2/22/2017

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Marianne Curran, PA‐C

3/1/17

Learning Objective

Discuss the pathophysiology, clinical presentation, diagnosis, and 

treatment of Asthma

Asthma Definition – many variations

Chronic Disorder with Reversible (Intermittent & Recurring) Airflow Obstruction, Bronchial 

Hyperresponsiveness with underlying inflammation

…+/‐ with Shortness of Breath, cough, wheezing

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Asthma – Why is this Important? Statistics

~17‐20 million U.S. Adults have asthma

~6‐7 million U.S. Children, most common chronic disease in children

2.o million ER visits with asthma S/S

~3,500 deaths in 2010 from asthma

Anatomy Review

Review of Lung Anatomy

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AsthmaThink of 3 things:

Airway Hyper‐Responsiveness

Inflammation

Airflow Obstruction

Review of Lung Anatomy

Asthma

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Asthma Demographics

Can be anyone

Urban > Rural population

Higher in minority populations

Asthma rates in black children increased 50% from ‘01 to ‘09

~1/2 develop > age of 10

~1/2 will have remission in adulthood

If develop as an adult, rarely goes into remission

Asthma Cause = Unknown

Genetic factor(s) present

Allergy plays a central role

AsthmaInflammation 1st

Lead to Hyperresponsiveness…

Bronchconstriction

Mucus hypersecretion

Airway edema

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Asthma Presentation

Wide range from mild to severe

Can be intermittent and non‐specific

Episodic shortness of breath with/without wheezing, cough (usually worse at night), sputum production

To Dx – need symptoms of the above + reversible expiratory airflow obstruction

Can look like many other conditions…

Asthma DDx:

Other pulmonary diseases; emphysema, chronic bronchitis, bronchiectasis

Chronic rhinosinusitis Vocal cord dysfunction (VCD) Cystic Fibrosis Heart Failure Pulmonary Embolism Foreign Body in the airway Obesity GERD Upper Respiratory Tract infection

AsthmaHistory

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AsthmaHistory Age at onset Exacerbation details; how frequent, duration, limitations Patterns; time of day, time of week, etc – look for triggers Family history Current medications Smoker? now or in the past? Past medication history (ACEI)

h/o Allergic manifestations

Number/freq. of ER visits Ever been hospitalized with asthma attack Ever been on a ventilator due to asthma attack

AsthmaTriggers – can be inhaled or systemic antigens

Smoke

Perfumes

Dust

Animals

Other pollutants

Cold air, dry air

Exercise

Illness

AsthmaHistory

ROS:

General

Skin

HEENT

Pulm

Cardiac

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AsthmaPhysical exam

No abnormal signs or many if in acute phase

Wheezing – especially during expiratory phase

Prolonged expiratory phase

Accessory respiratory muscles

Active expiration

Increase AP diameter = Barrel chest

Diaphoretic, tachycardia, elevated respiration rate

Asthma Samter’s syndome

1. Asthma

2. Nasal Polyps

3. Sensitivity to NSAIDs

....almost always a Board question

Important to educate these patients to avoid NSAIDs

Asthma Studies:

Spirometry (Spiro) is the gold standard

Easy – but is effort dependent

Fast

Inexpensive

Serial studies helpful

Baseline – get one

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Asthma Studies:

Spirometry cont.

FEV1:  Forced Expiratory Volume in 1 second

Decreased in Asthma

Normal > 80%

FVC:  Forced Expiratory Volume

Normal > 80%

FEV1/FVC Ratio:  This is what you use to determine obstruction

Less than 70% = obstructive process

Asthma Spiro

Asthma Spiro

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Asthma Spiro

Asthma Spirometry cont.

DO A POST

Asthma Studies:  cont.

