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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

The MANAGEMENT OF ASTHMA

B. WAYNE BLOUNT, MD, MPH


Objectives

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

CASE # 1

  • 45 Y.O. W MALE C/O COUGH X

    3 ½ WEEKS; DAILY, MOSTLY NOCTURNAL


Case 11

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

THE DIFFERENTIAL OF CHRONIC COUGH

  • POST URI INFLAMMATION

  • PND

  • ALLERGIES

  • ASTHMA

  • SINUSITIS

  • GERD

  • WHAT DO YOU WANT TO DO?


Our case

OUR CASE

  • HX.

  • P.E.


2 which of the following is a valid criterion for diagnosing asthma

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


The management of asthma

PFTs


3 which of the following pft parameters is most likely to be below normal in a patient with asthma

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 case1

OUR CASE

  • HIS PFTs :

    • PARAMETER% PREDICTED

      • FVC89

      • FEV178


4 our case

4. OUR CASE

  • We can now diagnose this patient with asthma.

  • A. True

  • B. False


Reversibilty of defect

REVERSIBILTY OF DEFECT

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


This means you have to do pfts

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


The management of asthma

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


5 how many stages of asthma severity are there

5. How many stages of asthma severity are there?

  • A. 3

  • B. 4

  • C. 5

  • D. 6


Staging the severity of asthma

STAGING THE SEVERITY OF ASTHMA

  • INTERMITTENT

  • MILD PERSISTENT

  • MODERATE PERSISTENT

  • SEVERE PERSISTENT


Intermittent

INTERMITTENT

  • SXNIGHT SXLUNG FXN

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


Mild persistent

MILD PERSISTENT

  • SX NIGHT SXLUNG FXN

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

    < 1/DAY

    EXACERBATIONS

    MAY AFFECT

    ACTIVITIES


Moderate persistent

MODERATE PERSISTENT

  • SXNIGHT SXLUNG FXN

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

    DAILY USE OF

    INHALED BETA-

    AGONIST

    EXACERBATIONS

    > 2/WK & AFFECT

    ACTIVITIES


Severe persistent

SEVERE PERSISTENT

  • SXNIGHT SX LUNG FXN

    CONTINUAL FREQUENT<60%

    FREQUENT

    EXACERBATIONS

    LIMITED PHYSICAL

    ACTIVITY


Our case2

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

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

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

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

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

  • A. 1

  • B. 2

  • C. 3

  • D. 4


The management of asthma

Asthma Pathophysiology

Smooth

muscle

dysfunction

Airway

inflammation

Airway

remodeling

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


The management of asthma

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.


The management of asthma

BRONCHOCONSTRICTION

10 Minutes After Allergen Challenge

Before


The management of asthma

SMOOTH MUSCLE HYPERPLASIA


The management of asthma

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

Inflammatory Cells in Lung Tissue

E = Epithelium

BM = Basement Membrane

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


The management of asthma

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

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

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

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

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

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

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


Intermittent1

INTERMITTENT

  • NO DAILY MED NEEDED

  • USE SHORT-ACTING BETA-AGONIST PRN SX.

  • EDUCATE :

    • ASTHMA

    • MDI USE

    • SELF MANAGEMENT

    • ACTION PLAN

    • ENVIRONMENTAL CONTROL MEASURES


Mild persistent1

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 persistent1

MODERATE PERSISTENT

  • INCREASE STEROID (MEDIUM DOSE)

  • ADD LONG-ACTING BETA-AGONIST*

  • ADD LTM

  • CONTINUE RESCUE MED & EDUCATION

    *CONTROVERSIAL


Severe persistent1

SEVERE PERSISTENT

  • HIGH DOSE INHALED STEROID

  • LABA

  • SYSTEMIC STEROID

  • LTM

  • THEOPHYLLINE

  • RESCUE MED(S)

  • INTENSIFY EDUCATION

  • “WHATEVER IT TAKES”


So our patient has

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 mdis1

USE OF MDIs


Use of mdis2

USE OF MDIs


Must teach mdi use

MUST TEACH MDI USE

  • TELL

  • DEMONSTATE

  • WATCH

  • ASSESS


Tricks with using mdis

TRICKS WITH USING MDIs ?

  • RINSE MOUTH ‘B’ REC

  • NEBS VS. CHAMBERS ‘A’ REC


Knowledge of and practical skills with the devices

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

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

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

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

INHALED STEROIDS

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

  • ‘A’ REC

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


The management of asthma

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.


The management of asthma

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

HOW DO YOU WANT TO FOLLOW UP WITH OUR PATIENT ?


