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EXTENSION FOR COMMUNITY HEALTHCARE OUTCOMES

EXTENSION FOR COMMUNITY HEALTHCARE OUTCOMES. Asthma. Michelle Harkins, MD University of New Mexico Pulmonary and Critical Care Project Echo. WORKING TO BRING SPECIALTY HEALTHCARE TO ALL PEOPLE.

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EXTENSION FOR COMMUNITY HEALTHCARE OUTCOMES

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  1. EXTENSION FOR COMMUNITY HEALTHCARE OUTCOMES Asthma Michelle Harkins, MD University of New Mexico Pulmonary and Critical Care Project Echo WORKING TO BRING SPECIALTY HEALTHCARE TO ALL PEOPLE

  2. The mission of Project ECHO is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes. Supported by Agency for Health Research and Quality HIT grant 1 UC1 HS015135-04, and MRISP, R24HS16510-02 and the New Mexico Legislature, Robert Wood Johnson Foundation.

  3. Asthma and School Absences • Asthma is one of the leading causes of school absenteeism. • In 2003, an estimated 12.8 million school days were missed due to asthma among the more than 4 million children who reported at least one asthma attack in the preceding year. • 39% reported receiving an asthma management plan Akinbami LJ. The State of Childhood Asthma (pdf 365K), United States, 1980-2005. Advance data from Vital and Health Statistics: no 381, Revised December 29, 2006. Hyattsville, MD: National Center for Health Statistics, 2006

  4. Asthma in New Mexico • 204,292 adults have had an asthma dx • 68.8K under age 17 • # of days missed by NM School children for asthma? • Estimated cost of treating asthma in those under 18 is $3.2 billion per year (Weiss KB, Sullivan SD, Lytle SD) • 30-40 deaths/year from asthma • Mortality decreased from 3.1/100,000 in 1993 to 1.5/100,000 in 2004 • >65 years at greatest risk • Dept. of Health Statistics, 2007, BRFSS

  5. 14.9* 23.3 33.1 16.8* 46.7 46.7 41.5 41.5 13.6* 13.6* 7.6* 25.5 14.2 13.2 49.2 49.2 28.7* 28.7* 26.8 23.4 42.9* 42.9* 27.7 27.7 9.0* 10.1* 15.5* 7.9* 0.0* 0.0* 0.0* 0.0* 56.5 38.2 9.5 10.3 22.5 22.5 35.1 35.1 39.2 39.2 11.1 13.7 12.0 15.3 41.8 41.8 16.5 14.9 19.0* 17.8* 135.6 135.6 17.7* 14.9 14.9 19.4 62.2 62.2 8.0* 8.0* 4.5* 4.5* 9.1* 6.6* 21.8 21.8 18.2 13.3 22.2 22.2 63.3 64.7 103.2 103.2 20.6* 22.7* 17.7* 17.7* 14.8* 6.2* 13.9* 5.8* 50.9 42.9 104.2 104.2 144.0 144.0 0.0 – 10.1 14.8* 14.8* 9.2* 13.7* 37.0 37.0 10.2 – 14.2 15.1 35.4 63.9 63.9 14.3 – 23.3 69.1 69.1 6.3* 10.5* 11.3* 11.6 77.9 23.4 – 77.9 60.4 60.4 118.2 76.3 76.3 10.9 11.4 80.1 80.1 23.7 46.5 11.5 11.7 37.9 37.9 95.3 95.3 75.4 75.4 24.5 26.1 15.6* 26.2* 24.0* 24.0* Asthma Hospitalization Rates (Age<15), New Mexico 2006-2008 STATE RATE: 20.1 Rates per 10,000 population. * Rates based of fewer than 20 cases should be interpreted with caution. SOURCE: NMHPC.

  6. What is Asthma? • A chronic inflammatory disease of the airways • The majority of asthma diagnosed in childhood • Common Symptoms: • Cough-may be only at night • Wheezing • Chest Tightness • Shortness of breath • Mucus (phlegm production)

  7. Features of Asthma • Intermittent wheezing, chest tightness, cough—times when there are no symptoms • Bronchial hyperresponsiveness-”twitchy” airways • Airway inflammation • Airway obstruction - initially reversible • gradual decline in lung function • Peak Flow variability

  8. All that wheezes is not asthma... • Bronchiolitis: RSV • Aspiration (micro versus foreign body) • vocal cord dysfunction, laryngeal dysfunction • Competitive athletes • 35% of “severe asthma” referred to specialty clinic • S. Wenzel, Pittsburgh • CF • Tracheal malacia

