Asthma lecture 100829


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  • An expert panel commissioned by the National Asthma Education and Prevention Program (NAEPP) Coordinating Committee (CC) developed the 2007 EPR 3 Guidelines on Asthma. The National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health coordinated the effort.
  • The expert panel used the 1997 guidelines and the 2004 update as the framework to organize the literature review, and the final guidelines report for four essential components of asthma care: assessment and monitoring, patient education, control of factors contributing to asthma severity, and pharmacologic treatment. Here are a few highlights.
  • Inhaled Corticosteroids Inhaled corticosteroids are the most effective medications for long-term management of persistent asthma, and they should be used by patients and clinicians as recommended in the guidelines for controlling asthma. Message: Asthma Action Plan All people who have asthma should receive a written asthma action plan to guide their self-management efforts. Message: Asthma Severity Message: All patients should have an initial severity assessment based on measures of current impairment and future risk to determine type and level of initial therapy needed. Message: Asthma Control Message: At planned follow-up visits, asthma patients should review the level of control with their health care providers on the basis of multiple measures of current impairment and future risk; this review can guide clinician decisions to either maintain or adjust therapy. Message: Follow-up Visits Patients who have asthma should be scheduled for planned follow-up visits at periodic intervals to assess their asthma control and to modify treatment if needed. Message: Allergen and Irritant Exposure Control Clinicians should review each patient’s sensitivity to allergens and irritants and provide a multipronged strategy to reduce exposure—i.e., avoid exposures that make the patient’s asthma worse.
  • Diagnosing Asthma
  • Diagnosing Asthma: Spirometry
  • Key Point: “ Impairment” and “risk” are important concepts that you will hear much about in the future. This is how we look at severity and risk. In terms of SEVERITY, it must be understood as the PRE-TREATMENT ASSESSMENT of asthma. Slide Notes: Asthma “severity” has always been a tricky term. The correlation between the intensity of symptoms and the “severity” category into which a patient would fall often seems contradictory It is important to remember that severity is an assessment BEFORE treatment. Herein, one must consider both the near-term and long-term assessment of a patient to have a full understanding of severity This slide depicts some of the concepts that fall under the two main components of severity: “Impairment” and “Risk”
  • Avoidance of allergens when possible is the most important aspect of allergy treatment. Decreasing exposure to allergens results in improvement in symptoms and less need for medications. Total avoidance of allergens is usually not possible, so medications are usually necessary. Fortunately we have many safe and effective medications for allergies. Allergy injections are usually reserved for those patients whose symptoms are not controlled by avoidance and medications. Allergy injections can be very effective in certain patients with certain allergies, but should be prescribed and administered by physicians with training or experience in this kind of therapy.
  • Medications to Treat Asthma
  • Asthma lecture 100829

    1. 2. Neil L. Kao, M.D. Assistant Professor of Medicine U.S.C. School of Medicine Director of Research ADAC Research, P.A. [Missions: teach, research, service]
    2. 3. Why should we care about asthma? <ul><li>7-9% of adults report they have asthma </li></ul><ul><li>35-40 million Americans have asthma </li></ul><ul><li>Deaths from asthma in the U.S. peaked in 1996 due to better recognition and long-term treatment (2004 had 3,800) </li></ul><ul><li>Morbidity from asthma remains high (missed school or work days) $20 billion </li></ul><ul><li>Costs remain high from 500,000 hospitalizations and 1,800,000 ED visits </li></ul>
