Asthma Talk For Obgyn

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  • SYMPTOMS/OBSTRUCTION/INFLAMMATION/HYPERRESPONSIVENESS
  • Current asthma tx with anti-inflammatory medications does not appear to prevent disease progression
  • Lung volumes, DLCO, ECHO
  • Mch not done if FEV1 < 65% predicted
  • No hgb A1C
  • Other biomarkers tend to reflect method of tx employed (LTRA, ICS…)
  • Joint panel of ACAAI and Am Col of Obs and Gyn
  • Asthma Talk For Obgyn

    1. 1. Asthma: Current Concepts in Diagnosis and Management Christie F. Michael, MD Assistant Professor University of Tennessee, Memphis
    2. 2. Goals of Talk <ul><li>Scope of asthma </li></ul><ul><li>Definition/diagnosis </li></ul><ul><li>NHLBI guidelines 2007 </li></ul><ul><li>Asthma in pregnancy </li></ul><ul><li>Omalizumab </li></ul>
    3. 3. Asthma in Adults <ul><li>14.7 million in US </li></ul><ul><li>>10million office visits/yr </li></ul><ul><li>~1.9million ED visits/yr </li></ul><ul><li>466,000 hospitalizations/yr </li></ul>
    4. 4. Asthma Mortality <ul><li>Asthma deaths: >5000 each year (1998,USA) </li></ul><ul><li>Asthma death in children </li></ul><ul><ul><li>36% severe persistent </li></ul></ul><ul><ul><li>31% moderate persistent </li></ul></ul><ul><ul><li>33% mild persistent </li></ul></ul>
    5. 5. The Good News <ul><li>Mortality on decline despite increasing incidence </li></ul><ul><li>Most asthmatics can lead normal, active life with proper treatment </li></ul>
    6. 6. Asthma Definition <ul><li>Obstructive lung disease with key features including partial reversibility, airway hyper-responsiveness and airway modeling </li></ul><ul><li>Davies, et al. Airway remodeling in asthma: new insights. JACI 2003; 111:215-25 </li></ul>
    7. 7. Asthma: Expanding Definition <ul><li>“ A chronic inflammatory disorder of the airways in which many cells and cellular elements play a role…” </li></ul><ul><li>1.“Reversibility incomplete in some patients..” </li></ul><ul><li>2. Anti-inflammatory tx fails to prevent dz progression. </li></ul>
    8. 8. Airway Remodeling <ul><li>Sub-basement fibrosis </li></ul><ul><li>Mucus hypersecretion </li></ul><ul><li>Epithelial injury </li></ul><ul><li>Smooth muscle hypertrophy </li></ul><ul><li>Angiogenesis </li></ul>
    9. 10. Not All That Wheezes Is Asthma… <ul><li>-Foreign body </li></ul><ul><li>- Upper airway diseases </li></ul><ul><li>- Enlarged lymph nodes or tumor </li></ul><ul><li>- Vocal cord dysfunction </li></ul><ul><li>- Aspiration/GERD </li></ul><ul><li>- COPD </li></ul><ul><li>- CHF </li></ul><ul><li>- PE </li></ul><ul><li>- Drug reaction/side effect </li></ul>
    10. 11. Asthma Does Not Always Wheeze… <ul><li>Chronic or nocturnal cough with awakenings </li></ul><ul><li>Exercise induced symptoms </li></ul><ul><li>Chest tightness </li></ul><ul><li>Viral induced symptoms </li></ul>
    11. 12. Asthma Diagnosis <ul><li>Lower airway obstruction </li></ul><ul><li>Variation in the magnitude of obstruction </li></ul><ul><li>Recurrence of obstruction on more than one occasion </li></ul><ul><li>PFT’s/ peak flow variability </li></ul><ul><li>Exclusion of alternative diagnoses </li></ul>
    12. 13. Diagnosis of Asthma <ul><li>PFTs - FEV1 <80% </li></ul><ul><li>- Fev1/FVC </li></ul><ul><li>Ratio <65% </li></ul><ul><li>- >12%(200ml) </li></ul><ul><li>Reversibility in </li></ul><ul><li>FEV1 after B2 </li></ul><ul><li>Agonist </li></ul>
    13. 14. Diagnosis of Asthma <ul><li>Methacholine challenge: </li></ul><ul><li>Peak expiratory flow rate (PEFR): </li></ul><ul><li>Ht (cm) X 5.25-425 </li></ul>
    14. 16. Gene by Environment <ul><li>RSV in pediatrics </li></ul><ul><li>Smoking/ smoke exposure </li></ul><ul><li>Atopy </li></ul><ul><li>Many others… </li></ul>
    15. 17. Link Between Asthma/Atopy: “One Airway, One Disease” <ul><li>~80% asthmatics with allergic rhinitis </li></ul><ul><li>40% AR pts with asthma </li></ul><ul><li>Of asymptomatic AR pts- up to 40% with AHR </li></ul><ul><li>Nasal allergen challenge increases AHR </li></ul><ul><li>tx AR lowers asthma sx’s and related costs </li></ul>
    16. 18. Guidelines for Asthma Diagnosis and Management <ul><li>ASSESSMENT and MONITORING </li></ul><ul><li>CONTRIBUTING FACTORS </li></ul><ul><li>PATIENT EDUCATION </li></ul><ul><li>PHARMACOTHERAPY </li></ul>
    17. 19. Asthma Severity Classification <ul><li>Intrinsic intensity of dz process </li></ul><ul><li>Used as the basis for selection of therapy </li></ul><ul><li>Incorporates subjective and objective parameters </li></ul><ul><li>Must apply with clinical judgement </li></ul>
