1 / 59

Asthma

Asthma. The University of Kansas Medical Center Family Care Clinic Danielle Herrmann. Epidemiology and Etiology. Most prevalent chronic disease of childhood Very prevalent in 5-17 year olds Puerto Ricans and non-hispanic blacks have an increased risk

miya
Télécharger la présentation

Asthma

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Asthma The University of Kansas Medical Center Family Care Clinic Danielle Herrmann

  2. Epidemiology and Etiology • Most prevalent chronic disease of childhood • Very prevalent in 5-17 year olds • Puerto Ricans and non-hispanic blacks have an increased risk • 10.1 million workdays and 12.8 school days missed • 1.77 million emergency room visits • Economic burden of $19.7 billion • Inherited component • Environmental factors

  3. Pathophysiology • Inhaled antigens induce a type 2 T-helper CD4 response • Antigens taken up by APC --> activation of the TH2 response • Leading to B cell production of IgE and proinflamatory cytokines and chemokines that recruit and activate eosinophils, neutrophils, and alveolar macrophages • Subsequent exposure to the antigen results in cross linking of cell-bound IgE in mast cells and basophils • This causes the release of histamine, leukotrienes and prostaglandins

  4. Clinical Presentation and Diagnosis- Chronic Asthma • Symptoms- • Dyspnea, cough • Wheezing and chest tightness (episodic, seasonal, or with known triggers) • Symptoms may occur more at night, early in the morning, or with exercise • Many patients with intermittent asthma symptom free and normal pulmonary function between exacerbations • Laboratory tests- • Increased IgE and eisinophils- but not diagnostic • Signs- • End-expiratory wheezing and dry cough

  5. Clinical Presentation and Diagnosis- Acute Asthma • Symptoms- • Dyspnea, cough, shortness of breath, chest tightness • Anxious • Mental status changes • Laboratory tests- • Arterial blood gases • CBC with differential in patients with fever or purulent sputum • Serum electrolytes • Signs- • Tachypnea • Tachycardia • Bradycardia • Wheezing with expiration and inspiration • Hyperinflation, and use of accessory muscles to breathe, cyanosis, and diaphoresis

  6. Factors Affecting Asthma Severity • Allergens • Environmental chemical exposure • Environmental Pollution • Tobacco Smoke exposure • Contaminant rhinitis • GERD • Non-selective B-Blockers should be avoided in asthmatics

  7. Classification Of Asthma Severity in Patients ≥12

  8. Intermittent • Symptoms • ≤2 days/week • Nighttime Awakenings • ≤2x/month • Short-acting beta 2 agonist use for symptom control • ≤2 days/week • Interference with normal activities • None • Lung Function • Normal FEV1 between exacerbations • FEV1> 80% predicted • FEV/FVC normal • Exacerbations requiring oral systemic corticosteroids • ≥2/year

  9. Mild Persistent • Symptoms • >2 days/week but not daily • Nighttime Awakenings • 3-4x/month • Short-acting beta 2 agonist use for symptom control • >2 days/week but not daily, and not more than 1x per day • Interference with normal activities • Minor limitation • Lung Function • FEV1> 80% predicted • FEV/FVC normal • Exacerbations requiring oral systemic corticosteroids • >2/year

  10. Moderate Persistent • Symptoms • Daily • Nighttime Awakenings • >1x/week but not nightly • Short-acting beta 2 agonist use for symptom control • Daily • Interference with normal activities • Some limitation • Lung Function • FEV1> 60% but <80% predicted • FEV/FVC reduced 5% • Exacerbations requiring oral systemic corticosteroids • >2/year

  11. Severe Persistent • Symptoms • Throughout the day • Nighttime Awakenings • Often 7x/week • Short-acting beta 2 agonist use for symptom control • Several times per day • Interference with normal activities • Extremely limited • Lung Function • FEV1> 60% • FEV/FVC reduced 5% • Exacerbations requiring oral systemic corticosteroids • >2/year

  12. Step Wise Approach for managing Asthma in youths >12 years of age and adults • Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment • Step down possible if symptoms controlled for 3 months

  13. Step 1 Used in patients with Intermittent Asthma • Preferred • SABA PRN

  14. Step 2 • Used in patients with Mild Persistent Asthma • Preferred • Low Dose ICS • Alternative • Cromolyn • LTRA • Nedocromill • Theophylline

  15. Step 3 Used in patients with Moderate Persistent Asthma • Preferred • Low-dose ICS+LABA • Medium-dose ICS • Alternative • Low-dose ICS + either LTRA, Theophylline, or Zileuton

  16. Step 4 • Used in patients with Severe Persistent Asthma • Preferred • Medium-dose ICS + LABA • Alternative • Medium-dose ICS + either LTRA, Theophylline, or Zileuton