Action plans

ACTION PLANS

THE PATIENT :

KNOWS PEAK FLOWS

KNOWS SX

KNOWS THE ACTION PLAN

WHAT TO DO ABOUT URIs

GETS CONTROL


Action plans1

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 plans2

ACTION PLANS

  • GREEN ZONE

  • YELLOW ZONE

  • RED ZONE


Action plan peak flows

ACTION PLAN PEAK FLOWS

% OF BEST PEFZONE

> 80% GREEN

> 50% - 79%YELLOW

< 50%RED


Action plans3

ACTION PLANS


Action plans4

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 plans5

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

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

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

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


The management of asthma

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

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

Subepithelial Collagen Deposition in Mild Asthma

Lumen

Epithelium

Subepithelial Collagen

Deposition

Holloway et al. Asthma and Rhinitis.1995.


The management of asthma

Epithelial Remodeling in Asthma

Normal

Asthmatic


Increased vascularity in asthma

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 fev 1

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

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

WHAT DO YOU WANT TO DO WITH OUR PATIENT?

  • MEDS?

  • EDUCATION?


Our patient 2 weeks later

OUR PATIENT 2 WEEKS LATER

  • ASX

  • WITHIN ACTION PLAN

  • WITHIN RULE OF 2’s


Treatment key points

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

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

THE TREATMENT OF AN ASTHMA EXACCERBATION

  • PROMPT RX :

    • O2

    • BETA AGONIST

  • CLOSE OBSERVATION

  • INITIAL ASSESSMENT:

    • LOOK FOR SEVERITY


The treatment of an asthma exaccerbation1

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

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 death1

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

SEVERITY SCORES

  • SUBJECTIVE

  • OBJECTIVE

  • ‘C’ RECOMMENDATION

  • SX SIGNS

    • BREATHLESSNESS RR, HR, PP

    • TALKING ACCESSORY MUSCLE

    • ALERTWHEEZE , PEF, O2


Further rx

FURTHER RX

  • PEF or FEV1

    • > 50%

    • < 50%

  • RESPIRATORY ARREST


Pef 50

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 501

PEF < 50%

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

  • INHALED AS GOOD AS IV ‘A’

  • O2 ‘C’

  • SYSTEMIC STEROID ‘A’


Mgso4

MgSO4

  • DOESN’T HELP ALL PTS ‘B’ REC

  • CAN HELP SEVERE EXACERBATIONS ‘B’ REC


Should we admit our patient

SHOULD WE ADMIT OUR PATIENT?


Should we admit our patient1

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 patient2

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

SYSTEMIC STEROIDS ?‘A’ RECOMMENDATION

  • MODERATE TO SEVERE EXACERBATIONS

  • OR

  • INCOMPLETE RESPONDERS TO BETA-AGONISTS

  • ORAL = I.V.

  • GIVE EARLY, ESP. IN KIDS


Other rxs

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

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

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

ANTICHOLINERGICS ‘B’ RECOMMENDATION

  • WORKS BETTER IN SEVERE OBSTRUCTION & THOSE OF LONGER DURATION


Clinical pearls1

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

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

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

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

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 issues1

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

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 sites1

USEFUL INTERNET SITES

  • www.goldcopd.com

  • www.tarwars.org

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

  • www.icsi.org

  • www.jfponline.com


Bibliography

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)


Bibliography1

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.


Bibliography2

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


The management of asthma

  • EXTRAS


Asthma facts mortality morbidity

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

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

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


Exercise induced bronchospasm1

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 bronchospasm2

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 bronchospasm3

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

OUR PATIENT RETURNS IN MAY OF THE NEXT YEAR

  • C/O WORSENING ASTHMA SX

  • WHAT DO YOU WANT TO DO NOW?


Causes of worsening1

CAUSES OF WORSENING

  • NONCOMPLIANCE WITH RX

  • URI

  • ALLERGIES

  • SINUSITIS

  • GERD

  • INCORRECT STAGING

  • PREGNANCY


Our patient

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


The asthma allergy connection1

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 connection2

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

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

HOW DO YOU WANT TO TREAT OUR PATIENT?


The asthma allergy connection3

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

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

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

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


Occupational asthma1

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

THE USUAL CULPRITS‘B’ REC

  • AMMONIA

  • CHLORINE

  • HYDROCHLORIC ACID

  • SILO GAS

  • SILICON

  • WELDING FUMES

  • SMOKE

  • FLOOR SEALANT

  • BLEACHING AGENTS


The usual occupations

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 asthma2

OCCUPATIONAL ASTHMA

  • DIAGNOSIS :

  • HISTORY

  • CAN DO PRE- & DURING- WORK PEFRs

  • ALLERGY TESTING


Treatment1

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


The management of asthma

  • MORE EXTRAS


Strong evidence ref ics

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


The management of 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

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

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 guidelines rationale

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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