Asthma

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Asthma

• Elisabeth Wilson, MD, MPH
• December, 2005

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Objectives

• Scope of problem
• Diagnosis
• Prevention and Education
• Monitoring
• Treatment
• Childhood and Adult Asthma

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Definition

• Chronic
• Inflammation
• Bronchoconstriction
• Hypersensitivity

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Scope of the Problem

• 500,000 hospitalizations/yr
• 2 million ER visits/yr
• 5,000 deaths/yr
• Prevalence 16 million (7.5) U.S. adults
• Higher rates and worse outcomes for poor,
  minorities, less educated, urban/inner city
  dwellers

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Childhood Asthma Facts

• On the rise
• Higher rates with inner city kids
• 1 cause of school absences
• 1 admitting diagnosis
• 7-13 of kids have asthma
• Majority diagnoses lt age 5
• Often associated with allergies
• Family history is common

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Disparities Facts

• Non-Hispanic blacks experience higher rates than
  non-Hispanic whites for ED visits,
  hospitalizations, and deaths these trends are
  not explained entirely by higher asthma
  prevalence among non-Hispanic blacks (MMWR, 2002)
• Asthma education, deemed critically important in
  the successful treatment of asthma, may not
  adequately reach patients suffering the greatest
  morbidity and mortality due to language and
  literacy barriers (Williams MV, 1998)

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Diagnosis

• Clinical Diagnosis
• Subjective Findings
• Objective Findings
• Differential not all that wheezes is asthma
• Diagnostic Tests

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Subjective Findings

• Dyspnea
• Cough
• may be nocturnal or exercise induced
• this may be the only sign in a child
• Wheezing
• "Tight" sensation in chest
• URI and environmental triggers

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Objective Findings

• Wheezing
• Tachypnea
• Tachycardia
• Labored respirations accessory muscle use
• Severe exacerbation
• Decreased breath sounds (no wheezing)
• Paradoxical movements of diaphragm
• Cyanosis

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Differential Not all that Wheezes

• Infants and children
• Allergic rhinosinusitis
• Cystic fibrosis
• Enlarged lymph nodes
• Foreign body
• Heart disease
• Tumor
• Viral bronchiolitis
• Vocal cord dysfunction

• Adults
• Chronic obstructive pulmonary disease
• Congestive heart failure
• Cough secondary to use of ACE Inhibitor
• Mechanical obstruction of airway
• Pulmonary embolism
• Pulmonary infiltration, with eosinophilia
• Vocal cord dysfunction

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Diagnosis

• Reduced FEV1 and FEV1/FVC ratio using spirometry
  (indicates obstruction)
• Increase of at least 12 percent and 200 mL in
  FEV1 after bronchodilator use (indicates
  reversibility)

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PEF/Spirometry

• PEF (peak expiratory flow as measured by peak
  flow meter) is comparable to FEV1 (forced
  expiratory volume in 1 sec as measured by
  spirometry/PFTs)
• PEF not meant to be used as diagnostic tool, used
  for management
• Spirometry can measure FEV1/FVC and DLco to help
  distinguish between obstructive (reversible vs.
  non-reversible) and restrictive disease
• PFTs baseline and then q1-2 years or if symptom
  changes
• Bronchoprovocation if spirometry is normal or
  near-normal but patient has symptoms
  (methacholine/histamine challenge)

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Diagnosis Classification
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Other Diagnostic Tests

• Skin testing to assess suspected atopy
• May serve to identify precipitating allergen(s)
• Pulse oximetry
• Arterial blood gas (ABG)
• Sputum analysis generally non-specific
• Chests x-ray is generally non-specific
• May pick up evidence of other lung disease

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Prevention and Education

• Discuss Prevention
• Encourage breast feeding (for many reasons) - may
  help reduce URI triggers
• Identify environmental triggers and decrease
  exposure
• allergy testing
• dust mites - plastic covering pillows and
  mattresses, hot water wash qweek, remove carpets
• pets, especially at young age
• tobacco ask and address
• Review medications
• Proper peak flow, MDI and diskus use

