Asthma update
Download
1 / 30

ASTHMA UPDATE - PowerPoint PPT Presentation


  • 136 Views
  • Updated On :

ASTHMA UPDATE. NEW DIRECTIONS IN 2009 CHANGES IN NIH GUIDELINES CONTROL VS. SEVERITY HETEROGENEITY REGARDING ETIOLOGY DIFFERENT PHENOTYPES DIFFERENTIAL DIAGNOSIS- MASQUERADERS BETTER MONITORING ASTHMA EDUCATION BETTER SELF MONITORING MEDICAL MONITORING:SPIROMETRY NEW THERAPIES

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'ASTHMA UPDATE' - tegan


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Asthma update
ASTHMA UPDATE

  • NEW DIRECTIONS IN 2009

    • CHANGES IN NIH GUIDELINES

      • CONTROL VS. SEVERITY

    • HETEROGENEITY REGARDING ETIOLOGY

      • DIFFERENT PHENOTYPES

    • DIFFERENTIAL DIAGNOSIS- MASQUERADERS

    • BETTER MONITORING

      • ASTHMA EDUCATION

      • BETTER SELF MONITORING

      • MEDICAL MONITORING:SPIROMETRY

    • NEW THERAPIES

      • INHALED STEROIDS WITH NO OR MINIMAL BIOVAILABILITY

      • OTHER NEW MOLECULES

      • IMPROVED IMMUNOTHERAPIES

      • IMPROVED EMPHASIS ON SELF-IMPROVEMENT: NUTRITION; PERSONAL HABITS; HOME ENVIRONMENT


Asthma update1
ASTHMA UPDATE

  • PREVALENCE & IMPACT:

    • 22 million in U.S. (9 million children)

    • Hospitalizations-stable except for children under 4 years.

    • 500,000 hospitalizations annually

    • Increase incidence noted throughout the world

    • Cost: estimated 16 billion dollars annually

    • Estimated days missed (school-14 million school days; work-24 million work days)


Asthma update2
ASTHMA UPDATE

  • EARLY IDENTIFICATION OF HIGH RISK PATIENTS:

    • IMMEDIATE CONCERNS:

      • Improve quality of life

      • Reduce risk for hospitalizations and death.

    • LONG TERM CONCERNS:

      • Prevent irreversible changes in airway structure i.e. remodeling with sub-basement fibrosis, mucus hypersecretion, s.m hypertrophy, & injury of lining (epithelium).


Asthma update3
ASTHMA UPDATE

WHICH PATIENTS ARE AT RISK:

CHILDREN:

  • Children with early onset under 3 yrs have more out of control asthma after 6 yrs. age & lung deficits later on in life.

    • More then 3 episodes of wheezing a year

    • Eczema or parental hx of asthma

    • 2/3 phenotypes (eosinophilia; wheezing without URI; allergic rhinitis


ASTHMA UPDATE

  • USEFUL PREDICTIVE INDEX FOR CHILDREN -VERY IMPORTANT!

    • 76% of children with asthma after age 6 yr had positive predictive index;

    • 97% of children without asthma had negative predictive index.


Asthma update4
ASTHMA UPDATE

WHICH PATIENTS ARE AT RISK:

CHILDREN:

  • Children with early onset under 3 yrs have more out of control asthma after 6 yrs. age & lung deficits later on in life.

    • More then 3 episodes of wheezing a year

    • Eczema or parental hx of asthma

    • 2/3 phenotypes (eosinophilia; wheezing without URI; allergic rhinitis


Asthma update5
ASTHMA UPDATE

ADULTS at RISK:

  • ATS (1 or 2 major; 2 minor).

    • Major

      • Rx with steroids >50% year

      • High dose inhaled steroid

    • Minor

      • Need for additional controller Rx.

      • Daily use of beta 2 agonist

      • Persistent airway obst (Fev1<80%; PEF variability >20%


Asthma update6
ASTHMA UPDATE

ADULTS:

Minor (CONTINUED):

  • One or more emergency visits per yr.

  • 3 or more steroid burst per yr.

  • Deterioration following <25% reduction of steroid

  • Near fatal asthma (intubation in past).


Asthma update7
ASTHMA UPDATE

  • DEFINITION OF ASTHMA:

    • Chronic inflammatory disease with >12 % (>250ml ) FEV1 reversibility:

      • Airflow limitation

      • Airway hyper-responsiveness


Asthma update8
ASTHMA UPDATE

  • AIRFLOW LIMITATION

    • Bronchoconstriction occurs secondary to release of multi-mediators (histamine, leukotrienes, prostaglandins, PAF etc.

