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The MANAGEMENT OF ASTHMA . B. WAYNE BLOUNT, MD, MPH. OBJECTIVES. Define asthma Name the stages of asthma & their respective criteria List the recommended treatment for each stage Describe an action plan Review the recommendations of 3 rd Expert Panel Report (EPR-3)

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The MANAGEMENT OF ASTHMA

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The MANAGEMENT OF ASTHMA

B. WAYNE BLOUNT, MD, MPH


OBJECTIVES

  • Define asthma

  • Name the stages of asthma & their respective criteria

  • List the recommended treatment for each stage

  • Describe an action plan

  • Review the recommendations of 3rd Expert Panel Report (EPR-3)

  • UNLESS OTHERWISE NOTED, ALL EBM RECOMMENDATIONS ARE FROM COCHRANE


CASE # 1

  • 45 Y.O. W MALE C/O COUGH X

    3 ½ WEEKS; DAILY, MOSTLY NOCTURNAL


CASE # 1

  • Which of the following is NOT in your top 5 differential diagnoses?

  • A. Post URI Inflammation

  • B. Post Nasal Drip

  • C. Allergies

  • D. Asthma

  • E. Sinusitis


THE DIFFERENTIAL OF CHRONIC COUGH

  • POST URI INFLAMMATION

  • PND

  • ALLERGIES

  • ASTHMA

  • SINUSITIS

  • GERD

  • WHAT DO YOU WANT TO DO?


OUR CASE

  • HX.

  • P.E.


2. Which of the following is a valid criterion for diagnosing asthma?

  • A. Wheezing on physical exam

  • B. Spirometry

  • C. Symptomatology

  • D. Sound of the cough


PFTs


3. Which of the following PFT parameters is MOST likely to be below normal in a patient with asthma?

  • A. FVC

  • B. FEV1

  • C. TLC

  • D. FRC


OUR CASE

  • HIS PFTs :

    • PARAMETER% PREDICTED

      • FVC89

      • FEV178


4. OUR CASE

  • We can now diagnose this patient with asthma.

  • A. True

  • B. False


REVERSIBILTY OF DEFECT

  • FEV1 OR PEFR NEEDS TO IMPROVE BY AT LEAST 12%;


THIS MEANS YOU HAVE TO DO PFTs

  • @ INITIAL ASSESSMENT

  • AFTER TREATMENT & SX STABILZE

    • DOCUMENTS “NORMAL” AIRWAY FXN

  • A MINIMUM OF Q 1-2 YEARS AFTER THAT

  • WITH EACH EXACERBATION

  • ‘C’ REC


  • SPIROMETRY & PEFRs ARE TO ASTHMA AS BLOOD PRESSURE IS TO HYPERTENSION


5. How many stages of asthma severity are there?

  • A. 3

  • B. 4

  • C. 5

  • D. 6


STAGING THE SEVERITY OF ASTHMA

  • INTERMITTENT

  • MILD PERSISTENT

  • MODERATE PERSISTENT

  • SEVERE PERSISTENT


INTERMITTENT

  • SXNIGHT SXLUNG FXN

    < 2/WK< 2/MO FEV1 or PEF > 80%


MILD PERSISTENT

  • SX NIGHT SXLUNG FXN

  • >2/WK BUT > 2/MO FEV1 or PEF > 80%

    < 1/DAY

    EXACERBATIONS

    MAY AFFECT

    ACTIVITIES


MODERATE PERSISTENT

  • SXNIGHT SXLUNG FXN

    DAILY > 1/WK>60% & <80%

    DAILY USE OF

    INHALED BETA-

    AGONIST

    EXACERBATIONS

    > 2/WK & AFFECT

    ACTIVITIES


SEVERE PERSISTENT

  • SXNIGHT SX LUNG FXN

    CONTINUAL FREQUENT<60%

    FREQUENT

    EXACERBATIONS

    LIMITED PHYSICAL

    ACTIVITY


OUR CASE

  • HOW DO YOU WANT TO TREAT THIS PATIENT & WHY?


6. According to EPR-3, how many age categories are there when considering treatment for asthma?

  • A. 2

  • B. 3

  • C. 4

  • D. 5


7. According to EPR-3, how many STEPS are there when considering treatment for asthma?

  • A. 3

  • B. 4

  • C. 5

  • D. 6


EPR-3

  • Assess severity before starting Rx

  • Assess control to guide RX adjustments

  • 3 age categories for treatment

  • 6 steps in management to individualize treatment


8. How many known pathophysiologic dysfunctions are in the pathogenesis of Asthma?

  • A. 1

  • B. 2

  • C. 3

  • D. 4


Asthma Pathophysiology

Smooth

muscle

dysfunction

Airway

inflammation

Airway

remodeling

Adapted from Bousquet et al. Am J Respir Crit Care Med. 2000;161:1720-1745.


