Asthma in Pregnancy

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Asthma, breathing difficulty, pregnancy, shortness of breath, asthma medications, pregnancy, spirometry,

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Asthma in Pregnancy

  1. 1. By La Lura White MD Maternal Fetal Medicine *
  2. 2. * *Asthma: * Chronic disease. *Increased airway responsiveness. *Can occur spontaneously or in response to various stimuli. * Physical exertion, allergens, medications, infection, emotions and stress.
  3. 3. * * In response to contact with a triggering agents: * Mast cells of the immune system, which are found in loose connective tissue release vasoactive chemical mediators: *Histamine *Bradykinin *Leukotrienes *Cytokines * Prostaglands
  4. 4. * * Mast cells cause neutrophils, lymphocytes and eosinophils to infiltrate the cells of the bronchial lining. * Cause bronchoconstriction, vascular congestion and increases in capillary and mucosal edema. * Impaired mucociliary action and increased mucus production and airway resistance. *Airway obstruction that is partially or completely reversible. *Development of symptoms.
  5. 5. * *Symptoms: * Wheezing *SOB *Cough *Chest tightness *Difficulty breathing
  6. 6. * *Diagnosis: *History of symptoms. * Spirometry :evaluation: measures airflow *Records the amount and the rate of air that you breathe in and out over a period of time.
  7. 7. * *Volume-time curve: showing volume (liters) along the Y-axis and time (seconds) along the X-axis *FEV1 is the volume of air that can forcibly be blown out in one second, after full inspiration
  8. 8. * *Dx: *Symptoms *Improvement in FEV1 after administration of a short-acting inhaled B2-agonist.
  9. 9. * *Asthma complicates 4–8% of pregnancies. *Prevalence of and morbidity from asthma are increasing, although asthma mortality rates have decreased . * Asthma symptoms peak in the late second or early third trimester. (29-36 weeks). *Less severe during the last month of pregnancy.
  10. 10. * *1/3 aggravate *1/3 improve (gradual improvement throughout pregnancy) *1/3 does not change *Most return to their prepregnancy baseline within 3 months postpartum *Most severe disease most likely to worsen during pregnancy *The severity of symptoms in first pregnancy is similar in subsequent pregnancies.
  11. 11. * * THE EFFECTS OF PREGNANCY ON ASTHMA * Asthma has been associated with considerable maternal morbidity. * In a large prospective study: * Mild asthma had an exacerbation rate of 12.6% and hospitalization rate of 2.3%. * Moderate asthma had an exacerbation rate of 25.7% and hospitalization rate of 6.8%. * Severe asthmatics had exacerbation of 51.9% and hospitalization rate 26.9%. * One of the most important conclusions to be made from this study is that pregnant asthmatic patients, even with mild or well-controlled disease, need to be monitored .
  12. 12. * *Well-controlled, asthma can be associated with excellent maternal and perinatal pregnancy outcomes. *Severe and poorly controlled asthma: (FEV1 < 80%) * Increased prematurity *Increased cesarean delivery rate *Preeclampsia *Growth restriction (SGA) *Increased maternal morbidity/ mortality *Hypertension *Existing studies on the effects of asthma on pregnancy *outcomes have had inconsistent results with regard to *maternal and perinatal outcomes
  13. 13. * *Risk Factors *Younger *Unmarried *Lower socioeconomic status *Ethinic: Hispanic, Latino or African-American *Obesity
  14. 14. * *National Asthma Education and Prevention Program (NAEPP)categorize asthma: *Mild intermittent *Mild persistent *Moderate persistent *Severe asthma
  15. 15. * *Mild Intermittent Asthma *Symptoms twice per week or less. *Nocturnal symptoms twice per month or less. *PEFR or FEV1 80% predicted or more *Variability less than 20%
  16. 16. * *Mild Persistent Asthma *Symptoms more than twice per week but not daily. *Nocturnal symptoms more than twice per month. *PEFR or FEV1 80% predicted or more *Variability 20–30%
  17. 17. * *Moderate Persistent Asthma *Daily symptoms *Nocturnal symptoms more than once per week *PEFR or FEV1 more than 60% to less than 80% predicted *Variability more than 30% *Regular medications necessary to control symptoms
  18. 18. * *Severe Asthma *Continuous symptoms and frequent exacerbations. *Frequent nocturnal symptoms. *PEFR or FEV1 60% predicted or less. *Variability more than 30%. *Regular oral corticosteroids necessary to control symptoms.
  19. 19. * *Management Goal *Treat airway inflammation. * Decrease airway responsiveness. * Prevent asthma symptoms and exacerbations. *Maintain adequate oxygenation to the fetus by preventing hypoxic episodes in the mother.