Labs ‐‐ Serum IgE

CXR

Bronchial challenge aka Bronchoprovocation testing

Allergy testing

Peak Expiratory Flows (PEF) ‐‐>

Pulse oximetry

Arterial Blood Gas (ABG) – for acute settings

CPFT

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AsthmaClassification of asthma severity

Spirometry results

Frequency of symptoms

Nighttime symptoms

Frequency of Rescue Inhaler use

ADLs

AsthmaClassification of asthma severity

Mild intermittent

Mild persistent

Moderate persistent

Severe persistent

AsthmaClassification of asthma severity Mild intermittent:

Occasional symptoms ≤2/wk Asymptomatic & normal pulm. function (aka spirometry) between exacerbations

Exacerbations brief (few hrs to few days) Nocturnal symptoms ≤2/month Use of rescue inhaler ≤2/week

Mild persistent: Symptoms > 2/week, but <1/day Exacerbations may affect activities Nocturnal symptoms > 2/month Use of rescue inhaler > 2 days/week (not daily) FEV1  ≥ 80% predicted

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AsthmaClassification of asthma severity Moderate persistent:

Daily symptoms; interfere with activities Exacerbations ≥2/week; may last days Nocturnal symptoms > 1/week Daily use of rescue inhaler FEV1  ≥ 60% predicted, but < 80% predicted

Severe persistent: Continual symptoms ‐ daily Limited physical activities Nocturnal symptoms – usually nightly Frequent exacerbations Frequent nocturnal symptoms FEV1 < 60% predicted

AsthmaTreatment

Most important aspect...

Asthma

EDUCATION

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AsthmaPatient Education – To achieve optimal status:

ADLs

Rescue Inhaler use

Nocturnal symptoms

Normal/or as normal as you can get it – lung functions on serial spirometry

Maintenance medication:  lowest doses/combination possible to achieve the above (ideally no side effects)

Reduce ER visits

Reduce oral corticosteriod use

AsthmaPatient Education

Avoid triggers If they have allergies to dust, mites, smoke, pets, environmental items

Treat allergies:  Consider immunotherapy/allergy shots

Timing of Rescue inhaler

PEFs: Stepping up/down in their treatment plan

When to obtain treatment, seek ER

How to take their medications – especially inhalers

Other items to avoid: NSAIDs, ASA, non‐selective B‐blocker

NOOOOO smoking, avoid 2nd hand smoke

Yearly flu vaccine

AsthmaTreatment – Medications

Two main categories Quick relief

Rescue, taken as‐needed

Goal is to promptly reverse airflow obstruction & relieve symptoms

Examples: short‐acting B2‐agonists, anticholinergics

Long term Control, taken daily to maintain

Examples: long‐acting B2‐agonists, corticosteroids, leukotriene modifiers, theophylline

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AsthmaMedications – Delivery options

Majority are via Metered Dose Inhalers (MDIs) 

Nebulization

AsthmaMedications B2‐agonists

Produce bronchodilation Side effects:  Tremor & tachycardia Two types:

Short‐acting Quick relief for acute symptoms; aka Rescue Inhaler

Can also use prior to exercise if EIB Rapid onset w/in 5‐10 minutes; duration of 3‐6 hours Examples: albuterol, levalbuterol, pirbuterol

Long‐acting aka LABA Long term control Onset within 15‐30 minutes; duration of 12 hours Examples: Salmeterol (serevent), formoterol (foradil), Brovana

(arformoterol)

AsthmaTreatment

Corticosteroids

Decrease airway inflammation and hyperresponsiveness

Decrease frequency of exacerbations

Decrease severity of asthma symptoms

Up‐regulate expression & affinity of B2‐receptors in lung

Different routes of delivery

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AsthmaTreatment

Inhaled corticosteroids (ICS) Decrease airway inflammation

Very effective

Better to add a 2nd long‐acting med than initially increase dose of ICS

Side effects: cough, dysphonia, thrush

Examples: fluticasone (flovent), budesonide (pulmicort), beclamethasone (Qvar), Triamcnolone(Azmacort), others

NOT a rescue inhaler and NOT to be use as‐needed

AsthmaTreatment

Systemic corticosteroids

Can be delivered orally, IV, IM

Reduce rate of hospital visits, shorten duration of exacerbations and reduce risk of relapse

Typically used for exacerbations or for severe persistent

If long‐term use; TAPER

Side effects: Osteoporosis, hyperglycemia, cataracts, weight gain, mood swings, insomnia, suppress hypothalamic‐pituitary‐adrenal axis 