Asthma Pathophysiology

Smooth

muscle

dysfunction

  • Exaggerated contraction

  • Increased smooth muscle mass

  • Increased release of

  • inflammatory mediators

Adapted from Bousquet et al. Am J Respir Crit Care Med. 2000;161:1720-1745.


BRONCHOCONSTRICTION

10 Minutes After Allergen Challenge

Before


SMOOTH MUSCLE HYPERPLASIA


Asthma Pathophysiology

Acute

response

Chronic

inflammatory

response

  • Bronchial hyperreact ivity

  • Mucosal edema

  • Airway secretions

  • Increased inflammatorycell numbers

  • Epithelial damage

Adapted from Bousquet et al. Am J Respir Crit Care Med. 2000;161:1720-1745.


Inflammatory Cells in Lung Tissue

E = Epithelium

BM = Basement Membrane

Laitinen et al. J Allergy Clin Immunol. 1992;90:32-42.


Asthma Pathophysiology

Airway

remodeling

  • Cellular proliferation

  • -smooth muscle cells

  • -mucous glands

  • Increased matrix protein deposition

  • Basement membrane thickening

  • Angiogenesis

Adapted from Bousquet et al. Am J Respir Crit Care Med. 2000;161:1720-1745.


WHAT ARE THE THERAPEUTIC TARGETS?

Smooth muscle

dysfunction

Airway

inflammation

  • lnflammatory cell infiltration/activation

  • Mucosal edema

  • Cellular proliferation

  • Epithelial damage

  • Basement membrane thickening

  • Bronchoconstriction

  • Bronchial hyperreactivity

  • Hyperplasia/Hypertrophy

  • Inflammatory mediator release

Symptoms/Exacerbations

Adapted from Bousquet et al. Am J Respir Crit Care Med. 2000;161:1720-1745.


ASTHMA: GOALS OF THERAPY

  • Control chronic and nocturnal symptoms

  • Maintain normal activity levels, including exercise

  • Maintain near-normal pulmonary function

  • Prevent acute episodes of asthma

  • Minimize emergency department (ED) visits and hospitalizations

  • Avoid adverse effects of asthma medications

Guidelines for the Diagnosis and Management of Asthma. 1997. NIH Publication No. 97-4051.


TREATMENT

  • 40 – 50% ARE NOT FOLLOWED CORRECTLY

    • ‘A’ REC

  • WRITTEN ACTION PLANS IMPROVE THIS BY A CLINICALLY SIGNIFICANT AMOUNT

  • ‘B’ REC


THE TREATMENT OF ASTHMA

DETERMINED BY CATEGORY OF ASTHMA; A STAGED RESPONSE :

  • INTERMITTENT

  • MILD PERSISTENT

  • MODERATE PERSISTENT

  • SEVERE PERSISTENT

    START HIGH AND BACK OFF ‘B’ REC

    New: 6 steps for the 4 stages


EPR-3’s 6 steps

  • Step 1 – Intermittent

  • Step 2 – Mild Persistent

  • Step 3 – Moderate Persistent

  • Step 4 – Moderate Persistent

  • Step 5 – Severe Persistent

  • Step 6 – Severe Persistent


Stepwise treatment: Ages > 12 years

  • Step 1 : SABA PRN

  • Step 2 : Low dose ICS

  • Step 3 : Low dose ICS & LABA or medium dose ICS

  • Step 4 : Medium dose ICS & LABA

  • Step 5 : High dose ICS & LABA; consider Xolair if allergies

  • Step 6 : High dose ICS & LABA & oral steroids; consider Xolair if allergies


INTERMITTENT

  • NO DAILY MED NEEDED

  • USE SHORT-ACTING BETA-AGONIST PRN SX.

  • EDUCATE :

    • ASTHMA

    • MDI USE

    • SELF MANAGEMENT

    • ACTION PLAN

    • ENVIRONMENTAL CONTROL MEASURES


MILD PERSISTENT

  • A CONTROLLER MED :

    • INHALED STEROID IS PREFERRED

    • A CROMONE MAY SUFFICE IN SOME

    • UNCOMMON: LTM

    • RARE: THEOPHYLLINE

  • RESCUE MED :

    • INHALED BETA-AGONIST

  • EDUCATION


MODERATE PERSISTENT

  • INCREASE STEROID (MEDIUM DOSE)

  • ADD LONG-ACTING BETA-AGONIST*

  • ADD LTM

  • CONTINUE RESCUE MED & EDUCATION

    *CONTROVERSIAL


SEVERE PERSISTENT

  • HIGH DOSE INHALED STEROID

  • LABA

  • SYSTEMIC STEROID

  • LTM

  • THEOPHYLLINE

  • RESCUE MED(S)

  • INTENSIFY EDUCATION

  • “WHATEVER IT TAKES”


SO OUR PATIENT HAS _____

  • AND WE WILL USE WHAT MED(S) FOR HIM?