    3. 4. Clinical Management of Asthma <ul><li>Expert Panel Report 3 </li></ul><ul><li>National Asthma Education and Prevention Program </li></ul><ul><li>National Heart, Lung and Blood Institute, 2007 </li></ul>Source:
    4. 5. 2007 EPR-3 <ul><li>Treatment recommendations based on: </li></ul><ul><ul><li>Severity </li></ul></ul><ul><ul><li>Control </li></ul></ul><ul><ul><li>Responsiveness </li></ul></ul><ul><li>Provide patient self-management education at multiple points of care </li></ul><ul><li>Reduce exposure to inhaled indoor allergens to control asthma-multifaceted approach </li></ul>Source:
    5. 6. <ul><li>Inhaled Corticosteroids </li></ul><ul><li>Asthma Action Plan </li></ul><ul><li>Measure Asthma Severity </li></ul>EPR 3’s Six Key Messages <ul><li>Asthma Control </li></ul><ul><li>Follow-up Visits </li></ul><ul><li>Allergen and Irritant Exposure Control </li></ul>Source:
    6. 7. Lung function and physiology <ul><li>Sole purpose is gas exchange, specifically get oxygen to the alveoli and remove carbon dioxide from the alveoli </li></ul><ul><li>Intercostal muscles between ribs and diaphragm contract, rib cage expands, creating negative pressure, drawing air into the lungs </li></ul><ul><li>Muscles relax, air is pushed out of the lungs </li></ul><ul><li>Sound: gentle air flow </li></ul>
    7. 8. What is asthma? <ul><li>Depends on who you ask! </li></ul><ul><li>Very complicated because of heterogenous phenotype, often silent, many different medications used to treat, experts disagree </li></ul><ul><li>A maddening, usually intermittant, sometimes unpredictable, waxing and waning, potentially life-threatening disease of the lungs (Got it?) </li></ul><ul><li>Lung biopsies show that asthma is present chronically even without symptoms </li></ul><ul><li>Can’t be cured, but can be controlled </li></ul>
    8. 9. Asthma pathophysiology <ul><li>Inflammatory reaction: Lining of the bronchioles looks like a burn </li></ul><ul><li>Top lining peels off, plugging up lumen </li></ul><ul><li>Next layer leaks mucus into the lumen </li></ul><ul><li>Muscle layer greatly constricts , shrinking the diameter, like a purse draw string, and becomes twitchy or hyper-reactive to triggers </li></ul><ul><li>Work of simply breathing greatly increases </li></ul><ul><li>Restless, hot, tired, chest symptoms </li></ul>
    9. 10. Asthma histology <ul><li>Folded mucosa, thickened airway wall </li></ul><ul><li>Fatal: goblet cell hyperplasia, eosinophilic inflammation, mucus plug </li></ul><ul><li>Normal </li></ul>
    10. 11. Asthma triggers <ul><li>Viral respiratory infections </li></ul><ul><li>Sinusitis </li></ul><ul><li>Weather changes, cold air </li></ul><ul><li>Aeroallergens (dust, pollen, mold, dander) </li></ul><ul><li>Exercise </li></ul><ul><li>Irritants (smoke, strong odors, cleaners) </li></ul><ul><li>GERD </li></ul><ul><li>Menstrual cycles </li></ul><ul><li>Strong emotions (laughing, crying/upset) </li></ul>
    11. 12. Asthma diagnosis triad <ul><li>History! Intermittant: shortness of breath, cough, chest pain, wheezing – from triggers </li></ul><ul><li>+Associated diseases: allergic rhinitis, atopic dermatitis, food allergy </li></ul><ul><li>+family history, genes for asthma & allergy </li></ul><ul><li>Physical exam </li></ul><ul><li>Spirometry </li></ul>
    12. 13. Diagnosing Asthma on Exam <ul><li>Wheezing sounds during normal breathing </li></ul><ul><li>Hyperexpansion of the thorax </li></ul><ul><li>Increased nasal secretions or nasal polyps </li></ul><ul><li>Atopic dermatitis, eczema, or other allergic skin conditions </li></ul>
    13. 14. Diagnosing Asthma: Spirometry <ul><li>Test lung function when diagnosing asthma </li></ul>
    14. 15. New in EPR-3: Allergy Testing for All Patients With Persistent Asthma <ul><li>All patients with persistent asthma are recommended for evaluation of allergens as possible contributing factors </li></ul><ul><ul><li>Especially perennial allergens </li></ul></ul><ul><ul><li>Can be done through skin or in vitro testing </li></ul></ul><ul><li>Allergies are significant triggers for asthma in ≥80% of children and 50%-60% of adults </li></ul>National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma (EPR-3) 2007 . Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; August 2007. NIH publication no. 08-4051.