  20. 20. * *Optimal management: *Avoiding or controlling asthma triggers (Allergens (pet dander, house dust, strong perfumes, smoking) *85% of asthma patients test skin positive to common allergens. *Allergen-impermeable pillow and mattress covers, weekly washing bedding in hot water, air sanitizers/humidifiers, leave when vaccuming is done, etc.
  21. 21. * *Patient education: *Teach early recognition of signs and symptoms. *Improve compliance with medication. *Seek prompt treatment when necessary. *Prompt management of: allergic rhinitis sinusitis gastroesophageal reflux *May exacerbate asthma symptom.s
  22. 22. * *Monitoring lung function: *Spirometer *FEV1 after a maximal inspiration is the single best measure of pulmonary function.
  23. 23. *The Peak Expiratory Flow Rate (PEFR) correlates well with the FEV1. *Measured reliably with inexpensive, disposable, portable peak flow meters. *Insight to course of asthma throughout the day. *Help detect early signs of deterioration. *Twice daily. *Upon awakening and after 12 hr. *
  24. 24. * *The typical PEFR in pregnancy should be 380–550 L/min. *Patient should establish her “personal best” PEFR, then calculate her individualized PEFR. *Green Zone more than 80% of personal best. *Yellow Zone 50 to 80% of personal best. *Red Zone less than 50% of personal best PEFR.
  25. 25. * *Adequate pharmacologic therapy *Well controlled: *No limitations of activity. *None or minimal daytime symptoms. *No nocturnal symptoms. *No (or minimal) need for rescue medication. *Normal lung function. *No exacerbations.
  26. 26. * *Step wise management to therapy: step up to more intensive therapy if not controlled. * Based on asthma severity (initial assessment.) * Level of control (subsequent evaluations). *Treat asthma aggressively. *Attaining peak expiratory flow rate or forced expiratory volume in 1 second of 70% or > predicted value.
  27. 27. * *Step-care *Use least amount of drug to control a patient’s asthma. * Increases number and frequency of medications with increasing asthma severity. * Safer to be treated appropriately than have asthma symptoms and exacerbations. *Maintaining adequate oxygenation of the fetus. *Prevention of hypoxic episodes in the mother.
  28. 28. * *Pharmacology Management *Relievers *Controllers
  29. 29. * *Relievers *Bronchodilators: short-acting inhaled β 2- adrenergic receptor agonist used for the relief of bronchospasm. *Short-acting: rapid relief of symptoms by relaxing airways and reducing bronchospasm. *No anti-inflammatory action. *They do not block the development of airway hyperresponsiveness. *Ex: Albuterol (Proventil, Ventolin, Salbutamol) * Metaproterenol (Alupent)
  30. 30. * *Controllers: *Control inflammation and treat disease. *Reduce the risk of Asthma attack and airway remodeling. *Mainly anti-inflammatory. *Inhaled corticosteroids *LABA *Cromolyn *Theophylline *Leukotrene antagonists
  31. 31. * *Glucocorticoids: *Inhaled: *Preferred treatment for all persistent asthma levels. *Anti-inflammatory reduce pulmonary response to allergens. *Beclomethasone (Qvar) * ** Budesonide (Pulmicort) Class B * Fluticasone (Flovent)
  32. 32. * *Longer-acting bronchodilators. (LABA) *Used for long term control of asthma, usually in combination with an inhaled glucocorticoid. (Advair, Symbicort). *Not for rapid relief of symptoms. *Ex: Salmeterol (Servent) * Formoterol (Foradil)
  33. 33. * *Cromolyn sodium: * Is virtually devoid of significant side effects *Blocks both the early and late phase pulmonary response to allergen challenge. * Preventing the development of airway hyperresponsiveness. *Alternative treatment for mild persistent asthma. *Does not have any intrinsic bronchodilator or antihistaminic activity.
  34. 34. * *Theophylline * Alternative treatment for mild persistent. * Adjunctive treatment for the management of moderate and severe persistent asthma during pregnancy. *Adverse theophylline effects including, insomnia, heartburn, palpitations, and nausea, may be difficult to differentiate from typical pregnancy symptoms. * High doses have been observed to cause jitteriness, tachycardia, and vomiting in mothers and neonates. *New dosing guidelines have recommended that serum theophylline concentrations be maintained at 5–12 µg/mL during pregnancy. (Yeh TF, Pildes RS. Transplacental aminophylline toxicity in a neonate [letter]. Lancet 1977;1:910).49
  35. 35. * *Leukotriene Moderators * Arachidonic acid metabolites reduce bronchospasm, mucous secretion and increased vascular permeabilit.y *Improve pulmonary function significantly as measured by FEV1. * An alternative treatment for mild persistent and an adjunctive treatment for the management of moderate and severe persistent asthma. *Ex: zafirlukast (Accolate) * montelukast (Singulair) *Pregnancy category B. * Minimal data regarding the efficacy or safety of these agents during human pregnancy.