  • GO BACK TO HIS SX & PFTs


USE OF MDIs


USE OF MDIs


USE OF MDIs


MUST TEACH MDI USE

  • TELL

  • DEMONSTATE

  • WATCH

  • ASSESS


TRICKS WITH USING MDIs ?

  • RINSE MOUTH ‘B’ REC

  • NEBS VS. CHAMBERS ‘A’ REC


KNOWLEDGE OF AND PRACTICAL SKILLS WITH THE DEVICES

75

67*

RT

RN

48

MD

MeanKnowledgeScore(%)

50

39

25

0

n = 30

n = 30

n = 30

*P<0.0001 vs RN and MD

Hanania et al. Chest. 1994;105:111-116.


MEDICAL STAFF’S ABILITY TO EFFECTIVELY DEMONSTRATE PROPER INHALER TECHNIQUES

RT

98*

97*

100

RN

82

78

MD

80

69

Mean

DemonstrationScore

(%)

60*

57

60

40

21

20

12

0

MDI

Turbuhaler®

MDI + AeroChamber®

*P<0.0001 vs RN and MD

Hanania et al. Chest. 1994;105:111-116.


9. Which of the following statements about Inhaled steroids is NOT true?

  • A. Going to a higher dose of ICS is better

    than adding a leukotriene modifier.

  • B. They can decrease linear growth in kids.

  • C. Long term use increases risk for

    lowering bone mineral density and

    fractures.

  • D. They are the mainstay of treatment for

    asthma, overall.


DRAWBACKS OF ICS

  • CAN DECREASE LINEAR GROWTH IN KIDS BY 1 – 1.5 CM/YR OF USE

    • ‘A’ REC

  • 2 – 3 YRS OF USE DOES NOT INCREASE RISK FOR LOWERING BMD OR INCREASING VERTEBRAL FXs ‘A’ REC


INHALED STEROIDS

  • MODERATE DOSE MAY BE EQUIVALENT TO HIGH DOSE IN ACUTE SITUATIONS

  • ‘A’ REC

  • WHICH ONE PROBABLY DOESN’T MATTER ’B’ REC


BENEFITS OF ICS

  • Reduces symptom severity

  • Improves pulmonary function

  • Reduces bronchial hyperreactivity

  • Reduces rescue inhaler use

  • Reduces exacerbations and hospitalizations

  • May prevent airway remodeling

  • HIGHER DOSE MORE EFFECTIVE THAN ADDING LTM ‘A’ REC

Guidelines for the Diagnosis and Management of Asthma. 1997. NIH Publication No. 97-4051.


UNDERUTILIZATION OF ICS

  • Inadequately prescribed by physicians

    • Safety concerns

    • Inconvenience

  • Inadequately taken by patients

    • Poor compliance when prescribed

    • Fear of “steroids”

    • Lack of perception of effect


HOW DO YOU WANT TO FOLLOW UP WITH OUR PATIENT ?


ACTION PLANS

THE PATIENT :

KNOWS PEAK FLOWS

KNOWS SX

KNOWS THE ACTION PLAN

WHAT TO DO ABOUT URIs

GETS CONTROL


ACTION PLANS

  • LAY OUT SPECIFIC STEPS THE PATIENT CAN TAKE UNDER CHANGING CLINICAL CONDITIONS

  • INCLUDES GUIDELINES FOR WHEN TO SEEK URGENT OR EMERGENT CARE

  • MADE WITH THE PATIENT & FAMILY TO ENSURE THAT IT CAN BE INCORPORATED INTO DAILY ACTIVITIES

  • REQUIRES ADEQUATE INSTRUCTION ON SX AND PEFRs


ACTION PLANS

  • GREEN ZONE

  • YELLOW ZONE

  • RED ZONE


ACTION PLAN PEAK FLOWS

% OF BEST PEFZONE

> 80% GREEN

> 50% - 79%YELLOW

< 50%RED


ACTION PLANS


ACTION PLANS

  • DOES IT MATTER IF THE ACTION PLAN IS SX-BASED OR PEFR-BASED ?

