Outpatient Management of Asthma

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Outpatient Management of Asthma

• Margo Vener, MD, MPH

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Case 1

• You are seeing a 24 year old woman who is a
  recent immigrant from El Salvador. She complains
  of night time cough and occasional chest
  tightness in the early morning. She has no other
  medical problems except allergies and takes no
  medications. She has a family history of HTN. She
  is taking ESL classes and works cleaning houses.
  
• What is your differential? What further
  information will you need on H and P today?

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Consider Asthma If H/O.

• Cough, worse at night (especially if awaken from
  sleep)
• Recurrent Wheeze
• Recurrent Difficulty Breathing or Tightness
• Sx worse with exercise, URI, animals with fur or
  feathers, dust mites, mold, pollen, smoke,
  changes in weather, strong emotion, airborne
  chemicals or dust, menses.

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Assessment of Sx

• Continual, episodic, or seasonal?
• Onset (age), duration, recent changes?
• Worst at night or early morning?
• In the past 2 weeks, how many times have you had
  sx in day? Night? Awoke with sx in AM? Had sx
  that did not improve 15 mins after albuterol?
• Days of work missed/month?
• Known triggers? Any prodrome?
• Number of ED visits, hospitalizations?
• Ever intubated?
• Ever used steriods?
• Use MDI correctly? Spacer?

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Physical Exam

• HR, RR, O2 sat
• Air movement? Accessory muscles?
• Breath sounds? Wheezing?
• URI?
• Stigmata of steroid use?
• Demonstrate correct med technique? Spacer?
• Reversible airflow limitation measured by peak
  flow meter - ie Peak expiratory flow varies
  gt20 from arising in AM (before inhaled B
  agonist) to PEF in early afternoon (after B
  agonist)

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Differential Diagnosis

• Upper airway obstruction/foreign body
• Bronchitis
• Pneumonia
• COPD
• Tumor
• Pulmonary Embolism
• CHF
• Vocal Cord Dysfunction
• URI

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Definitive Diagnosis

• Spirometry indicates gt12 increase in Forced
  Expiratory Volume 1 second (FEV 1) after inhaling
  a short acting bronchodilator or after receiving
  a short (2-3 week course) of steroids.
• Spirometry better than PEF for dx because less
  variation. PEF is preferred to follow sx.
• Kids 5 and up can usually do spirometry.

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Case 1, continued

• On further questioning, you discover that her
  symptoms began shortly after moving to San
  Francisco and worsened after she began to clean
  houses three days per week. Her physical exam
  shows good air movement, clear lungs, and is
  otherwise normal. Her PEF is 270.
• You send her for spirometry and her FEV1 is 75
  predicted before albuterol and 91 after. Does
  she have asthma? What are treatment options? How
  would you do a stepwise approach?

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Asthma Treatment

• Drug Delivery MDI vs Dry Powder Inhaler vs Oral
• Beta 2 agonists, short acting (albuterol).
  Regular use no benefit over prn.
• Long acting (salmeterol). BID helpful with
  nocturnal sx. Still use albuterol prn. In mod
  asthma, salmeterollow dose inhaled steroid may
  be better than higher dose steroid (advair diskus
  combines both).
• SE Tachycardia, palps, tremor, paridoxical
  bronchospasm, hypokalemia (if high dose).

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Inhaled Corticosteroids

• Decreases inflammation, bronchial
  hyperresponsiveness, and sx.
• Use lowest dose that controls sx.
• Inhaled Funisolide (aerobid), fluticsone
  (flovent), beclamethasone (QVAR)
• Best drug for long term control
• SE Decrease linear growth in kids (in 6-12
  weeks final effect uncertain), suppress
  hypothal/pit/adrenal axis in high dose, oral
  candida.

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Oral Steroids

• Most effective drug for asthma unresponsive to
  bronchodilators
• Tx up to 10 days if acute
• Chronic SE glucose intolerance, weight gain,
  increased BP, osteoperosis, cataracts,
  immunosupression, etc.

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Leukotriene Modifiers

• Leukotrienes are products of arachadonic acid
  metabolism that increase migration of eos,
  production of mucus andedema in ariway wall, and
  cause bronchoconstriction.
• Montelukast (singulair) and zafirlukast are L
  antagonists zilueton inhibits synthesis.
• Overall, less effect than inhaled steroid as
  monotherapy, but may permit decreasing steroid
  dose.