  17. Step 5 • Used in patients with Severe Persistent Asthma • Preferred • High-dose ICS + LABA • Alternative • Consider Omalizumab for patients who have allergies

  18. Step 6 • Used in patients with Severe Persistent Asthma • Preferred • High-dose ICS + LABA+ oral corticosteroid • Alternative • Consider Omalizumab for patients who have allergies

  19. Special Populations • Pregnancy: • 8% of pregnant women are affected by asthma • Risk to baby • Budesonide is the preferred ICS • Albuterol is the drug of choice

  20. Special Populations Cont… • Aspirin Sensitive • Exercise induced asthma • Patients encouraged to warm up • Gradually decreasing and increasing intensity • Pretreatment with albuterol • Pretreatment with leukotriene

  21. Asthma Exacerbations -Assess Severity -Initial treatment -Good response, Incomplete Response, Poor Response

  22. Nonpharmacologic Therapy • Goals for asthma treatment shared • Patient education • At time of diagnosis and tailored to meet individual patient needs

  23. Pharmacological therapy: B2 Adrenergic Agonists • Relax airway smooth muscle • Increase mucociliary clearance • Stabilize mast cell membranes • Adverse effects: • Tachycardia • Tremor • Hypokalemia

  24. Pharmacological therapy: Short-Acting Inhaled B2 Agonists • Most effective agent for reversing acute airway obstruction • Drug of choice for treating acute severe asthma and chronic asthma • Onset of <5 minutes • Duration 4-6 hours

  25. Pharmacological therapy: Short-Acting Inhaled B2 Agonists -Albuterol HFA 90mcg/puff (Proair HFA, Ventolin,Proventil) - 0-4years: 1-2 puffs 5 minutes before exercise and 2 puffs every 4-6 hours PRN - 5- adult: 2 puffs 5 minutes before exercise and 2 puffs every 4-6 hours PRN • Albuterol nebulizer solution: • 0-4 years: 0.63-2.5mg in 3 mL saline every 4-6 hours • 5-adult: 1.25-5mg in 3mL saline every 4-8 hours as needed

  26. Pharmacological therapy: Short-Acting Inhaled B2 Agonists • Levalbuterol HFA 45mcg/puff (Xopenex) • 0-4 years: N/A • 5- adult: 2 puffs 5 minutes before exercise and 2 puffs every 4-6 hours PRN • Levalbuterol nebulizer solution: • 0-4 years: 0.31-1.25mg in 3 mL saline every 4-6 hours • 5-11years: 0.31-0.63mg every 8 hours as needed • Adult - 0.63-1.25mg every 8 hours

  27. Pharmacological therapy: Long-Acting Inhaled B2-Agonists • Provide up to 12 hours of bronchodialation • Approved for chronic prevention • Onset of 30 minutes • Add on therapy only • Many of these products also available in combination products

  28. Pharmacological therapy: Long-Acting Inhaled B2-Agonists • Salmeterol DPI 50mcg/blister (Serevent): • Not indicated in children under 4 • 5-adult- Contents of one blister every 12 hours • Formeterol PI 12 mcg/capsule: • Not indicated in children under 4 • 5-adult- Contents of one blister every 12 hours

  29. Combined medication • Fluticasone/Salmeterol DPI (Advair diskus and HFA) 100mcg/50mcg, 250mcg/50mcg, 500mcg/50mcg HFA MDI 45mcg/21mcg, 115mcg/21mcg, 230mcg/21mcg • 1 inhalation twice a day • Budesonide/Formoterol HFA MDI (Symbicort) 80mcg/4.5mcg, 160mcg/4.5mcg • 2 puffs twice a day

  30. Pharmacological therapy: Inhaled Corticosteroids • Preferred therapy for all forms of persistent asthma in all ages • Targeted drug delivery to the lungs • Clinical effects apparent after 2 weeks • Local effects: oral candidiasis, cough, hoarse voice, dysphonia, adrenal suppression, decreased bone mineral density, skin thinning, cataracts, easy bruising

  31. Pharmacological therapy: Inhaled Corticosteroids

  32. Pharmacological therapy: Systemic Corticosteroids • Effective as long term treatment and rescue medication • Serious potential side effects include • Cornerstone of treatment for worsening asthma and patients not responding

  33. Pharmacological therapy: Systemic Corticosteroids • Methyprednisolone- 2,4,6,8,16,32 mg oral tablets • Prednisolone (- 5mg oral tablets; 5mg/mL and 15mg/5mL oral liquids • Prednisone- 1, 2.5, 5, 10, 20, 50mg tablets; 5mg/mL and 5mg/5mL oral liquid • 0-4years- short course burst “1-2mg/kg/day PO, max 60mg/day po for 3-10 days • 5-adult- Short course burst 40-60mg/day po as a single or divided dose for 3-10 days