    ‘A’ RECOMMENDATION

    DON’T NEED TO FILL IT OUT ENTIRELY @ THE 1ST VISIT


Action Plans

  • Data are insufficient to support or refute the benefits of written action plans : ‘I’ Rec

  • Use is recommended by Expert Panel : ‘C’ Rec

  • Evidence neither supports nor refutes the benefits of peak flow monitoring : ‘I’ Rec


OUR PT RETURNS IN 2 WEEKS

  • USING RESCUE INHALER @ NIGHT 3X/WEEK FOR COUGH

  • USING CONTROLLER MED BID

  • NO PROBLEMS @ WORK

  • HOW ARE WE DOING?


CAUSES OF WORSENING ?

  • NONCOMPLIANCE WITH RX

  • URI

  • ALLERGIES

  • SINUSITIS

  • GERD (RX MAY NOT HELP. ‘I’ REC)

  • INCORRECT STAGING

  • ‘B’ REC


THE RULE OF 2’s

  • LESS THAN 2 RESCUES PER WEEK

  • LESS THAN 2 NIGHT TIME AWAKENINGS PER MONTH

  • LESS THAN 2 MDI CANNISTERS PER YEAR

  • ‘C’ RECOMMENDATION


AIRWAY REMODELING: OCCURS EVEN IN MILD ASTHMA

30

25

20

15

10

5

0

P<0.003

P<0.01

SubepithelialLayerThickness (µm)

*

Severe Moderate Mild Healthy(n=6) (n=14) (n=14) (n=8)

*P<0.001, healthy subjects vs patients with asthma.

Chetta et al. Chest. 1997;111:852-857.


AIRWAY WALL THICKNESS

  • Postmortem evaluation of lung tissue

    • Bronchial wall size

      • Asthma > nonasthma for all airway sizes(P<0.001)

    • The degree of smooth muscle shortening to produce airway closure

      • Asthma < nonasthma (P<0.001)

James et al. Am Rev Respir Dis.1989;159:242-246.


Subepithelial Collagen Deposition in Mild Asthma

Lumen

Epithelium

Subepithelial Collagen

Deposition

Holloway et al. Asthma and Rhinitis.1995.


Epithelial Remodeling in Asthma

Normal

Asthmatic


INCREASED VASCULARITY IN ASTHMA

1200

20

%

Vascularity

Vessels/

mm2

800

10

400

P=0.001

P=0.02

0

0

Asthma

Control

Asthma

Control

Li. Am J Respir Crit Care Med.1997;156:229-233.


RATE OF DECLINE IN FEV1

1.0

0.8

0.6

FEV1/Ht3

(L/m3)

0.4

Normal subjects (n=186)

0.2

Asthma patients (n=66)

0

20

0

40

60

80

Age (Yrs.)

Adapted from Peat. Eur J Respir Dis. 1987;70:171.


Effects of Inhaled Corticosteroids on Inflammation

E = Epithelium

BM = Basement Membrane

Pre– and post–3-month treatment with budesonide (BUD) 600 mcg b.i.d.

Laitinen. J Allergy Clin Immunol.1992;90:32-42.


WHAT DO YOU WANT TO DO WITH OUR PATIENT?

  • MEDS?

  • EDUCATION?


OUR PATIENT 2 WEEKS LATER

  • ASX

  • WITHIN ACTION PLAN

  • WITHIN RULE OF 2’s


Treatment Key Points

  • Long-acting inhaled beta2-agonists : Used together with inhaled steroids is the PREFERRED combo therapy for long-term control in moderate & severe asthma ‘A ‘ Rec

  • Cromolyn & nedocromil: Used as alternative meds for mild persistent ‘A ‘ Rec

  • Leukotriene Modifiers : As alternative meds for mild persistent asthma : ‘B’ Rec

  • Inhaled Steroid use regardless of patient age


OUR PATIENT RETURNS IN 6 WEEKS

  • C/O OF MODERATELY SEVERE S.O.B. AND PRETTY REGULAR COUGHING X 1 DAY

  • NO FEVER, CHILLS, U.R.I. SX

  • WHAT DO YOU WANT TO DO?