  9. Vocal Cord Dysfunction • VCD can mimic asthma, but it is a distinct disorder • VCD may coexist with asthma • Asthma medications typically do little, if anything, to relieve VCD symptoms • Variable flattening of the inspiratory flow volume loop on spirometry is strongly suggestive of VCD • Diagnosis of VCD is from indirect or direct vocal cord visualization during an episode, during which abnormal adduction can be documented • VCD should be considered in patients with difficult-to-treat, atypical asthma and in elite athletes who have exercise related breathlessness unresponsive to asthma medication Guidelines for the Diagnosis and Management of Asthma NHLBI NAEPP EPR 3November, 2007

  10. Spirometry and Flow Volume Loops Reversible airflow obstruction VCD possible Normal FEV1 4.36 (100%) FVC 5.04 (108%) FEV1 / FVC .86 FEF25-75 4.77 (108%) FEF50 / FIF50 0.84 2.27  2.71 (16%) 3.20  3.58 (11%) .71  .76 (6%) 1.63  2.13 (23%) 0.38  0.30 3.65 (99%) 3.71 (96%) .98 6.15 (155%) 4.33

  11. Pathophysiology of Asthma

  12. Epithelial Damage in Asthma Normal Asthmatic Jeffery P. In: Asthma, Academic Press 1998.

  13. Asthma Pathophysiology Smooth Muscle Dysfunction Airway Inflammation • Inflammatory cell infiltration/activation • Mucosal edema • Cellular proliferation • Epithelial damage • Basement membrane thickening • Bronchoconstriction • Bronchial hyperreactivity • Hypertrophy/hyperplasia • Inflammatory mediator release Symptoms/Exacerbations

  14. Intrinsic factors Genetics of disease Duration of asthma Severity of childhood asthma Gender Response to therapy Extrinsic factors Viral infections Allergen exposure Airway irritants Exercise Compliance Season Time of day Occupational—10-15% of adult asthma Western Lifestyle--obesity What Parameters Improve or Worsen Disease Control?

  15. Conditions Worsening Asthma • Sinusitis/Allergic Rhinitis--post nasal drip, inflammation • AR increases asthma risk 3 fold • It’s all one airway • Illicit drug use--cocaine Chest 2000;117:1324 • Non-compliance, environmental factors

  16. GERD and Asthma • Prevalence in asthmatics 15-40%, up to 80% abnormal GER (many asymptomatic) Chest 1997;111:1389-1402 • Pt with nocturnal asthma symptoms and GERD had improved PEF with high dose PPI BID. Am J Respir Crit Care Med 2006;173:1091-97. • Asymptomatic GERD likely not a cause of poorly controlled asthma. NEJM 2009; 360:1487-99 • Treatment in children with asthma not responding to standard tx and GERD is warranted though data are limited. J Investig All Clin Immunol 2009;19:1-5

  17. Bronchospasm caused by activity Distinct from environmental induced asthma Does not cause swelling, inflammation or mucous production Can be avoided by giving medication prior to activity and by warming up and cooling down Exercise Induced Asthma

  18. Symptoms include Coughing Wheezing Chest tightness Symptoms may begin during Activity and peak in severity 10-20 minutes after stopping Can spontaneously resolve 20-30 minutes after its onset Exercise Induced Asthma

  19. Use bronchodilator 10-15 minutes before onset of activity Do warm-up/cool down exercises Check ozone/allergy warnings Never encourage a child to “tough it out” Prevention of Exercise InducedAsthma

  20. Irritants Cigarette smoke and wood smoke Scented products such as hair spray, cosmetics, and cleaning products Strong odors from fresh paint or cooking Automobile fumes and air pollution Chemicals such as pesticides and lawn treatments Environmental triggers

  21. Infections in the upper airways, such as colds (a common trigger for both children and adults) Exercise Strong expressions of feelings (crying, laughing, fear) Changes in weather and temperature Environmental triggers

  22. The Four Components of Asthma Management • Measures of assessment and monitoring • Objective tests, physical exam, history • Severity and control of asthma • Education for a partnership in asthma care • Control of environmental factors and comorbid conditions that affect asthma • Pharmacologic therapy

  23. Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 care or higher is required.Consider consultation at step 3. IntermittentAsthma Step 6 Preferred: High-doseICS + LABA + oral corticosteroid AND Consider Omalizumab for patients who have allergies Step up if needed (first, check adherence, environmental control, and comorbid conditions) Step down if possible (and asthma is well controlled at least3 months) Step 5 Preferred: High-dose ICS + LABA AND Consider Omalizumab for patients who have allergies ≥ 12 years old Step 4 Preferred: Medium-dose ICS + LABA Alternative: Medium-dose ICS + either LTRA, Theophylline, or Zileuton Step 3 Preferred: Medium-dose ICS OR Low-doseICS + LABA Alternative: Low-dose ICS + either LTRA, Theophylline, or Zileuton Step 2 Preferred: Low-dose ICS Alternative: Cromolyn,Nedocromil, LTRA, orTheophylline Step 1 Preferred: SABA PRN Assess control Patient Education and Environmental Control at Each Step Steps 2-4: Consider SQ allergen immunotherapy for allergic patients • Quick-Relief Medication for All Patients • SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed. • Use of beta2-agonist >2 days a week for symptom control (not prevention of EIB) indicates inadequate control and the need to step up treatment.