      • Aeroallergen sensitivity

      • Aspirin ( Non-IgE)

      • Multi-factorial (exercise and cold air-osmotic; airborne irritants, laughing, GERD & sinusitis via neurogenic reflex; infections)


Asthma update9
ASTHMA UPDATE

  • OTHER FACTORS LIMITING AIRFLOW

    • Airway edema secondary to eosinophilic inflammation

    • Mucus hypersecretion

    • Structural changes i.e. hypertrophy and hyperplasia of smooth muscular tissue; tissue fibrosis as part of remodeling.


Asthma update10
ASTHMA UPDATE

  • AIRWAY HYPER-RESPONSIVENESS (TWITCHY LUNGS)

    • Exaggerated bronchoconstrictor response to stimuli- triggers such as exercise, cold air, laughing, stress.

    • Defined by methacholine/adenosine/mannitol responsiveness

    • Rx directed towards reducing inflammation can reduce airway hyper-responsiveness.


Asthma update11
ASTHMA UPDATE

HETEROGENOUS PHENOTYPES OF ASTHMA:

Different patterns of inflammation-targets for eventual treatment

Many patients have overlapping phenotypes.

  • Intermittent; Persistent

  • Atopic (extrinsic) vs. Intrinsic

  • Exercise induced

  • Aspirin sensitive

  • Late Onset

  • Infection induced (RSV; parainfluenza; adenovirus, rhinovirus)

  • Cough variant asthma

  • Steroid resistant


Asthma update12
ASTHMA UPDATE

  • ESTABLISH DIAGNOSIS OF ASTHMA:

    • History, physical and PFT to establish there are symptoms of airflow obstruction and/or airway hyperresponsiveness;

    • At least evidence for reversibility

    • Value of history

      • What are the triggers in the home?

      • Outdoor triggers?-pollens, time of year

      • What else triggers asthma- aspirin, NSAIDs, URI’s cold air exercise, forest fires, smoking; positioning, foods,

      • Family history


Asthma update13

Differential diagnosis:co-morbidities

GERD;

vocal cord dysfunction;

foreign body;

anatomical abn;

hypersensitivity bronchopulmonary aspergillosis;

Chronic sinusitis

Churg’s syndrome;

Samter’s syndrome;

Cystic Fibrosis

bronchiectasis;

sleep apnea with aspiration;

occupation and hobbies (birds);

wheezing” with COPD

ASTHMA UPDATE


Asthma update14
ASTHMA UPDATE

PHYSICAL EXAM:

  • Nasal exam- polyps

  • Level of wheezing (high, low)

    • High level over trachea: consider vocal cord dysfunction

    • Hyperexpansion of chest

  • Signs of chronicity i.e.(clubbing); consider bronchiectasis, COPD, C.F.

  • Signs of hypoxemia (cyanotic nail beds)

  • Lymphadenopathy or lack of with history of recurring respiratory infections (consider ID workup)

  • Keep in mind undiagnosed adult CF (sweat test is not useful in adults)


Asthma update15
ASTHMA UPDATE

LABORATORY EVALUATION:

  • r/o Atopy: skin tests properly applied and interpreted; RAST cap IgE

  • Properly performed PFT pre and post BD

    • PEF > FEV1; Expiration plateau for at least 6 seconds

    • Reproducibility with BD- at least 2 measurements with FEV1 within 0.15 L.

    • Reversibility in adults: >250 ml; FEV1> 12% or

      > 10% increase of pred FEV1% for adults. Later may separate COPD from asthma. May need oral steroids for reversibility.

    • FEV1/FVC% should be included for children .


Asthma update16
ASTHMA UPDATE

Laboratory evaluation:

  • Other PFT:

    • Inspiratory loop for VCD

    • Methacholine challenge

  • Nasal exam/endoscopy- polyps; sinusitis;VCD

  • Chest Xray/ CT of chest on rare occasion

  • Sinus CT

  • Trial with protonics as a diagnostic tool (pH studies)

  • Consider bronchoscopy and lung biopsy for difficult to diagnose and/or treat.


Asthma update17
ASTHMA UPDATE

NIH Guidelines: asthma classification

  • Initially severity assessment:

    • Based on medication usage; history of recent exacerbations, PFT; night time awakenings; persistent or intermittent.

    • Initial Rx based on classification of severity

  • Manage based on control of symptoms i.e. more functional emphasis:

    • Use of rescue meds

    • Night time awakenings

    • Exacerbation rate

    • Objective parameters –PFT; NO measurements


Asthma update18
ASTHMA UPDATE

  • Goals of Therapy

    • Reduce impairment (current)

      • Prevent troublesome symptoms (cough, breathlessness with exertion and at night)

      • Reduce frequent use of SABA to < 2 days a week

      • Maintain near normal PFT

      • Maintain normal activity

    • Reduce risk (future)

      • Exacerbations

      • Prevent ER visits and hospitalizations

      • Prevent loss of lung function; children-prevent reduced lung growth


Update on asthma
UPDATE ON ASTHMA

Therapeutic Strategies to Improve Control:

  • Education: preferably by experienced or certified asthma educator:

    • Peak flows- setting parameters of when to call.