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Others

• Cromolyn inhibits mast cell degranulation and
  decreases airway hyperresponsiveness. No systemic
  toxicity. Need 4 week trial. Much less effective
  than inhaled steroids.
• Ipratroprium-inhaled anticholinergic
  bronchodilates in COPD, bronchitis. Slower onset.
  Use only if cant tolerate albuterol.
  Anticholinergic SE.
• Theophylline-Limited usefulness. Slow onset. Ok
  for nocturnal sx. Narrow theraputic index, follow
  serum levels.

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Case 2

• You are seeing a 16 year old boy who runs cross
  country track in high school. He complains of
  chest tightness, wheezing and SOB with vigorous
  exercise. He takes no meds and has no PMH. Chest
  and cardiac exam are normal.
• Would you suggest any tests?
• What classification of asthma does he have?
• How would you treat this? What would you warn him
  about?

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Classification of Asthma Severity

• Step 1 Mild Intermittent
• Step 2 Mild Persistent
• Step 3 Moderate Persistent
• Step 4 Severe Persistent
• Notes
• Clinical features before treatment.
• Assign the most severe grade where any feature
  occurs.
• May have exacerbations (including
  life-threatening) at any level of severity. Some
  pts with mild, intermittent asthma have severs
  exacerbations and no sx in between.

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Mild Intermittent

• Sx twice (or less) per week.
• Asymptomatic and normal PEF between
  exacerbations.
• Exacerbations brief (hours to days) but intensity
  varies.
• Nighttime sx twice or less per month.
• FEV1 or PEF gt 80 of predicted
• PEF variability lt 20

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Tx of Mild Intermittent

• Long term control None
• Quick relief Inhaled Beta 2 agonist prn
• (but if need inhaled Beta 2 agonist more than
  twice a week, may need indicate need for long
  term control).
• Patient Education

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Case 3

• You are seeing a 38 year old man with a history
  of HTN and asthma when I was a kid. He
  complains of awakening with SOB 3 times a week
  for the past month. Otherwise he feels well and
  denies daytime cough except in cold air. He works
  in a lab and admits that he is a couch potato
  most of the time. You send him for spirometry and
  his FEV1 is 82 of predicted and shows reversible
  airway obstruction.
• What classification of asthma does he have? How
  should you treat him?

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Mild Persistent

• Sx gt twice a week but lt once per day
• Exacerbations may affect activity
• Night sx gttwice per month
• FEV1 or PEF gt 80 of predicted
• PEF variability 20-30

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Tx of Mild Persistent

• Long-Term Control Need anti-inflammatory.
  Inhaled corticosteroid (low dose) preferred. May
  also try cromolyn, leukotriene modifier,
  nedocromil or sustained release theophylline.
• Quick Relief Short acting Beta 2 agonist prn
  oral steroids may be required.
• Patient Education/Action Plan

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Moderate Persistent

• Daily sx
• Daily use of short-acting beta 2 agonist
• Exacerbations may affect activity
• Exacerbations more than 2x/week may last days
• Night sx gt once per week
• FEV1 or PEF 60-80 predicted
• PEF variability gt 30

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Tx of Moderate Persistent

• Daily Medication Need anti-inflammatory. Low to
  medium dose inhaled corticosteroid with long
  acting B2 agonist (eg, salmeterol) preferred. May
  add leukotriene modifier or theophylline (serum
  goal 5 15).
• Quick relief Short acting Beta 2 agonist. May
  need oral steroids.
• Patient Education/Action Plan

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Severe Persistent

• Continual sx
• Limited physical activity
• Frequent exacerbations
• Frequent night sx
• FEV1 or PEF lt 60
• PEF variability gt 30

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Tx of Severe Persistent

• Long term control Need anti-inflammatory.
  Inhaled corticosteroid (high dose) and long
  acting Beta 2 agonist. If needed add oral
  steroids.
• Quick relief Short acting Beta 2 agonist. May
  need oral steroids.
• Patient Education/Action Plan

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Case 3

• In an acute visit you see a 41 year old woman
  with a long history of asthma who now has to use
  her albuterol inhaler 3 to 10 times per day. She
  has a cough and SOB on exertion that limit her
  activity. Her exam shows exp wheezes over both
  lungs with fair air movement. Her best PEF is
  290. Today it is 170.
• What further information do you need? What
  category of asthma does she have? How would you
  treat her acutely? What would you recommend
  chronically? How can she prevent further
  exacerbations in the future?