  34. Pharmacological therapy: Anticholinergics • Inhibit the effects of acetylcholine on muscarinic receptors in the airways • Bothersome side effect profile: blurred vision, dry mouth, urinary retention, and constipation • Not absorbed systemically

  35. Pharmacological therapy: Anticholinergics • Ipratropium HFA (Atrovent)- • Only for use in adults • 2-3 puffs every 6 hours, nebulizer- 0.25mg every 6 hours • Ipratropium with albuterol • Only for use in adults • 2-3 puffs every 6 hours, nebulizer- 3mL every 6 hours • Tiotropium HFA (Spiriva)- -- Onset of action of 30 minutes • Little evidence in asthma

  36. Pharmacological therapy: Leukotriene Modifiers • Inhibit 5-lipoxygenase or competitively antagonize effect of leukotriene D • Improve FEV and decrease symptoms • Less effective than ICS

  37. Pharmacological therapy: Leukotriene Modifiers • Montelukast 4 or 5mg chewable tabs or granule packs, and 10mg tabs (Singular) • 0-4 years old- 4mg tablet at bedtime • 6-14 years old- 5mg tablet at bedtime • Adult 10mg tablet at bedtime

  38. Pharmacological therapy: Leukotriene Modifiers • Zafirlukast 10 or 20mg tablets (Accolate) • Take with meals • 5-11 year olds- 10mg BID • Adult dose- 40mg daily

  39. Pharmacological therapy: Leukotriene Modifiers • Zileuton 600 mg tablets (Zyflo) • Only for use in adults 4 times a day • Monitor hepatic enzymes

  40. Pharmacological therapy: Cromolyn and Nedocromil • Inhaled inflammatory agents • Inhibit release of mediators from mast cells • Alternatives to ICS treatment • Maximal benefit after 4-6 weeks • Adverse effects= cough, wheezing, bad taste, and headache

  41. Pharmacological therapy: Cromolyn and Nedocromil • Nedocromil (Tilade, Alocril) • 2 puffs 4 times a day • Once controlled frequency of dosing can be reduced • Cromolyn • 2 puffs 4 times a day • Or one ampule 4 times a day

  42. Pharmacological therapy: Methylxanthines • Causes bronchodilator by inhibiting phosphodiesterase and antagonizing adenosine • Limited use • Increase risk for adverse drug reactions with serum levels of > 15mg/L • Large number of drug interactions

  43. Pharmacological therapy: Methylxanthines • Theophylline • 10mg/kg/day with a max dose of 16mg/kg/day (same for 0-adult) • Monitor for serum theophylline level

  44. Pharmacological therapy: Omalizumab (Zolair) • Recombinant humanized monoclonal anti-IgE antibody • Inhibits binding of IgE to receptors on mast cells and basophils • Positive skin test or invitro reactivity to perennial allergens • Decreases ICS use • High cost • Side effects: bruising, pain, stinging, itching, burning, and anaphylactic reactions

  45. Pharmacological therapy: Omalizumab • Omalizumab subcutaneous injection • Adults 150-375mcg SC every 2-4 weeks depending on body weight and pretreatment serum IgE levels • Monitor for anaphylaxis • Do not administer more than 150mcg per injection site

  46. Patient Monitoring • 1.Monitoring of asthma control • 2.Establishing goals of therapy • 3.Periodic assessment and monitoring of asthma control, including • Signs and symptom • Pulmonary function, via spirometry or peak flow monitoring • Quality of life • History of exacerbations • Pharmacotherapy (adherence and side effects) • Patient-provider communication and patient satisfaction

  47. Inhaler Technique • Remove the cap • Shake the inhaler • Tilt your head back slightly and breathe out slowly • Position the inhaler 1-2 inches away from mouth, in a chamber, or in the mouth • Press down on the inhaler to release medication while starting to breathe in slowly • Breathe in for 3-5 seconds (slowly) • Hold breath for 10 seconds to allow medication to reach all the way deep into lungs • Repeat puff. Wait one minute between puffs will allow the second one to penetrate your lungs better • Spacers and chambers are very useful and are recommended for young children and older adults and for use with corticosteroids

  48. Common inhaler mistakes to watch for • Breathing out while pressing inhaler • Inhaling quickly • Breathing in trough nose • Pressing down before starting to inhale • Stopping inhalation as pressing down on inhaler • Pressing inhaler more than once during inhalation • Not breathing evenly and deeply

More Related