    • Awareness of questions to ask: nocturnal awakenings, use of rescue meds.

    • Asthma treatment plan: what to do when sx develop.

    • How to use medications and when- very important

    • Compliance checks


Asthma update19
ASTHMA UPDATE

Environmental & Personal Health Strategies

  • Eliminate tobacco smoke ( in utero and passive)

    • Associated with severity and dec. response to steroid Rx.

  • Air pollution- forest fires

  • Wood burning stoves

  • Use of air purifier (HEPA) especially near open windows during pollen seasons


Update on asthma1
UPDATE ON ASTHMA

Environmental & Personal Health Strategies

  • Encourage breast feeding up to 6 months to minimize food allergy induction

  • Home environmental control

  • Individualize recommendations for aerobics in cold weather and during peak pollen counts.

  • Speculative HYGIENE THEORY but worth noting:

    • early exposure to daycare; rural environment; early exposure to animals- Favor immune responses away from allergy development;

    • antibiotic use; Western lifestyle- Favor immune responses towards allergy responses.


Update on asthma2
UPDATE ON ASTHMA

Environmental & Personal Health Strategies

  • Control co-morbidities that can increase asthma:

    • Allergic rhinitis/sinusitis –studies demonstrate that regular use of nasal steroids and/or AH reduce asthma flares and ER visits

    • GERD- use of protonics decreases asthma.

    • Obesity-dieting is important

      • Leptin increases in obesity: inc. IgE sensitization

      • Adiponectin decreases in obesity: enhancing remodeling and increased inflammation.

    • CPAP for sleep apnea can help control obesity, aspiration

    • New concerns: overuse of vitamins, folic acid in pregnancy may be increase incidence of asthma: based on mice studies.


Asthma update20
ASTHMA UPDATE

  • MONITORING ASTHMA TO ASSESS CONTROL:

    • Symptom retrieval- ACT

    • Spirometrics- frequency

    • Other Monitoring Parameters

      • Peak flow measurements

      • Sputum Eosinophils

      • Nitric Oxide and pH Measurements on Exhaled Air


Asthma update21
ASTHMA UPDATE

  • Sputum eosinophils : correlates with inflammatory response but impractical

  • NO produced by epithelial and alveoli cells. Correlates with eosinophil bronchial lavage studies

    • Many convincing studies that suggest NO can be used to reflect status of eosinophilic inflammation in asthma.

    • May be best used as a compliance check with inhaled steroids.


Asthma update22
ASTHMA UPDATE

Medications:

  • Rescue medications and long term beta agonists:

    • Controversy re’ LABA. New data supports use with ICS.

    • Xopenex® vs. albuterol

  • Inhaled corticosteroids- reduced decline in lung function (FEV1)

    • Mometasone and ciclesonide –both have minimal or no bioavailability (absorption)

    • Dynamic dosing- use of ICS as a burst to treat exacerbations in well controlled asthma patients and normal lung function


Asthma update23
ASTHMA UPDATE

  • TARGETED THERAPY:

    • IgE- anti-IgE (Xolair)

    • Leukotrienes (anti-leukotrienes – Singulair; Zyflo

    • Trials with Anti-IL-5- reduce eosinophils

    • Anti- IL-4 trials-reduce IgE


Asthma update24
ASTHMA UPDATE

  • Monoclonal anti-IgE (Xolair)

    • Must be used for difficult to manage severe and persistent asthmatics

      • Resistant to high dose inhaled steroids

      • Require oral steroids

    • Must have IgE levels in a certain range

    • Expensive

    • Does it work –in some cases, noticeable reduction in exacerbations

    • Side effects-anaphylaxis-very rare but requires close observation for 2 hours after dose.

  • Leukotriene modifiers:

    • Montelukast ( prevents exercise induction up to 24 hrs- single dose)

    • Zyflo ( aspirin sensitive asthmatics)


  • Asthma update25
    ASTHMA UPDATE

    Approaches Based on Hygiene Theory

    • Shifting Th2 to Th1 to modify asthma. The shift to Th1 induces IL-2 and IFN critical in defense against infection

      • Alter balance between Th1 and Th2- towards Th1 by immunotherapies

      • SLIT vs. SCIT

    • Factors favoring Th1:

      • Older siblings; early exposure to daycare; rural environment; certain infections (TB, measles, hep A); early exposure to animals;

    • Factors favoring Th2:

      • Antibiotic use; Western lifestyle; urban environment; diet; house dust mite and cockroach sensitization; RSV


    ad