An Overview of the Treatment of Asthma in Native Americans

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An Overview of the Treatment of Asthma in Native
Americans

• 15 Oct 2003

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Asthma in AI/AN

• Incidence and prevalence thought to be rare in
  1960s and 1970s
• Current prevalence appears to be comparable to
  other US races
• National Health Interview Survery (1986-1990)
• AI men vs Caucasian men 4.45/4.26
• AI women vs Caucasian women 6.02/4.3

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Asthma in AI/AN

• Etiologic factors
• Pollution
• 50 of AI live in urban areas
• Cigarette smoking
• Primary and secondary
• Respiratory syncytial virus (RSV)
• A lower respiratory infection which can be
  potentially fatal in infants and young children
• An important risk factor in the development of
  childhood asthma

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Epidemiology

• Number eight in the chronic disease top ten
• 14-15 million people in the US
• Prevalence is increasing worldwide
• Early exposure to allergens and irritants
• Most common chronic disease in children
• 4.8 million
• 13.7 million ambulatory care visits 1993-1994
  (53.4/1000)

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Epidemiology

• 470,000 hospitalizations and 5,000 deaths
  annually
• Hospitalization more common among children and
  African Americans
• African Americans age 15-24 have the highest rate
  of death from asthma

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Pathology of Asthma

• Chronic Inflammation
• T-cells, macrophages, neutrophils, mast cells,
  eosinophils, epithelial cells
• Environmental precipitants
• Allergens, irritants, viruses, exercise
• Recurrent episodes due to inflammation
• Breathlessness, coughing, wheezing, chest
  tightness especially at night and early morning

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Pathology of Asthma

• Inflammation causes an increase in airway
  hyper-responsiveness to stimuli
• Reversible airflow obstruction
• Bronchoconstriction, edema, mucus plug formation,
  remodeling

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Long-term Asthma Control

• Four key components
• Assessment and monitoring
• Pharmacologic therapy
• Control of factors contributing to asthma
  severity
• Patient education for a partnership

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Assessment and Monitoring

• Medical History
• S/S of asthma
• Worsening symptoms with exposure to allergens,
  irritants, or exercise
• Worsening of symptoms at night symptoms awake
  patient
• Allergic rhinitis, atopic dermatitis
• FH of allergies, rhinitis, sinusitis, asthma

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Assessment and Monitoring

• Establishing a diagnosis
• History or presence of episodic symptoms of
  airflow obstruction
• Airflow obstruction is at least partially
  reversible
• FEV1 lt80 predicted
• FEV1 increases at least 12 or 200 mL after a
  quick-acting beta2 agonist (albuterol)
• Exclusion of an alternative diagnosis

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Assessment and Monitoring
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Long-term Asthma Control

• Four key components
• Assessment and monitoring
• Pharmacologic therapy
• Control of factors contributing to asthma
  severity
• Patient education for a partnership

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Pharmacologic Therapy - Goals

• Prevent chronic and troublesome symptoms
• Maintain (near) normal pulmonary function
• Maintain normal activity levels (including
  exercise and other physical activity)
• Prevent recurrent exacerbations of asthma and
  minimize the need for emergency department visits
  or hospitalizations
• Provide optimal pharmacotherapy with minimal or
  no adverse effects
• Meet patients and families expectations of and
  satisfaction with asthma care

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Pharmacologic Therapy

• Long-term control meds
• Corticosteroids
• Cromolyn sodium and nedocromil
• Long-acting beta2 agonists
• Methylxanthines
• Leukotriene modifiers
• Quick-relief meds
• Short-acting beta2 agonists
• Anticholinergics
• Systemic corticosteroids

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Long-term Asthma Control

• Four key components
• Assessment and monitoring
• Pharmacologic therapy
• Control of factors contributing to asthma
  severity
• Patient education for a partnership

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Control of Factors

• Goal is to improve symptoms and reduce the need
  for medication
• Allergen avoidance
• Remove carpet, wash sheets in hot water, use
  plastic pillow and mattress covers
• Smoking cessation

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Long-term Asthma Control

• Four key components
• Assessment and monitoring
• Pharmacologic therapy
• Control of factors contributing to asthma
  severity
• Patient education for a partnership

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Patient Education

• Basic Facts About Asthma
• Difference between a normal airway and an
  asthmatic one
• What happens during an asthma attack
• Medications
• How they work
• Long-term meds vs. quick-relief meds
• Importance of long-term meds in preventing
  symptoms

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Patient Education

• Skills
• Have patient demonstrate inhaler technique
• Spacers and holding chambers
• Monitoring symptoms, peak flow, and being able to
  recognize deterioration early
• Environmental
• Identify and avoid precipitants
• When to Take Rescue Action
• Written daily management plan and action plan

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References

• Kelly HW, Kamada AK. Asthma. In Dipiro JT,
  Talbert RL, Yee GC, Matzke GR, Wells BG, Posey
  LM, editors. Pharmacotherapy A
  Pathophysiologic Approach. 4th edition. New
  York McGraw-Hill 1999. p. 430-459.
• National Heart, Lung, and Blood Institute.
  Guidelines for the Diagnosis and Management of
  Asthma NAEPP Expert Panel Report 2. Available
  from URL http//www.nhlbi.nih.gov/guidelines/asth
  ma/asthgdln.htm accessed 10/03.
• Rhoades ER, editor. American Indian Health.
  Baltimore John Hopkins University Press 2000.