    15. 17. Goals of asthma treatment: Reduce impairment <ul><li>Reduce or eliminate daytime and nighttime symptoms (quality sleep through the night!) </li></ul><ul><li>Reduce or eliminate limitations with any activity (full exercise!) </li></ul><ul><li>Reduce or eliminate effects on school or work </li></ul><ul><li>Maintain (near) normal lung function </li></ul><ul><li>Minimize rescue medication use </li></ul><ul><li>Meet or exceed patients’ or families’ expectations of asthma care </li></ul>
    16. 18. Goals of asthma treatment: Reduce risk <ul><li>Prevent recurrent exacerbations of asthma </li></ul><ul><li>Reduce or eliminate ED visits & hospitalizations </li></ul><ul><li>Prevent loss of lung function on spirometry </li></ul><ul><li>Minimize adverse effects from medications </li></ul>
    17. 19. New in EPR-3: Differentiating Severity, Control, and Responsiveness <ul><li>Severity </li></ul><ul><ul><li>The intrinsic intensity of the disease process </li></ul></ul><ul><ul><li>Measured before receiving long-term control therapy </li></ul></ul><ul><li>Control </li></ul><ul><ul><li>The degree to which asthma’s manifestations are minimized and the goals of therapy are met </li></ul></ul><ul><ul><li>Guide decisions to maintain or adjust therapy </li></ul></ul><ul><li>Responsiveness </li></ul><ul><ul><li>The ease with which asthma control is achieved by therapy </li></ul></ul><ul><li>Both severity and control have 2 domains: </li></ul><ul><ul><li>Impairment: immediate manifestations of the disease </li></ul></ul><ul><ul><li>Risk: potential for exacerbations or decreased lung function </li></ul></ul>National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma (EPR-3) 2007 . Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; August 2007. NIH publication no. 08-4051.
    18. 20. Severity: Impairment and Risk Domains
    19. 21. Defining Disease Control in Asthma Is Difficult FEV 1 =forced expiratory volume at 1 second. PEF=peak expiratory flow. <ul><li>Oncology </li></ul><ul><ul><li>Disease-free survival </li></ul></ul><ul><ul><li>Tumor recurrence or growth </li></ul></ul><ul><li>Diabetes mellitus </li></ul><ul><ul><li>Serum glucose </li></ul></ul><ul><ul><li>Hemoglobin A 1C </li></ul></ul><ul><li>Rheumatoid arthritis </li></ul><ul><ul><li>Composite disease scores </li></ul></ul><ul><ul><li>X-ray progression </li></ul></ul><ul><li>Asthma </li></ul><ul><ul><li>Symptoms? </li></ul></ul><ul><ul><li>SABA use? </li></ul></ul><ul><ul><li>FEV 1 /PEF? </li></ul></ul><ul><ul><li>Quality of life? </li></ul></ul><ul><ul><li>Healthcare </li></ul></ul><ul><ul><li>utilization? </li></ul></ul><ul><ul><li>Exacerbations? </li></ul></ul><ul><ul><li>Exercise tolerance? </li></ul></ul><ul><ul><li>Exhaled nitric oxide? </li></ul></ul><ul><ul><li>Sputum eosinophils? </li></ul></ul>
    20. 23. Kao’s Asthma step therapy <ul><ul><ul><li>Empathy, compassion, hope </li></ul></ul></ul><ul><ul><ul><li>Education </li></ul></ul></ul><ul><ul><ul><li>Avoidance of triggers </li></ul></ul></ul><ul><ul><ul><li>Medications </li></ul></ul></ul><ul><ul><ul><li>Allergy Immunotherapy (shots) </li></ul></ul></ul><ul><ul><ul><li>Routine followup & spirometry </li></ul></ul></ul><ul><ul><ul><li>Asthma action plan and practice </li></ul></ul></ul>
    21. 24. Medications to Treat Asthma <ul><li>Medications come in several forms. </li></ul><ul><li>Two major categories of medications are: </li></ul><ul><ul><li>Long-term control </li></ul></ul><ul><ul><li>Quick relief </li></ul></ul>
