Asthma Control: Guideline Based
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Michael P. Pietila, MD Pulmonary, Critical Care and Internal Medicine Yankton Medical Clinic, P.C. Assistant Professor Sanford School of Medicine at USD PowerPoint PPT Presentation


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Asthma Control: Guideline Based American Thoracic Society (ATS), National Asthma Education and Prevention Program (NAEPP), and Global Initiative for Asthma (GINA). Michael P. Pietila, MD Pulmonary, Critical Care and Internal Medicine Yankton Medical Clinic, P.C.

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Michael P. Pietila, MD Pulmonary, Critical Care and Internal Medicine Yankton Medical Clinic, P.C. Assistant Professor Sanford School of Medicine at USD

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Asthma control guideline based american thoracic society ats national asthma education and prevention program naepp

Asthma Control: Guideline BasedAmerican Thoracic Society (ATS), National Asthma Education and Prevention Program (NAEPP), and Global Initiative for Asthma (GINA)

Michael P. Pietila, MD

Pulmonary, Critical Care and Internal Medicine Yankton Medical Clinic, P.C.

Assistant Professor Sanford School of Medicine at USD


Professional relationships

Professional Relationships

  • I am a contracted speaker for:

    • Merck Pharmaceuticals

    • Dey Pharma L.P. Bureau of COPD Research and Education to Advance Therapeutic Excellence (BREATHE)

  • I will not be speaking specifically about any of these companies products today.


Defining and recognizing asthma

Defining and Recognizing Asthma

Netter’s Anatomy


Asthma epidemiology

Asthma Epidemiology

  • Estimated > 23 million Americans

    • Prevalence 5-25% of population

  • Increasing prevalence and severity

    • USA and worldwide

    • Socioeconomics > genetics

  • $14 Billion direct annual costs in USA


Epidemiology

Epidemiology

  • More common in males (equal after age 20).

  • Atopy – Skin test reactivity, elevated IgE levels, blood eosinophilia.

  • Indoor allergens – dust mites, animal dander.

  • Environmental pollution, occupational exposure.

  • Respiratory infections.

  • TOBACCO SMOKE.


Increasing asthma mortality

Increasing Asthma Mortality

  • 500,000 hospitalizations per year in U.S.

  • 5-6,000 deaths per year

  • 1978 - beginning of increasing mortality

  • Role of poverty (vs. race)

    • Access to health care, medications, education

    • Greater environmental exposure

    • Importance of identifying persons with high risk of death


Definition of asthma

Definition of Asthma

  • Obstructive lung disease with characteristics of:

    • Airway obstruction;reversible in most patients

    • Chronic airwayinflammation (eosinophils)

    • Increased airwayresponsiveness

  • Onset of symptoms can occur at any age

    NAEP - Guidelines for the Diagnosis and Management of Asthma 1991


Guidelines for the diagnosis and management of asthma

Guidelines for the Diagnosis and Management of Asthma

Key Messages

  • Asthma is an inflammatory disease

  • Environmental factors are important

  • Objective measures are needed

  • Health education is crucial

  • Emphasis on recognition and avoidance of triggers

    Buist & Vollmer. NEJM 331:1584-5;1996

    Asthma Guidelines 2007


Asthma guidelines 2007

Asthma Guidelines 2007

  • Components of severity:

    • Symptoms and objective testing.

    • FEV1 and FEV1/FVC measurement.

    • Need for short-acting beta-agonist (SABA).

    • Nighttime awakenings.

    • Interference with normal activity.


Diagnosing asthma

Diagnosing Asthma

  • Symptoms and Medical History

    • Wheezing, cough, difficult breathing and chest tightness

  • Symptoms worse at night/on awakening

  • Seasonal pattern

  • Eczema, hay fever, family history

  • Triggers – animal fur, chemicals, temperature change, dust mites, drugs, exercise, pollen, URI, smoke

  • Symptoms respond to anti-asthma therapy

  • Colds “go to the chest” or last > 10 days.

Pocket Guide for Asthma Management and Prevention 2011


Asthma phenotypes

Asthma Phenotypes

  • Intermittent/Persistent

    • Mild/Moderate/Severe

  • Adult onset wheezing

    • Primary asthma and secondary causes

    • Tends to me more severe

  • Occupational asthma

  • Neutrophilic inflammation


Diagnostic tests

Diagnostic Tests

  • No single test can secure a diagnosis of asthma

  • Spirometry is the most helpful, preferred method for establishing diagnosis.

    • Increase in FEV1 of > 12% and 200 ml after inhaled bronchodilator.

    • Many asthma patients are negative and repeat testing is advised.


Diagnostic testing

Diagnostic Testing

  • Peak expiratory flow (PEF) – aid in diagnosis and management.

    • Compare to patient's previous best effort

    • 60 L/min improvement after BD or diurnal variation in PEF of more than 20%

  • Bronchoprovaction testing.

    • Methacholine, histamine or inhaled mannitol

  • Skin testing or specific IgE testing for allergens.


Diagnostic challenges

Diagnostic Challenges

  • Cough variant asthma

    • Chronic cough, often at night

  • Exercise induced bronchospasm

    • Exercise challenge

  • Asthma in the elderly

    • COPD vs asthma

  • Occupational asthma

    • Must correlate symptoms with occupation


Goals of therapy

Goals of Therapy

  • Avoid troublesome symptoms night and day

  • Use little or no reliever meds

  • Have productive and physically active life

  • Have (near) normal lung function

  • Avoid serious attacks


Initiating therapy

Initiating Therapy

  • Determine level of severity.