THE TREATMENT OF AN ASTHMA EXACCERBATION

  • PROMPT RX :

    • O2

    • BETA AGONIST

  • CLOSE OBSERVATION

  • INITIAL ASSESSMENT:

    • LOOK FOR SEVERITY


THE TREATMENT OF AN ASTHMA EXACCERBATION

  • PEF or FEV1 :

    • @ PRESENTATION

      • AFTER INITIAL RX

      • FREQUENTLY

  • O2 SAT

  • BRIEF HX :

    • ASSESS RISK FACTORS FOR DEATH

    • TIME & CAUSE

    • MEDS

    • SEVERITY


RISK FACTORS FOR DEATH

  • HX OF SUDDEN SEVERE EXACERBATION

  • HX OF INTUBATION

  • HX OF ICU

  • > 2 ADMISSIONS/YR

  • IN E.D. OR ADMIT IN

    LAST MON

  • > 2 MDIs OF BETA-AGONIST

    PER MO


RISK FACTORS FOR DEATH

  • CURRENT/RECENT

    USE OF SYSTEMIC STEROID

  • COMORBIDITY

  • LACK OF PERCEPTION

  • PSYCH ISSUE

  • DRUG ABUSE

  • LOW S.E. OR URBAN

    RESIDENCE


SEVERITY SCORES

  • SUBJECTIVE

  • OBJECTIVE

  • ‘C’ RECOMMENDATION

  • SX SIGNS

    • BREATHLESSNESS RR, HR, PP

    • TALKING ACCESSORY MUSCLE

    • ALERTWHEEZE , PEF, O2


FURTHER RX

  • PEF or FEV1

    • > 50%

    • < 50%

  • RESPIRATORY ARREST


PEF > 50%

  • INHALED BETA-AGONIST Q 20 MINS X 3 ‘A’ REC

  • GET O2 SAT > 90%

  • Early use of Bi-PAP may prevent

    intubation

  • SYSTEMIC STEROIDS IF

    PT RECENTLY ON

    (WITHIN 2 WKS) ‘A’


PEF < 50%

  • CONTINOUS BETA-AGONIST (‘A’) & ANTICHOLINERGIC ‘B’

  • INHALED AS GOOD AS IV ‘A’

  • O2 ‘C’

  • SYSTEMIC STEROID ‘A’


MgSO4

  • DOESN’T HELP ALL PTS ‘B’ REC

  • CAN HELP SEVERE EXACERBATIONS ‘B’ REC


SHOULD WE ADMIT OUR PATIENT?


SHOULD WE ADMIT OUR PATIENT?

  • SX DURATION

  • SX SEVERITY

  • PRIOR SEVERE EXACERBATION

  • RESPONSE TO RX

  • CURRENT MEDS

  • HOME CONDITIONS

  • PEF < 70%

  • ‘C’ RECOMMENDATION


SHOULD WE ADMIT OUR PATIENT?

  • PEF OF < 30% PREDICTED THAT IMPROVE BY < 10% AFTER BRONCHODILATOR RX IS A VERY HIGH RISK FOR DEATH

  • ‘B’ RECOMMENDATION


SYSTEMIC STEROIDS ?‘A’ RECOMMENDATION

  • MODERATE TO SEVERE EXACERBATIONS

  • OR

  • INCOMPLETE RESPONDERS TO BETA-AGONISTS

  • ORAL = I.V.

  • GIVE EARLY, ESP. IN KIDS


OTHER RXs ?

  • METHYLXANTHINES ‘D’ REC

  • ABX ‘I’ REC, UNLESS COMORBID

  • AGGRESSIVE HYDRATION :

    • ‘D’ IN OLDER KIDS & ADULTS

    • ‘C’ IN YOUNGER KIDS

  • CHEST PHYSIOTHERAPY ‘D’

  • MUCOLYTICS ‘D’

  • SEDATION ‘E’

  • SELENIUM ‘I’


CLINICAL PEARLS

  • BEST MEASURE OF VENTILATION IS PCO2

    • NORMAL IS BAD

  • INFANTS @ GREATER RISK FOR

    RESPIRATORY FAILURE

  • IN INFANTS:

    ENSURE POX > 95%


BETA-AGONISTS‘B’ RECOMMENDATION

  • ALL PTs

  • BEST WAY TO REVERSE OBSTRUCTION

  • 3 RXs IN 1ST HR OR CONTINOUSLY

  • NEBULIZER OR MDI WITH SPACER

  • IF MDI, USE 6-12 PUFFS VS 2

  • ONSET IN 5 MINs


ANTICHOLINERGICS ‘B’ RECOMMENDATION

  • WORKS BETTER IN SEVERE OBSTRUCTION & THOSE OF LONGER DURATION


CLINICAL PEARLS

  • PROBABLY DO NOT NEED TO WORRY ABOUT K+ OR QT DISTURBANCE IN KIDS WITH ALBUTEROL

  • IVIG NOT USEFUL ‘D’

  • CROMONES & LTMs NOT IN URGENCY ‘C’

  • CBC?CXR?