    18. 20. Impairment AND Risk <ul><li>Domains of both assessment and control </li></ul><ul><li>Current symptoms </li></ul><ul><li>Future risk </li></ul><ul><li>Objective and subjective measures </li></ul>
    19. 21. Impairment <ul><li>Quality of life </li></ul><ul><li>Missed school or work </li></ul><ul><li>Surveys (ACT, ACQ..) </li></ul><ul><li>Lung functions </li></ul>
    20. 22. Risk <ul><li>Hospital stays/ICU </li></ul><ul><li>ED visits </li></ul><ul><li>Oral steroid bursts </li></ul><ul><li>Lung function (FEV1, FEV1/FVC) </li></ul><ul><li>Other biomarkers not proven (FeNO, serum IgE, bld/sputum eos) </li></ul>
    21. 26. Assess Control <ul><li>Once long-term control therapy initiated </li></ul><ul><li>Responsiveness- the ease with which control achieved </li></ul><ul><li>Continue to assess impairment and risk </li></ul>
    22. 30. Guidelines for Asthma Diagnosis and Management <ul><li>ASSESSMENT and MONITORING </li></ul><ul><li>CONTRIBUTING FACTORS </li></ul><ul><li>PATIENT EDUCATION </li></ul><ul><li>PHARMACOTHERAPY </li></ul>
    23. 31. Precipitating Factors <ul><li>Viral URIs </li></ul><ul><li>Inhalant allergens- grasses, trees, molds, pets, dust/dust mite, feather, cockroach </li></ul><ul><li>Food allergens- soy, wheat, milk, nuts, eggs </li></ul><ul><li>Irritant triggers- strong odors, smoke, cold air </li></ul><ul><li>Weather changes </li></ul>
    24. 32. Comorbid Conditions <ul><li>Sinusitis </li></ul><ul><li>Rhinitis </li></ul><ul><li>Gastroesophageal reflux </li></ul><ul><li>ABPA </li></ul><ul><li>Vocal cord dysfunction </li></ul><ul><li>OSA </li></ul>
    25. 33. Recognizing High-risk Asthmatics <ul><li>Beta2-agonist over-use </li></ul><ul><li>Disregard of symptoms </li></ul><ul><li>Psychosocial factors </li></ul><ul><li>Previous respiratory arrest or ICU admit </li></ul>
    26. 34. Asthma in Pregnancy <ul><li>1/3 patients better </li></ul><ul><li>1/3 stay the same </li></ul><ul><li>1/3 worsen </li></ul>
    27. 35. Acute Treatment of Asthma <ul><li> 2 Agonists- PO, IV (albuterol, terbutaline) </li></ul><ul><li>Anticholinergics- Ipatropium (Atrovent) </li></ul><ul><li>Steroids- PO, IV (solumedrol, prednisone) </li></ul><ul><li>Methylxanthines- PO, IV (Aminophylline, Theophylline) </li></ul><ul><li>Heliox (60/40) </li></ul><ul><li>Magnesium Sulfate </li></ul><ul><li>Intubation </li></ul>
    28. 37. Treatment of Asthma -Controller Therapy <ul><li>Inhaled Corticosteroids- gold standard </li></ul><ul><li>Long-Acting B2 Agonists </li></ul><ul><li>Leukotriene Modifiers </li></ul><ul><li>Mast Cell Stabilizers </li></ul><ul><li>Theophylline </li></ul><ul><li>Omalizumab (Xolair) </li></ul><ul><li>Immunotherapy </li></ul>
    29. 40. Inhaled corticosteroids <ul><li>Preferred treatment for all classes of persistent asthma </li></ul><ul><li>Maximize benefit/ minimize risks </li></ul><ul><li>combination therapies to minimize doses (leukotriene modifiers, long acting beta2- agonists…) </li></ul>
    30. 41. Medications in Pregnancy <ul><li>NASAL </li></ul><ul><li>Pseudoephedrine (avoid in 1st trimester) </li></ul><ul><li>Oxymetazoline nasal spray (3-5 days) </li></ul><ul><li>Nasal steroids </li></ul><ul><li>budesonide* </li></ul><ul><li>beclomethasone </li></ul><ul><li>Nasal saline irrigation </li></ul><ul><li>Antihistamines </li></ul><ul><li>chlorpheniramine </li></ul><ul><li>cetirizine (after 1st trimester) </li></ul><ul><li>loratadine (after 1st trimester) </li></ul>
    31. 42. Medications in Pregnancy <ul><li>ASTHMA </li></ul><ul><li>theophylline </li></ul><ul><li>inhaled beta-agonists </li></ul><ul><li>cromolyn </li></ul><ul><li>prednisone (when indicated) </li></ul><ul><li>inhaled steroids </li></ul><ul><li>budesonide* </li></ul><ul><li>beclomethasone </li></ul>
    32. 43. Anti- IgE Therapy: Omalizumab <ul><li>XOLAIR </li></ul><ul><li>multicenter, randomized, DBPCT, phase III </li></ul><ul><li>Anti-IgE reduces asthma exacerbations, ED visits and hospitalization rates </li></ul><ul><li>Adjunctive tx in poorly controlled asthmatics and pt in need of IT but unable to tolerate due to severity of asthma </li></ul>
    33. 45. Anti-IgE: Qualifying for tx <ul><li>Documented allergy to perennial allergen </li></ul><ul><li>Serum total IgE 30-700 </li></ul><ul><li>Asthma </li></ul>
    34. 46. Referral Guidelines <ul><li>Difficulty achieving/mx control </li></ul><ul><li>Step 4 or higher </li></ul><ul><li>Immunotherapy </li></ul><ul><li>Omalizumab </li></ul><ul><li>ICU stay </li></ul>

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