AsthmaTreatment

Combined ICS and long acting beta‐agonists

Combines two medications into one inhaler

Examples:  Symbicort (budesonide & formoterol), Advair (fluticasone & formoterol), Dulera (mometasone& formoterol)

NOT a rescue inhaler and NOT to be use as‐needed

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AsthmaMedications

Leukotriene modifiers:

Allows a decrease in the cellular infiltration of asthmatic bronchial mucosa

Side effects:  Drowsiness, GI symptoms, headache

Example:  Singulair (QD) and Zafirlukast/Accolate(BID)

AsthmaMedications Anticholinergic drugs

Produces bronchodilator Low side effect profile; dry mouth Typically slower onset than B2‐agonists Examples:

Atrovent (ipratropium bromide): MDI and solution/SVN, short‐acting Spiriva (tiotrpium bromide): handihaler, long‐acting

Theophylline Produces bronchodilation, increased mucociliary clearance, increased diaphragmatic muscle contraction

Side effects; insomnia, GERD, GI symptoms, nausea, tremor (and many drug interactions)

Need to measure blood levels – watch for toxicity

AsthmaTreatment – Misc.

Omalizumab/Xolair

Reduces sensitivity to allergens – used for moderate to severe allergic asthmatics

Route: subcutaneous every 2‐4 wks (depending on IgElevels & body weight)

Side effects:  anaphylaxis – pts watched in office after each injection

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AsthmaBack to our classifications...

Mild intermittent

Mild persistent

Moderate persistent

Severe persistent

AsthmaTreatment

Mild intermittent: short‐acting B2‐agonists PRN

Mild persistent: 1st line: low‐dose inhaled corticosteroid (ICS)

2nd line: long‐acting B2‐agonist, leukotriene modifiers, theophylline

Moderate persistent:  low‐dose ICS PLUS one of the other long‐term control med

Severe persistent:  high‐dose ICS plus one of the other long‐term control meds.  Usually need systemic corticosteroids

AsthmaTreatment:  Step protocol

Step 1:  Rescue inhaler as needed

Step 2: Low dose ICS

Step 3:  Low dose ICS & long‐acting beta‐agonist OR medium dose ICS

Step 4:  Medium dose ICS & long‐acting beta‐agonist

Step 5:  High dose ICS & long‐acting beta‐agonist

Step 6:  High dose ICS & long‐acting beta‐agonist + oral steroids

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AsthmaTreatment

Monitor these patients

More frequent with medication changes

More frequent with change in S/S

Serial spirometry studies in office

Peak Flow monitoring at home

Create a formal written action plan based on peak flow changes

AsthmaSpecial cases

Exercise induced asthma

Usu. controlled w/short‐acting B2‐agonist 15‐30 minutes prior to exercise

Nocturnal asthma

Aspirin sensitivity asthma

Consider leukotrienes modifiers

Pregnancy

Pre‐surgical evaluation

AsthmaNon‐responders

Consider Bronchial Challenge test

Consider concomitant conditions that are not optimally treated:

GERD

VCD

Sleep Apnea

Chronic rhinitis

Chronic sinusitis

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AsthmaAcute Exacerbation

Signs: Tachypnea

Tachycardia

Tri‐pod position

Difficulty speaking in complete sentences

Accessory muscle use

O2 – 90%

Hypercapnia

Get to it early! How severe?

Remove triggers if possible

Think ER, think IV steroids

AsthmaComplications:

Immediate:  Status asthmaticus

Acute, life threatening, sustained & severe airway obstruction refractory to treatment.

Carbon dioxide retention, hypoxemia and respiratory failure

Need ER/hospital

Long‐term if not optimally treated: Airway Remodeling causes Fixed airway obstruction

AsthmaIn conclusion

Investigate – ask questions

Lots of treatment/Rx options – base on severity

Can step up and can step down

Remove triggers when possible

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Asthma

Questions

References1. Manual of Clinical Problems in Pulmonary Medicine 5th edition. By Richard 

A. Bordow2. www.cdc.gov3. www.nhlbi.nih.gov/.../asthma/asthstat.pdf 4. www.medscape.com

EDB24

Slide 57

EDB24 You should have a slide of your references for each lecture.Emily D Babcock, 2/18/2014