IF YOU WANT TO SEND OUR PT HOME

  • WATCH FOR 30-60 MINs AFTER LAST INHALATION RX

  • PEF > 70%

  • THOSE WITH ALLERGIC COMPONENT CAN REBOUND IN 3-4 HRS : STEROIDS

  • ENOUGH MEDS

  • F/U CARE/PLAN

  • ACTION PLAN

  • PEAK FLOW METER


WHAT’S COMING IN ACUTE RX?

  • EXHALED NITRIC OXIDE AS MARKER FOR IMPROVEMENT

  • ASTHMA PROJECTS CUT E.D. VISITS

  • ICS DECREASE ADMISSIONS

  • STEROID-INSENSITIVE ASTHMA

  • RAPID- VS SLOW- ONSET ATTACKS


CLINIC EFFICIENCY

  • GIVE PTs ASSESSMENT QUESTIONNAIRE IN WAITING ROOM

  • USE NURSES TO DO TEACHING (AT LEAST ANNUAL ASSESSMENT OF THEIR TEACHING)

  • BRING PTs BACK OFTEN @ THE BEGINNING

  • CASE MANAGERS

  • GROUP OFFICE VISITS

  • NURSES DO SPIROMETRY


CODING ISSUES

ASTHMA : 493.90

  • COPD : 416.9

  • PFTS : 94010

  • PRE- & POST NEB PFTs : 94060

  • PRE- & POST- EXERCISE PFTs : 94620

  • PEFR : CANNOT BILL

  • PULSE OXIMETRY : BUNDLED

  • UNLISTED PULMONARY SVC : 94799


CODING ISSUES

  • TEACHING OR EVALUATION OF USE OF MDI USE: 94664

  • CLINIC NEBULIZER USE : 94644

    • SUPPLIES :

  • EXTENDED CARE IN CLINIC : 99354 -57;

    • BASED ON TIME :

      • EACH ADDITIONAL 30 MINS BEYOND 1ST HR.

      • FACE-TO-FACE TIME


USEFUL INTERNET SITES

  • //secure.pharmacytimes.com/lessons/200604-01.asp

  • AAFP.ORG

  • FAMILYDOCTOR.ORG

  • www.ginasthma.org

  • www-fhs.mcmaster.ca/hrqol/qolintro.htm


USEFUL INTERNET SITES

  • www.goldcopd.com

  • www.tarwars.org

  • www.nhlbi.nih.goc/guidelines/asthma/asthgdln

  • www.icsi.org

  • www.jfponline.com


BIBLIOGRAPHY

  • Global Initiative For Asthma. 2006 Report.

  • Chronic Obstructive Pulmonary Disease. CME Report. NJAFP, vol 4, June, 2006.

  • Scow DT. Leukotriene Inhibitors in the Treatment of Allergy & Asthma. AFP 2007;75:65-70.

  • NATIONAL ASTHMA EDUCATION PROGRAM. NHLBI; NIH. 301-951-3260 (FOR PUB & EDUCATION MATERIALS)


BIBLIOGRAPHY

  • KEMP JP. MANAGEMENT OF ASTHMA IN CHILDREN. AFP 2001;63:1341-8.

  • SINHA T. RECOGNITION & MEANAGEMENT OF EXERCISE-INDUCED BRONCHOSPASM. AFP 2003;67:769-74.

  • Higgins JC. The ‘crashing asthmatic’. AFP 2003;67:997-1004.

  • MINTZ M. ASTHMA UPDATE: PART I. AFP 2004;70:893-8.

  • MINTZ M. ASTHMA UPDATE: PART II. AFP 2004;70:1061-6.


BIBLIOGRAPHY

  • Stoloff SW. The latest government guidelines. JFP. 2008, Sept.; 57. www.jfponline.com

  • Anderson G, et al. Diagnosis & Treatment of Respiratory Illness in Children & Adults. 2008. www.ICSI.org

  • Bach B, et al. Diagnosis & Management of Asthma. 2008. www.ICSI.org


  • EXTRAS


Asthma Facts: Mortality / Morbidity

  • 17 million asthma patients1

  • Asthma deaths: more than 5,000 each year1

  • Asthma-related hospitalizations: 466,000 in 19941

  • Emergency department visits for asthma: 1.9 million in 19951

  • Healthcare costs for asthma care: estimated at more than $11 billion a year2

  • 3 million lost workdays in the US3

1 Surveillance for Asthma--United States, 1960-1995. MMWR Morb Mortal Wkly Rep. April 1998;47(SS-1):1-28.

2 NHLBI. Data Fact Sheet on Asthma Statistics. 1999. Publication 55-798.

3 Weiss et al. N Engl J Med. 1992;326:862-866.


The Goals of Asthma Therapy Are Inadequately Realized

60

48

40

32

Patients(%)

30

23

20

0

Sleep

Disruption

 Once/Week

Missed

School/Work

in Past Year

Unscheduled

ED Visits

in Past Year

Limited

Sports/

Recreation

Rickard et al. J Allergy Clin Immunol. 1999;103:A655.