  24. Pharmacotherapy in Asthma • Short acting beta-2 agonists • Albuterol, levalbuterol • Long acting beta-2 agonists • Salmeterol, Formoterol • Inhaled corticosteroids—fluticasone, budesonide, mometasone, ciclesonide, beclomethasone, flunisolide, triamcinolone • Leukotriene modifiers • Combination inhalers • ICS/LABA • Theophylline • Oral steroids for exacerbations

  25. Barnes et.al 1998 Asthma Basic Mechanisms and Clinical Management

  26. Not all Spacers are created equal

  27. One Way Valves

  28. Beta-2 agonists • Acute relief of bronchoconstriction • Rescue inhaler • Inhaled is preferred route • Albuterol prn, not scheduled dosing • Xopenex, Proventil, Proair, Ventolin • Alupent no longer being made • HFA just as effective as CFC inhalers • MDI with spacer--just as effective as nebulizer (4-6 puffs per neb) Chest 1993;106:661- 665 Am Rev Resp Dis 1991;144:347 • Albuterol HFA review: Hendeles et al, NEJM 2007 356: 13

  29. Long-acting beta2 agonistsSalmeterol or Formoterol • Are they safe? FDA update 2/18/10 • Yes, when used correctly. • Not a substitute for anti-inflammatory therapy • Not for monotherapy • Not for quick relief of symptoms • Still the most effective class of drugs to add on to inhaled steroids as the next step • Should step down therapy when asthma is controlled • Data from a large placebo-controlled US study that compared the safety of salmeterol or placebo added to usual asthma therapy showed an increase in asthma‑related deaths in patients receiving salmeterol (13 deaths out of 13,176 patients treated for 28 weeks on salmeterol versus 3 deaths out of 13,179 patients on placebo)

  30. Theophylline • May have a role for nocturnal symptoms but: • no benefit to intensive inhaled -agonists for acute exacerbation • Arch Int Med 1993;153:1784 Pediatrics 1994; 93:205 • side-effect profile significant • many drug interactions, need to monitor levels • not a strong role in outpatient asthma management (worsens GERD)

  31. Inhaled Corticosteroids • Mainstay of treatment for all asthmatics with persistent disease (symptoms more than 2 times/week) • Blocks many of the inflammatory pathways in asthma • Increase or decrease dose in stepwise manner--may take 3 months for full effect • Reduce potential for adverse events • Use a spacer and rinsing mouth • Use lowest possible dose

  32. Effects of Inhaled Corticosteroids E = Epithelium BM = Basement Membrane Pre- and post- 3 month treatment with budesonide(BUD) 600 mcg BID Laitinen. J Allergy Clin Immunol.1992;90:32-42.

  33. Leukotriene ModifiersMontelukast, Zafirlukast, Zileutin • Anti-inflammatory, affecting cysteinyl leukotriene pathway • Effective, allow decrease in ICS dosing • Decrease exercise induced bronchospasm by 30-50% when compared to placebo • Not better than albuterol and warm up • May be beneficial for true ASA allergic asthmatics

  34. KEY EDUCATIONAL MESSAGES: TEACH AND REINFORCE AT EVERY OPPORTUNITY! Teach the Basic Facts About Asthma The role of inflammation What happens to the airways during an asthma attack Asthma Management: Patient Education the Key

  35. Role of Medications: Understanding the Difference Between: Long-term control medications: prevent symptoms, often by reducing inflammation. Must be taken daily. Do not expect them to give quick relief. Quick-relief medications: SABAs relax airway muscles to provide prompt relief of symptoms. Do not expect them to provide long-term asthma control. Using SABA >2 days a week indicates the need for starting or increasing long term control medications. Asthma Management:Patient Education the Key

  36. Teach Patient Skills Taking medications correctly Inhaler technique (demonstrate to the patient and have the patient return the demonstration). Use of devices, as prescribed (e.g., valved holding chamber (VHC) or spacer, nebulizer). Identifying and avoiding environmental exposures that worsen the patient’s asthma; e.g., allergens, irritants, tobacco smoke. Asthma Management:Patient Education the Key

  37. Websites for further info • www.cdc.gov • www.nhlbi.nih.gov/guidelines/asthma • http://echo.unm.edu

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