  36. 36. * *Mild intermittent *Mild persistent *Moderate persistent *Severe persistent *PRN Salbutamol *Inhaled corticoteroid *Inhaled corticoteroid + LABA *Inhaled corticoteroid + LABA
  37. 37. * *Oral Corticisreroids *Burst may be needed for exacerbations. *Especially if inciting incident can be identified. *Oral prednisone 40-60 mg/d X 7 days *Then taper over 7-14 days. *Data on risk of congenital anomalies conflicting, ? Cleft lip/palate if < 13 weeks.
  38. 38. * * Management * Patients with moderate and severe asthma should be considered high risk for pregnancy complications. * Adverse outcomes can be increased by underestimation of asthma severity and undertreatment of asthma. * The first prenatal visit should include a detailed medical history with attention to medical conditions that could complicate the management of asthma, including active pulmonary disease. * Question smoking history, presence and severity of symptoms, episodes of nocturnal asthma, days of work missed, emergency care visits, hospitalizations and intubations. * The type and amount of asthma medications.
  39. 39. * *Identifying and avoiding asthma triggers. * Scheduling of prenatal visits based upon clinical severity * Pulmonary function (FEV1 or PEFR) are recommended. *Because asthma has been associated with intrauterine growth restriction and preterm birth, it is useful to establish pregnancy dating accurately by first trimester ultrasonography where possible.
  40. 40. * *Antepartum Survellience *Pregnancies complicated by moderate or severe asthma: * Ultrasound for fetal growth *Antenatal assessment of fetal well-being (about 32 weeks). *Asthma medications should be continued during labor. *Encourage breastfeeding.
  41. 41. * * Home Management of Asthma Exacerbations *An asthma exacerbation that causes minimal problems for the mother may have severe sequelae for the fetus. * Indeed, abnormal fetal heart rate tracing may be the initial manifestation of an asthmatic exacerbation. *Therefore, asthma exacerbations in pregnancy should be aggressively managed. *Patients should be given an individualized guide for decision making and rescue management. * Educated to recognize signs and symptoms of early asthma exacerbations such as coughing, chest tightness, dyspnea, or wheezing. 20% decrease in their PEFR.
  42. 42. * *Patients should use inhaled albuterol 2–4 puffs every 20 minutes up to one hour. *A good response is considered if symptoms are resolved or become subjectively mild and normal activities can be resumed. * PEFR is more than 70% of personal best. May continue inhaled albuterol 2–4 puffs MDI every 3–4 hours as needed. *The patient should seek further medical attention if the response is incomplete, or if fetal activity is decreased.
  43. 43. * *Incomplete response: *PEFR is 50–80% predicted. * Persistent wheezing and shortness of breath, then repeat albuterol treatment 2–4 puffs MDI at 20-minute intervals up to two more times. * If repeat PEFR 50–80% predicted or if decreased fetal movement, contact caregiver or go for emergency care.
  44. 44. * *Poor response: *PEFR less than 50% predicted, or severe wheezing and shortness of breath, or decreased fetal movement. *Repeat albuterol 2–4 puffs by MDI and obtain emergency care.
  45. 45. * *Emergency Department and Hospital-Based Management of Asthma Exacerbation *Initial assessment and treatment • History and examination (auscultation, use of accessory muscles, heart rate, respiratory rate *Peak expiratory flow rate (PEFR) or forced expiratory volume in 1 second (FEsaV1), oxygen saturation, ABG if < 95%. * Initiate fetal assessment (consider fetal monitoring and/or biophysical profile if fetus is potentially viable)
  46. 46. * *• Albuterol by metered-dose inhaler or nebulizer, up to three doses in first hour *• Oral corticosteroid if no immediate response or if patient recently treated with systemic corticosteroid. *• Oxygen to maintain saturation more than 95% *• Repeat assessment: symptoms, physical examination, PEFR, oxygen saturation *• Continue albuterol every 60 minutes for 1–3 hours provided there is improvement *• Continue fetal assessment
  47. 47. * *Good response *• FEV1 or PEFR 70% or more *• Response sustained 60 minutes after last treatment *• No distress *• Physical examination is normal *• Reassuring fetal status *• Discharge home
  48. 48. * *Incomplete response *• FEV1 or PEFR 50% or more but less than 70% *• Mild or moderate symptoms *• Continue fetal assessment until patient is stabilized *• Monitor FEV1 or PEFR, oxygen saturation, pulse *• Individualize decision for hospitalization
  49. 49. * *Poor response *• FEV1 or PEFR less than 50% *• Pco2 more than 42 mm Hg *• Physical examination: symptoms severe, drowsiness, confusion *• Continue fetal assessment *• Admit to intensive care unit Intravenous corticosteroid
  50. 50. * *Early assessment *Implement patient education and involvement *Aggressively manage *Close surveillance *Aware of worsening conditions *Treat all phases of asthma as potential complications

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