Asthma in America Survey. SRBI. December 1998.


OUR PATIENT RETURNS 4 MONTHS (DEC.) LATER WITH HIS 15 Y.O. DAUGHTER

  • HE IS DOING WELL, SANS COMPLAINTS. HE FOLLOWS HIS ACTION PLAN AND IS WELL UNDER THE “RULE OF 2’s” CRITERIA

  • HIS DAUGHTER IS THE PT AND SHE C/O OF COUGHING WHILE PLAYING VOLLEYBALL & TIRING OUT MORE QUICKLY THAN SHE USED TO

  • WHAT DO YOU WANT TO DO?


EXERCISE-INDUCED BRONCHOSPASM


EXERCISE-INDUCED BRONCHOSPASM

  • 80 – 90% OF PTs WITH ASTHMA ALSO HAVE EIB

  • DX BASED ON DETAILED HX OR PRE- & POST- EXERCISE PFTs

  • SX IN 1ST 5 MINS OF EXERCISE ARE NOT USUALLY INDICATIVE OF EIB

  • IF USE PFTs, MUST EXERCISE FOR > 5 MINs


EXERCISE-INDUCED BRONCHOSPASM

  • NONPHARMACOLOGIC RX

    • INCREASE PHYSICAL CONDITIONING

    • WARM UP FOR > 10 MINS

    • COVER MOUTH & NOSE DURING COLD WEATHER

    • COOL DOWN

    • WAIT > 2 HRS AFTER MEALS

    • ‘C’ REC


EXERCISE-INDUCED BRONCHOSPASM

  • PHARMACOLOGIC RX :

    • SHORT BETA-AGONIST

    • CROMOLYN

    • INHALED STEROIDS (TAKES DAYS TO WORK)

    • IPATROPIUM

    • THEOPHYLLINE

    • ‘A’ REC


OUR PATIENT RETURNS IN MAY OF THE NEXT YEAR

  • C/O WORSENING ASTHMA SX

  • WHAT DO YOU WANT TO DO NOW?


CAUSES OF WORSENING

  • NONCOMPLIANCE WITH RX

  • URI

  • ALLERGIES

  • SINUSITIS

  • GERD

  • INCORRECT STAGING

  • PREGNANCY


OUR PATIENT

  • “HAYFEVER” SX EVERY YEAR @ THIS TIME

  • HAS AN INDOOR CAT

  • DOES NOT HAVE

    • EXPOSURE TO SMOKE


THE ASTHMA – ALLERGY CONNECTION


THE ASTHMA – ALLERGY CONNECTION

  • ASTHMA & AR ARE BOTH INFLAMMATORY DZs OF THE AIRWAY

  • MANAGEMENT THAT CONSIDERS THIS ASSOCIATION IMPROVES OVERALL OUTCOMES

  • COMMON RISK FACTORS:

    • FAMILY HX

    • ALLERGEN SENSITIVITY

    • TOBACCO SMOKE EXPOSURE

    • EBM ‘A’


THE ASTHMA – ALLERGY CONNECTION

  • PTs WITH ASTHMA HAVE UPPER AIRWAY INFLAMMATION

  • PTs WITH AR HAVE LOWER AIRWAY HYPERRESPONSIVENESS

  • SIMILAR TISSUE HISTOPATHOLOGY

  • ‘B’ REC


THE ASTHMA – ALLERGY CONNECTION : CLINICAL IMPLICATIONS

  • ASSESS UPPER AIRWAY IN PTs WITH ASTHMA

  • ASSESS LOWER AIRWAY IN PTs WITH AR

  • CONSIDER COMBINING RX FOR BOTH

  • EBM ‘A’


HOW DO YOU WANT TO TREAT OUR PATIENT?


