Medications • Use a stepwise approach when adjusting asthma therapy
What are SABAs?
• Bronchodilators that relax smooth muscle - Albuterol (Ventolin) - Levalbuterol (Xopenex) - Pirbuterol (Maxair) • Treatment of choice for relief of acute symptoms and prevention of EIB
How are exacerbations managed?
• Classifying Severity - Do not underestimate the severity of an exacerbation. - Severe exacerbations can be life threatening and can occur in patients at any level of asthma severity—i.e., intermittent, or mild, moderate, or severe persistent asthma.
What history questions should be asked for asthma?
• Do you have a history of asthma? • Have you been taking your medications? • Have you been having problems recently with your asthma? • Have you ever been admitted to the hospital? - How many times? • Have you ever been intubated? • Is this attack as bad as when you were intubated (admitted)?
What are safety concerns with ICS and LABAs?
• In general, ICSs are well tolerated and safe at the recommended dosages. • The risk of adverse effects increases with the dose. • High doses of ICS administered for prolonged periods of time - e.g., >1 year - have significantly less potential than oral systemic corticosteroids for having adverse effects. • High doses of ICS used for prolonged periods of Lme, particularly in combination with frequent courses of oral corticosteroids, may be associated with risk of posterior subcapsular cataracts or reduced bone density.
When do you use LABA?
• In patients who require more than low-‐dose ICS alone, the addition of a LABA: - improves lung funcLon - decreases symptoms - reduces exacerbations - reduces use of SABA for quick relief • The addition of salmeterol or formoterol improves control in most patients to a greater extent than doubling the dose of ICSs. • Daily use should not exceed 100 mcg salmeterol or 24 mcg formoterol • Not to be used as monotherapy for long-‐term control
What are characteristics of LABAs?
• Inhaled bronchodilators that have a duration of at least 12 hours after a single dose - Salmeterol - Formoterol • Not to be used as monotherapy • Used in combination with ICSs for long-‐term control and prevention of symptoms in moderate or severe persistent asthma • Preferred therapy to combine with ICS in youths 12 years of age and adults • May be used before exercise to prevent EIB
What is Urgent Care/Hospital management in children?
• Lung function measures may be useful for children ≥ 5 years of age • Pulse oximetry may be useful for assessing the initial severity • A repeated measure of pulse oximetry of <92-94 percent after 1 hour is predictive of the need for hospitalization.
What are immunomodulators?
• Omalizumab (anti-‐IgE) - A monoclonal antibody that prevents binding of IgE to the high-‐affinity receptors on basophils and mast cells. - administered subcutaneously in 1 to 3 injections every 2 or 4 weeks. - Adjunctive therapy for patients 12 years of age who have sensiLvity to relevant allergens and who require step 5 or 6 care: • Be prepared and equipped to identify and treat anaphylaxis
How are asthma exacerbations treated?
• Patients at high risk of asthma-‐related death require special attention • Such patients should be advised to seek medical care early during an exacerbation • Practitioners should have a lower threshold for considering hospital admission for these patients
What are the benefits of corticosteroids?
• Reduce airway hyperresponsiveness • Inhibit inflamatory cell migration and activation • Block late phase reaction to inhaled allergens • Corticosteroids may either be inhaled, taken orally or administered intravenously
What other factors are important for adults in the management of asthma in the Urgent Care/Hospital setting?
• Repeated lung funcLon measures - may not be helpful, or easily obtained, during severe exacerbaLons • Pulse oximetry • Signs and symptoms scores at 1 hour aier iniLal treatment - Beware of drowsiness
What are signs of a severe asthma attack?
• Severe agitation • Hunched sitting position with arms supporting torso (tripod) • Limited ability to speak • Use of accessory muscles • Lethargy or confusion • Respiratory rate >30/min • Cyanosis • Feeling of impending doom
What are characteristics of oral corticosteroids?
• Short courses of oral systemic corticosteroids are often used to gain prompt control of asthma • Oral systemic corticosteroids are used long term to treat patients who require step 6 care (for severe persistent asthma)
How is asthma managed in the ER?
• The administraLon of oxygen to maintain saturation of at least 94 percent • Inhaled short-‐acting beta2 agonist treatment • Combination of inhaled anticholinergics and beta2 agonists • Intravenous magnesium sulfate (25 to 100 mg per kg) • Methylprednisolone sodium succinate injection [Solu-‐ Medrol] in adults, or 1 to 2 mg per kg of prednisone or prednisolone in children one to 18 years of age) • Airway management/re-‐evaluaLon • Admission if no significant improvement
What is an alternative anti-cholinergic?
• Tiotropium (Spiriva) is an alternative to ipratropium having the advantage of QD dosing (ipratropium is given Q 6˚), and it comes in the form of dry powder capsules which are administered by means of a device called a HandiHaler
What are examples of LABAs?
• salmeterol (Serevent) and formoterol (Foradil Aerolizer)