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Outpatient Management of Exacerbations

• H P (incl HR, RR, O2 sat, access muscle use,
  air movement, lungs,PEF etc)
• PEF gt 50 - albuterol MDI or neb 3x/hr, O2, oral
  steroid. Reassess Q hr x 3 hr if responding and
  if PEF gt 70 can d/c with oral steriods, action
  plan, f/u.
• PEF lt 50 - albuterol anticholinergic neb
  contin for 1 hr, O2, oral steroid. Reassess If
  PEF 50 70 consider admit vs d/c home with f/u.
  If no improvement, admit.
• Impending/Actual Resp Arrest Admit to ICU

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Asthma Action Plan

• Green Zone No Sx. PEF is 80 100 of personal
  best. Continue daily plan as is.
• Yellow Zone Caution. Asthma sx present (cough,
  wheeze, tightness). PEF is 50-80 of best. Take
  XX puffs of albuterol and repeat XX times. Begin
  oral steroids at a dose of XX mg per day. Call
  your MD
• Red Zone Danger. PEF is lt50 of best or you
  continue to get worse after trying tx above. Take
  albuterol XX dose. Increase Oral steroids to XX.
  Call MD and/or go to ED.

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Reduce Asthma Triggers

• Animal dander Remove animals or out of bedroom
  (filter air ducts leading to bedrm)
• Dust Mattress and pillow in allergen covers.
  Wash sheets and blankets weekly in hot water.
  Reduce indoor humidity to lt50. Remove carpets,
  upholstered furniture. Damp mop floor.
• Cockroaches Bait and remove.
• Pollen and mold Stay indoors in worst season,
  esp in afternoons.

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Reduce Triggers, contd

• Indoor Mold Fix leaks and move out of the
  Sunset, clean surfaces, reduce humidity.
• Work Control allergens and chemicals.
• Tobacco Avoid.
• Pollutants Avoid wood burning stoves,
  fireplaces, unvented stoves/heaters, perfumes,
  cleaning agents, sprays, etc.

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Patient Self-Management Skills

• Recognize signs and sx of worsening asthma
• Take meds appropriately
• Use peak flow meter appropriately
• Monitor response to meds
• Follow a written action plan
• Seek medical tx prn

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Asthma Is A Chronic Disease

• Establish Dx
• Classify Severity
• Schedule Routine Follow Up
• Control Triggers
• Assess Co-Morbid Conditions
• Develop a Written Asthma Plan
• Provide Frequent Education
• Involve the Family
• Assess and Minimize Impact on Life

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Case 5

• A 37 year old female physician presents with
  cough induced by cold air or swimming in cold
  water. She also complains of prolonged coughs
  after URIs, but in between has no sx. She
  self-treats with albuterol which she says helps
  a little. She is ppd and s/p INH for 5 months
  in 1995. Otherwise, her PMH and FHX are
  unremarkable. She takes not other medications.
• Spirometry shows 75 predicted before albuterol
  and 81 predicted afterward (7 change) which is
  read as a reversible defect c/w asthma or
  bronchitis.

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Case 5, continued

• Three months ago she was playing with her kids
  and got kicked in the ribs. When the pain did
  not resolve after 6 weeks, she had a CXR. CXR
  showed a widened mediasteinum and several small
  pulmonary nodules. (The area of the rib was
  normal).
• By the time of the f/u chest CT, the patient had
  developed a persistent cough which improved
  slightly with albuterol. A follow up chest CT
  showed mediasteinal adenopathy and confirmed
  small pulmonary nodules. There was also an
  interstitial ground glass appearance c/w
  mycoplasma pneumonia. The patient was treated
  with azithromycin, flovent, and albuterol and the
  cough resolved. The pulmonologist gave the dx of
  CAP and asthma.

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Case 5, continued

• Two months later a follow up chest CT was
  performed. The pulmonary nodules were slightly
  larger.
• The patient remained asymptomatic after the abx
  and had no cough, SOB, sweats, weight loss,
  fatigue, etc. PE was unremarkable.
• A transthoracic, CT guided biopsy resulted in
  pulmonary hemorrhage. Results showed inflammation
  with eosinophils but was inadequate for
  definitive diagnosis.
• Mediasteinoscopy yielded a diagnostic result.

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Chronic Disease

• The patient is the expert. Each visit, try to
  teach your patient something about their disease
  and try to learn something from your patient
  about their disease.
• Asthma/COPD
• DM, HTN, DJD
• CAD, Angina
• RA, OA, Chronic LBP
• Depression/Anxiety, PTSD, BAD
• Alcoholism and Drug Use
• Cancer
• Life is precious and unpredictable. Normal life
  is very sweet.