THE ASTHMA – ALLERGY CONNECTION

  • AGENTS THAT TREAT THE UPPER AIRWAY AFFECT THE LOWER AIRWAY :

    • NASAL STEROIDS

    • ANTIHISTAMINES

  • AGENTS THAT TREAT THE LOWER AIRWAY AFFECT THE UPPER AIRWAY :

    • LEUKOTRIENE MODIFIERS

    • EBM ‘A’


TREATMENT OPTIONS‘A’ REC

  • ALLERGEN AVOIDANCE (‘B’ REC: DOESN’T WORK FOR DUST )

  • IMMUNOTHERAPYANTIHISTAMINE

  • INCREASE INHALED STEROID

  • NASAL STEROIDCROMOLYN

  • SYSTEMIC STEROID

  • LONG-ACTING BETA-AGONIST

  • LEUKOTRIENE MODIFIER

  • IONIZERS DO NOT HELP ‘I’ REC

  • PNEUMOCOCCAL & FLU VACCINE ‘I’ REC


OUR PATIENT RETURNS IN 8 DAYS

DOING QUITE WELL ON HIS MEDS;

FOLLOWING HIS ACTION PLAN

STAYING WITHIN ITS CRITERIA


OUR PATIENT RETURNS IN 5 WEEKS (JULY)

  • BRINGS IN HIS 45 Y.O. WIFE

  • SHE C/O DAYTIME COUGH WITH MILD INTERMITTENT S.O.B.

  • NO HX OF R.A.D.

  • IS NOT A SMOKER

  • WHAT DO YOU WANT TO DO?


OCCUPATIONAL ASTHMA


OCCUPATIONAL ASTHMA

  • ABOUT 10% OF ALL ADULT CASES OF ASTHMA ARE ATTRIBUTABLE TO AN OCCUPATIONAL ETIOLOGY; ‘A’ REC

  • 2 FORMS:

    • REACTIVE TO IRRITANTS

    • ALLERGIC


THE USUAL CULPRITS‘B’ REC

  • AMMONIA

  • CHLORINE

  • HYDROCHLORIC ACID

  • SILO GAS

  • SILICON

  • WELDING FUMES

  • SMOKE

  • FLOOR SEALANT

  • BLEACHING AGENTS


THE USUAL OCCUPATIONS

  • BAKERS, FARMERS, MILLERS, GRAIN ELEVATORS, RESEARCH LABS, SEAFOOD PROCESSORS, ANIMAL HANDLERS, CARPET MFG, SPRAY PAINTERS, WELDERS, REFINERIES, TEXTILES, ADHESIVE HANDLERS, RESIN WORKERS, LATEX MFG, SILK WORKERS, INSECT HANDLERS, WOODWORKERS

  • ‘A’ REC


OCCUPATIONAL ASTHMA

  • DIAGNOSIS :

  • HISTORY

  • CAN DO PRE- & DURING- WORK PEFRs

  • ALLERGY TESTING


TREATMENT

  • AVOIDANCE ( YEAH, RIGHT!)

  • STANDARD TREATMENT OF ASTHMA ‘A’ REC

  • COMPENSATION ISSUES (AMA GUIDELINES ON DEGREE OF IMPAIRMENT DUE TO ASTHMA); ASSESSMENT DONE AFTER 2 Yrs OF RX


  • MORE EXTRAS


Strong Evidence ref ICS

  • Long term use does not have clinically significan or irreversible effects on any of the outcomes studied.

  • Do improve health outcomes for kids with mild or moderate persistent asthma

  • Small but potential risk for delayed growth is out-weighed by their effectiveness.

  • Are the foundation of RX for patients of all ages with persistent asthma


  • A step-down trial is recommended for patients whose asthma is well-controlled for at least 3 months.

  • Reduce dose of ICS gradually, about 25-50% every 3 months.


Stepwise treatment: Ages 0-4 years

  • Step 1 : SABA PRN

  • Step 2 : Low dose ICS

  • Step 3 : Medium dose ICS

  • Step 4 : Medium dose ICS & LABA or singulair

  • Step 5 : High dose ICS & LABA or singulair

  • Step 6 : High dose ICS & oral steroid & LABA or singulair


Stepwise treatment: Ages 5-11 years

  • Step 1 : SABA PRN

  • Step 2 : Low dose ICS

  • Step 3 : Low dose ICS & LABA, LTRA or Theophylline or medium dose ICS

  • Step 4 : Medium dose ICS & LABA

  • Step 5 : High dose ICS & LABA

  • Step 6 : High dose ICS & LABA & oral steroid


ASTHMA TREATMENT GUIDELINESRATIONALE

  • Asthma is a disease of chronic airway inflammation and smooth muscle dysfunction

  • Even mild asthma is associated with risk of exacerbations, hospitalizations, and irreversible airflow obstruction

  • Anti-inflammatory treatment improves symptoms and reduces risks

  • Asthma is generally undertreated in the US

Guidelines for the Diagnosis and Management of Asthma. 1997. NIH Publication No. 97-4051.


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