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#1010 Asthma Update

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  1. #1010 Asthma Update November 30 to December 3 Philip E. Korenblat, MD Professor of Clinical Medicine Washington University School of Medicine St. Louis, Missouri Elizabeth Allen, MD Associate Professor of Clinical Pediatrics Section of Pulmonary Medicine Children’s Hospital & The Ohio State University Medical Center

  2. Philip E. Korenblat, MD Professor of Clinical Medicine Washington University School of Medicine St. Louis, Missouri 1

  3. Profile Carla • Young female History • Many hospitalizations and ER Visits • Asthma • Complication - paradoxical closure of vocal cords • Previously treated with large doses of prednesone and other steroids Diagnosis: Asthma with vocal cord dysfunction 2

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  5. Asthma In America • Asthma out of control for most Americans • Quality of life less than patients should attain • Docs say they are following NHLBI guidelines • Level of care does not meet current standards 4

  6. National Asthma EducationAnd Prevention Program • Pathogenesis and definition: Chronic inflammatory disorder of the airways in which many cells and cellular elements play a role, in particular mast cells, eosinophils, T lymphocytes, neutrophils, and epithelial cells 4 A

  7. National Asthma EducationAnd Prevention Program • Definition (Con’t): In susceptible individuals this inflammation causes recurrent episodes of wheezing, breathlessness, shortness of breath, and cough, particularly at night and in the early morning 5

  8. Differential Diagnosis: AirwayObstruction, Excluding Asthma • Localized obstruction - Endobronchial tumor - Endobronchial foreign body - External obstruction, including paradoxical closure of the vocal cords - Congenital anomaly 6

  9. Differential Diagnosis: AirwayObstruction, Excluding Asthma • Generalized obstruction - COPD - Cystic fibrosis - Bronchiectasis - Congestive heart failure - Churg-Strauss syndrome (Angiitis and allergic granulomatosis) 7

  10. Differential Diagnosis: AirwayObstruction, Excluding Asthma • Generalized obstruction (cont’d) - Carcinoid - Alpha-1 antitrypsin deficiency - Immotile cilia syndrome - Pulmonary embolus 8

  11. Immunologic: - IgE mediated hypersensitivity - Allergic alveolitis Infectious Factors: - Viral-induced infection - Post lower respiratory viral infection (followed by persistent asthma) - Bronchitis - Sinusitis Causative And ContributoryFactors In Asthma 9

  12. Drugs And Chemicals • Aspirin and NSAIA • Angiotensen converting enzyme inhibitors • Beta-Adrenergic antagonist agents • Metabisulfites • Additives • Note: Leukotriene modifiers decrease ASA / NSAIA respiratory reaction 10

  13. Causative And ContributoryFactors In Asthma • Exercise-induced • Occupational • Gastroesophageal reflux • Psychosocial dysfunction • Irritant sensitivity • Pollution • Tobacco use or passive exposure 11

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  15. CONTROLLER Daily medications: Either Inhaled corticosteroid (200-500mcg), Cromoglycate, nedocromil or sustained release theophylline. Anti-leukotrienes may be considered, but their position in therapy has not been fully established RELIEVERS Short acting, inhaled b2 agonist for symptoms (but less than 3-4 times per day *(Preferred treatments) Treatment - Step 2:Mild Persistent 13

  16. CONTROLLER Daily medications: Inhaled corticosteroid (800-2000mcg); AND Long-acting bronchodilator: long acting inhaled b2 agonist or sustained-release theophylline Anti-leukotrienes - for aspirin sensitive patients, and preventing exercise induced bronchospasm RELIEVERS Short acting, inhaled b2 agonist for symptoms (but less than 3-4 times per day *(Preferred treatments) Treatment - Step 3:Moderate Persistent 14

  17. CONTROLLER Daily medications: Inhaled corticosteroid (800-2000mcg or more); AND Long-acting bronchodilator: long acting inhaled B2 agonist or sustained-release theophylline Corticosteroid tablets or syrup long term RELIEVERS Short acting bronchodilater; inhaled b2 agonist as needed for symptoms *(Preferred treatments) Treatment - Step 4:Severe Persistent 15

  18. Summary Carla • Multiple medications, high doses of prednesone • Asthma with vocal cord dysfunction Evaluation • Pulmonary functions • Visualizing vocal cords 16

  19. Summary Carla Treatment • Bronchodialators • Inhaled steroids • Care directed at halting symptoms Prognosis: Good, a normal life 17

  20. Elizabeth Allen, MDAssociate Professor of Clinical PediatricsSection of Pulmonary MedicineChildren’s Hospital & The Ohio State University Medical Center 19

  21. Profile Ryan, Colleen and Molly • Ryan - 13 • Colleen - 9 • Molly - 7 Symptoms • Varying degrees of asthma • Cough, wheeze, shortness of breath 20

  22. Profile Ryan, Colleen and Molly Treatment - Albuterol - Prednesone • Still having problems Diagnosis: Asthma incompletely controlled 20 A