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Proper MDI Use

• Remove the cap and shake the inhaler to mix the
  contents
• Breathe out to exhale as much air as possible
• Use a spacer or hold the inhaler upright 2-4 cm
  from the mouth.
• Breathe in slowly and deeply and immediately
  depress the canister. Continue to breathe in
  slowly for 5-10 seconds.
• Hold breath for 10 seconds, or as long as is
  comfortable
• Breathe out slowly
• If more than one puff is prescribed, wait one
  minute and then repeat the procedure
• Rinse mouth if using steroid inhaler

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More Education

• Consider asthma clinic, home visits, RN educator
• Patient education/resources websites
• http//www.krames.com
• http//www.familydoctor.org
• http//www.rampasthma.org
• http//www.calasthma.org
• http//www.nhlbi.nih.gov/health/public/lung/index.
  htmasthma

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Monitoring

• Peak Flow
• Action Plan

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Monitoring with PEF

• Regular PEF monitoring allows early detection of
  worsening airflow obstruction, which may be of
  particular value in some patients (poor
  perceivers)
• Excessive diurnal variation and a morning dip of
  PEF imply poor control and a need to change the
  management plan
• PEF should be part of a comprehensive patient
  education program

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Proper Peak Flow Use

• Check that the pointer is at zero
• Stand up
• Hold the peak flow meter level (horizontally) and
  keep fingers away from the pointer
• Take a deep breath and close lips firmly around
  the mouthpiece
• Blow as hard and as fast as possible
• Check the number
• Do this 3 times and record the highest reading

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Peak Flow Personal Best

• Take peak flow readings
• Every day for 2 weeks
• Mornings and evenings
• Just mornings for routine peak flows
• Before and after taking B2 agonist
• Create Action Plan
• To monitor severity and adjust treatment

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Treatment Approach

• Step-wise approach
• Recommended medication type by asthma
  classification, symptom and function
• National Asthma Education and Prevention Program
  (NAEEP) Guidelines
• 1997 Update in 2002
• http//www.nhlbi.nih.gov/guidelines/asthma/asthgdl
  n.htm

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Guidelines

• 2002 Updates
• Inhaled steroids improves outcomes
• Use earlier, even for young children
• Start at MILD persistent (Step 2)
• Combination therapy works better
• Add long-acting B2 agonist instead of increasing
  steroid dose
• Antibiotics often not useful
• Bacterial infections not usual cause of
  exacerbations
• Pregnancy (2004 update)
• Safer to treat than to have exacerbation of
  symptoms

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Step 1

• Mild Intermittent
• Daytime symptoms lt 2 x week
• Nighttime symptoms lt 2 x month
• Normal activities between symptoms
• FEV1 or PEF gt 80
• No daily medication needed
• Short acting B2 agonist for exacerbations
• Education asthma facts, triggers, medication,
  develop action plan

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Step 2

• Mild Persistent
• Daytime symptoms gt 2 x week but lt 1 x day
• Nighttime symptoms gt 2 x month
• Symptoms may affect activities
• FEV1 or PEF gt 80
• Inhaled corticosteroid (ICS)
• Long acting B2 agonist as second agent if needed
• Other medications as indicated
• Short acting B2 agonist for breakthrough symptoms
• Education review asthma facts, triggers,
  medication revise action plan refer for group
  education

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Step 3

• Moderate Persistent
• Daytime symptoms daily
• Nighttime symptoms gt 1 x week
• Symptoms affect activities
• FEV1 or PEF gt 60 lt 80
• Inhaled corticosteroid (ICS) ?medium dose
• Long acting B2 agonist as second agent
• Other medications as indicated
• Short acting B2 agonist for breakthrough symptoms
• Education review asthma facts, triggers,
  medication revise action plan refer for
  individual or group education

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Step 4

• Severe Persistent
• Daytime symptoms continuous
• Nighttime symptoms frequent
• Limited activities
• FEV1 or PEF lt 60
• Inhaled corticosteroid (ICS) ?high dose
• Long acting B2 agonist as second agent
• Other medications as indicated
• Short acting B2 agonist for breakthrough symptoms
• Education review asthma facts, triggers,
  medication revise action plan refer for
  individual education, specialist

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Step Down and Up
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Medications B2 agonists

• Short-acting B2 agonist
• albuterol, ventolin, proventil
• Mild intermittent and as rescue medication
• Regular use can lead to tolerance and increased
  exacerbations
• Oral forms less favorable benefit/risk ratio and
  slower onset
• Long-acting B2 agonist
• Salmeterol, serevent
• Add to inhaled steroid if breaking through
  (second agent)