  • Consider interval since last exacerbation.

    • Fluctuations in severity and frequency may occur.

  • Risk assessment:

    • Exacerbations requiring oral corticosteroids:

      • 0-1 per year in intermittent (low risk) patient.

      • > or equal to 2 per year in persistent (higher risk) patient.

  • Keep in mind the patients baseline FEV1.

  • Initiate treatment in a stepwise fashion.

    • Reevaluate level of control in 2-6 weeks.


Asthma care

Asthma Care

  • Patient/doctor relationship

    • Avoid triggers, understand and take meds, recognize symptoms and seek advice in timely fashion

  • Identify and reduce exposure to risk

    • Smoke, drugs, dust, fur, pollens, mold

  • Assess, treat and monitor

    • Stepwise approach, Ongoing monitoring q 3 monthly when stable, within 2 weeks after exacerbation.

  • Manage exacerbations


Stepwise approach

Stepwise Approach

  • If disease is poorly controlled

    • First evaluate for adherence to treatments and avoidance of triggers

    • Consider a step up treatments

  • If disease is well controlled

    • Step down treatments

  • Medications must be adjusted based on response to treatment and control of underlying disease, not on a fixed timetable.

    • If a medicine is not effective after 3 months, it should be stopped


Inhaler technique

Inhaler Technique


Moderate to severe persistent asthma

Moderate to Severe Persistent Asthma

  • Daytime symptoms daily and nighttime symptoms at least weekly.

  • Using their rescue inhaler at least once daily.

  • FEV1 < 80% of predicted.

  • FEV1/FVC ratio reduced by 5% from baseline.


Moderate to severe persistent asthma1

Moderate to Severe Persistent Asthma

  • Moderate to High dose Inhaled Corticosteroids (ICS) are the cornerstone of treatment.

    • Higher potency preparations require fewer puffs and encourage compliance

    • Under dosing of ICS will result in poorer control


Managing disease

Managing Disease

  • Add in a Long Acting Beta Agonist (LABA)

    • Most pts in the severe category require at least 2 controller agents

    • Should NEVER be used as monotherapy

  • Leukotriene antagonists are also an option:

    • Limited evidence in literature

    • Montelukast, Zafirlukast, Zilueton

  • Theophylline

    • Limited role, controller agent only, not as efficacious as LABA’s

  • If symptoms are severe add oral corticosteroids.

    • 5-7 days if normal FEV1, 14-21 days if reduced FEV1

  • Consider treatment with IgE antibody.


Oral glucocorticoids

Oral Glucocorticoids

  • Most potent and effective controller agent.

    • Reserve for severe disease and those with reduced FEV1, use lowest dose possible

    • Should see an improvement in FEV1 of 15% after 2-3 weeks

    • If requiring oral GC’s every 2-3 months consider daily low dose (5-10 mg)


Follow up

Follow-up

  • 4 to 8 week intervals.

    • Use a questionnaire to evaluate control

      • Asthma Control Test (ACT)

    • Consider spirometry if worsening symptoms or a step down in care


Asthma control guideline based american thoracic society ats national asthma education and prevention program naepp

http://www.asthma.com/resources/asthma-control-test.html


Xolair what is that

Xolair: What is That?

  • Xolair (Omalizumab): Is an recombinant monoclonal anti-IgE antibody designed to treat moderate to severe allergy associated asthma.

    • Must demonstrate sensitization to an allergen.

    • Inadequate control with inhaled steroids.


Asthma guidelines 20071

Asthma Guidelines 2007

  • Xolair therapy:

    • Reduce the need for systemic and inhaled glucocorticoids.

    • Reduce the number of exacerbations, especially severe exacerbations.

    • No effect on FEV1 values.

    • Given via SubQ route q 2 to 4 weeks.

    • 850 patients radomized

      • 25% reduction in rate of exacerbation

      • Overall response rate 30-50%

      • 12 week trial should be offered

Hanania, et al;Ann Intern Med 2011;154:573


Co morbid illness

Co-Morbid Illness

  • Allergic rhinitis – treat with nasal GC’s if surgical disease refer to ENT

  • GERD – treat with PPI if patient is symptomatic from GERD

  • Vocal cord dysfunction (VCD)- referral to qualified speech therapist

  • OSA – study in sleep lab and treat as indicated


Special considerations

Pregnancy

Variable, safe

Obesity

Weight loss helps

Surgery

PFT’s, if < 80% FEV1 steroids help

Chronic sinus/rhinitis

Treating these will improve asthma

Occupational

URI’s

GER

More common in asthma but treatment doesn’t reduce morbidity

ASA induced

28%

Anaphylaxis

Special Considerations


Summary

Summary

  • Accurate and complete history and physical is crucial.

  • Objective testing – spirometry, methacholine challenge, peak flows, serum studies.

  • Classify the patient.

  • Step care.

  • Reevaluation/follow-up.


Summary1

Summary

  • Written action plan

  • Proper inhaler technique

  • Trigger avoidance

  • Inhaled GC’s are cornerstone of therapy

  • LABA’s should be added next

  • LTA’s or theophylline follow

  • Consider IgE antibody in proper subset

  • Treat comorbid illnesses


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