    22. 25. Asthma rescue medications <ul><li>1. Bronchodilators relax smooth muscle and provide relief from asthma symptoms within 5-10 minutes </li></ul><ul><li>May be used preventatively before exercise </li></ul><ul><li>2. Systemic corticosteroids (oral, IV, IM) reduce inflammation and should be used for asthma exacerbations not responding to inhaler controller medications + bronchodilators above </li></ul><ul><li>Usually given as 3-day to 10-day burst </li></ul>
    23. 26. Reliever medication names <ul><li>Albuterol inhalers are (Proair HFA, Proventil HFA, Ventolin HFA) and nebs </li></ul><ul><li>Pirbuterol inhaler (Maxair AH) </li></ul><ul><li>Levalbuterol (Xopenex HFA and nebs) </li></ul><ul><li>* Confusion…there is NO generic albuterol mdi, only name brand products </li></ul>
    24. 27. Asthma controller medications <ul><li>Corticosteroids (Alvesco, Asmanex, Azmacort, Flovent, Pulmicort, Qvar) #1 </li></ul><ul><li>Leukotriene antagonists (Singulair, Zyflo, Accolate) #2 </li></ul><ul><li>Combination corticosteroid/Long-acting bronchodilating agents (Advair, Symbicort, Dulera) #1 </li></ul><ul><li>Theophylline #4 </li></ul><ul><li>Xolair #3 </li></ul>
    25. 28. Long-acting bronchodilating Agents (LABA) <ul><li>Formoterol (Foradil dpi) </li></ul><ul><li>Formoterol nebs (Brovanna, Perforomist) </li></ul><ul><li>Salmeterol (Serevent dpi and HFA) </li></ul><ul><li>Not rescue meds! Don’t use without an ICS (recent black box warning)! </li></ul><ul><li>Better thought of as assistants to controllers </li></ul>
    26. 31. Allergen Immunotherapy <ul><li>Normal people without allergies (70% population) have a high immunologic tolerance to allergens = no reaction </li></ul><ul><li>People with allergies have a lower tolerance. They don’t tolerate exposures. They react with allergy symptoms </li></ul><ul><li>Immunotherapy raises their tolerance levels up to normal, decreasing symptoms and complications and so decreasing med use and sick doctor visits </li></ul><ul><li>Long-term safe, most effective, but uncomfortable and time consuming. Used since 1911 in millions of patients </li></ul><ul><li>Cost-effective proven in multiple studies + meta-analysis </li></ul>
    27. 32. Asthma Control Test <ul><li>In the past 4 weeks, how time did your asthma keep you from getting as much done at school, at work, or at home? </li></ul><ul><li>During the past 4 weeks, how often have you had shortness of breath? </li></ul><ul><li>During the past 4 weeks, how often did your asthma symptoms wake you up at night or earlier than usual in the morning? </li></ul><ul><li>During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication? </li></ul><ul><li>How would you rate your asthma control in the past 4 weeks? </li></ul>
    28. 33. Why recommend referral to an asthma specialist for co-management? <ul><li>To establish the diagnosis of asthma </li></ul><ul><li>For routine spirometry if not available </li></ul><ul><li>For consideration of immunotherapy </li></ul><ul><li>For consideration of omalizumab (Xolair) </li></ul><ul><li>Patient has had a severe exacerbation </li></ul><ul><li>To educate the patient or family </li></ul><ul><li>To improve compliance and outcomes </li></ul><ul><li>To optimize medications and gain better control </li></ul><ul><li>To distinguish the triggers and minimize their effects </li></ul>
    29. 34. Asthma Summary <ul><li>Understand that asthma is a chronic inflammatory disease of the lower airways </li></ul><ul><li>Asthma is possible the most frustrating disease to have and manage, because it is so variable in symptoms and treatments </li></ul><ul><li>Have a goal and treatment plan </li></ul><ul><li>Work actively to minimize bronchial inflammation with daily controller use for the best short-term & long-term outcomes </li></ul>