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Medications Steroids

• Inhaled steroids (aerobid, flovent, azmacort,
  pulmicort)
• Mild or moderate persistent asthma
• All are equally effective at equivalent doses,
  optimum dose is lowest that controls symptoms
• Fluticasone and budesonide effective in infants
  and young children
• Doubling dose not effective in reducing
  exacerbations, but may increase toxicity
• More effective in reducing exacerbations than
  long-acting B2 agonists or leukotriene modifiers
• Oral Steroids (prednisone)
• Most effective drugs for acute exacerbations
• 40-60 mg a day (or divided bid) x 3-10 days, no
  taper needed unless on chronic steroids

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Medications Others

• Leukotriene modifiers (singulair, accolate)
• Most studies show less effective than inhaled
  steroid or inhaled steroid long-acting B2
  agonist (first or second agent)
• Good for aspirin intolerance, exercise induced
  symptoms, problems with inhaler
• Cromolyn Sodium (Intal)
• Decreases hypersensitivity not bronchodilation,
  less effective than inhaled steroid
• Theophylline
• Less effective as first or second agent
• Effective in some patients not responding to high
  dose/oral steroids
• Narrow therapeutic index, serum levels of 5-10
  can be effective with minimal adverse effects,
  lots of drug interactions
• Anticholinergics (Atrovent)
• Often used for COPD with or without short-acting
  B2 agonist
• Good for those who cant tolerate short-acting B2
  agonist, but slower onset
• New long acting Rx (tiotropium) has less adverse
  effects

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Medications New

• Anti-IgE antibody (omalizumab, xolair)
• Binds to free IgE and blocks its attachment to
  mast cells and basophils, preventing them from
  responding to allergens.
• Subcutaneous every 2-4 weeks
• Patients with moderate-severe persistent asthma
  w/ high levels of allergen-specific IgE and not
  controlled on inhaled steroid (6-12,000/yr)

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Medications Safety?

• Inhaled Steroids
• Concerns about growth in children
• Small difference in rate of growth in the first
  year of use (1 cm) and then no differences. Far
  better asthma outcomes.
• Concerns about bone mineral density
• Possible reduction with high dose, but not
  clinically significant.
• Skin bruising and thinning has been reported
• Concerns about cataracts, glaucoma,
  hypothalamic-pituitary- adrenal suppression (high
  does fluticasone)
• Salmeterol (SMART study)
• Higher rate of death among black patients using
  salmeterol
• (all patients using inhaled steroids had lower
  death rates)
• What we learned
• Long acting B2 agonists should be combined with
  inhaled steroid
• Asthma is a serious disease
• Black patients are at increased risk for bad
  outcomes (multifactorial)

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Special Considerations

• Exercise-Induced
• Short-acting B2 agonist before exercise
• Inhaled steroids
• Leukotriene modifier
• Pregnancy
• Albuterol has most data supporting safety in
  pregnancy
• Budesonide only inhaled steroid to receive
  category B rating from FDA
• Salmeterol is preferred second agent (longest
  safety record)
• Many other Rx considered safe (theophylline,
  cromolyn, ipratropium)
• Oral steroids may decrease birthweight and
  increase risk of prematurity, first trimester use
  increases risk of cleft lip. STILL, benefits
  outweigh risks.

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Elderly

• Most likely to be poor perceivers
• Inhaled steroids underused watch for adverse
  effects
• MDI may be difficult, consider using nebulizer
• B2 agonist side effects may be more pronounced
• Theophylline should be used with extreme caution

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Kids

• Steroids are safe and effective
• Rule of 2s For inhaled corticosteroids
• Daytime symptomsgt2xweekly
• Nighttime symptomsgt2xmonth
• Exacerbationsgt2xyearly
• If yes to any of the above, start ICS for 1-3
  months and then reassess
• Cough may be presenting complaint

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Final Thoughts

• Flu shots!!!
• Smoking Cessation
• Association with allergies, allergic rhinitis
• Samters triad (3)
• Aspirin allergy, asthma, nasal polyps
• Cautions with B-blockers (even eye drops)
• Consider referral if diagnosis unclear, difficult
  to control or severe disease

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Thank You