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  24. Pediatric Asthma:Adult Concepts - Kid Style • Impact of asthma on children • Diagnosis of asthma in kids • Differential diagnosis - the “biggies” • Management plans - Acute attack plan - Prevention plan • Reasons for therapy failure 22

  25. Pediatric Asthma: An Ongoing Source Of Frustration • 4 - 8% of children affected • Significant level of morbidity - #1 reason for medical hospitalization - Patients average 5 missed school days/year - Nearly 1/3 have activity limitations • Newly described airway remodeling may begin in childhood 23

  26. Is It Asthma? The Key’s In The History • Recurrent typical symptoms - Wheezing and / or persistent cough - “Bronchitis” - again and again! - “Winding” with exercise • Typical triggers • Response to asthma medicines - Inhaled albuterol - Systemic steroids 24

  27. When To Worry It’s Not Asthma • “Wheezed since birth” • Poor growth • Clubbing • Atypical CXR findings - Lobar infiltrates - Asymmetric lung size - Cardiomegally • Poor response to asthma therapy 25

  28. Pediatric Asthma Mimics • Most common - Infant viral-induced wheezing - Gastroesophageal reflux - Aspiration during swallowing (infants) - Vocal cord dysfunction (teens) • Less common - Chronic infection (Cystic fibrosis) - Large airway obstruction (congenital, FB) 26

  29. Acute attack plan (What to do when the airways get evil) Prevention plan (How to keep them from getting that way) Outpatient AsthmaManagement 27

  30. The Acute Attack Plan: Recognizing A Flare • “Conditions are ripe” • Importance of cough • Wheeze and trachypnea • Assessment of respiratory effort • Use of peak flow meter 28

  31. Acute Attack Plan: Treatment • Albuterol - When to start, how often to give - MDI vs nebulizer • Oral steroids - First dose on hand - First dose at caregiver discretion? • When to seek help 29

  32. Prevention Plan: When Is One Needed? • Severity estimation in pediatric asthma focuses on symptoms • Need for prophylactic therapy involves assessment of severity x frequency • Examples - Nagging cough / wheeze x daily - Steroid requiring flare x bimonthly - Intubated in ICU x once 30

  33. Key Elements Of Prevention Plan • Deciding to start prophylactic drugs - History taking as interrogation - Utility of PFTs • Choosing a therapeutic approach - The asthma “smorgasboard” • Convincing the family - Asthma won’t disappear (soon) on its own - Preventive meds take time to work 31

  34. The Asthma Prevention Smorgasboard • Main course: Anti-inflammatories - Cromolyn sulfate - Inhaled corticosteroids - Leukotriene inhibitors • Side dishes: - Environmental controls - Scheduled / long-acting beta agonists 32

  35. Cromolyn Sulfate • Delightful safety track record • Moderate efficacy in mild / young asthma - Different asthma? - Different dosage? (Nebulizer = 20 mg / dose, MDI = 0.8 mg / puff) • Should see benefits within 4 weeks • Compliance tough 33

  36. Inhaled Corticosteroids (ICS) • BEST asthma anti-inflammatory • Dose related, potential side effects - Height growth concerns • Appropriate use includes: - Monitoring of growth - Titration to lowest effective dose 34

  37. Leukotriene Inhibitors • Relative efficacy unclear (ranks between cromolyn and ICS) • (+) Additive effect to ICS • Major compliance advantages • Long term experience limited 35

  38. Prophylactic “Side Dishes” • Environmental controls - Eliminate passive smoking - Allergen avoidance if appropriate • Long acting beta-agonist use - Nagging nocturnal cough - Exercise intolerance - Patient already on ICS 36

  39. Causes Of Therapy Failure • Gastroesophageal reflux - May occur without GI symptoms - Diagnosis, therapy often challenging • Chronic sinusitus - Prolonged therapy required to control • Non-compliance • Poor inhalation technique 37

  40. Delivering Inhaled Medications To Kids • Options: - Nebulizers - Metered dose inhalers with spacers - Self-actuated inhalers • Caveats: - Don’t use an MDI alone - Know your gizmo(s) - Teach use in office whenever possible 38

  41. Pediatric Asthma Update • Asthma causes excessive morbidity • Every patient / family needs a clear “Acute attack plan” • ICS therapy should be considered early - Monitor height, and titrate dose • Newer drugs augment ICS efficacy • Nothing works if it doesn’t get in! 39

  42. Summary Ryan, Colleen and Molly • All three have improved significantly Treatment - Inhaled corticosteroids - Flovent, serevent - Singulair - Attention to inhalation techniques Prognosis: May grow out of it, but still keep under control 40

  43. NEXT WEEK #1011 Insulin Sensitizers in Managing Type 2 Diabetes Mellitus December 7 to 10 Samuel Cataland, MD Ralph W. Kurtz Chair of Endocrinology Professor of Internal Medicine Division of Endocrinology, Diabetes & Metabolism The Ohio State University Medical Center Adi Mehta, MD, SACE Department of Endocrinology Cleveland Clinic Foundation