1 / 138

The MANAGEMENT OF ASTHMA

The MANAGEMENT OF ASTHMA . B. WAYNE BLOUNT, MD, MPH. OBJECTIVES. Define asthma Name the stages of asthma & their respective criteria List the recommended treatment for each stage Describe an action plan Review the recommendations of 3 rd Expert Panel Report (EPR-3)

rianna
Télécharger la présentation

The MANAGEMENT OF 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. The MANAGEMENT OF ASTHMA B. WAYNE BLOUNT, MD, MPH

  2. OBJECTIVES • Define asthma • Name the stages of asthma & their respective criteria • List the recommended treatment for each stage • Describe an action plan • Review the recommendations of 3rd Expert Panel Report (EPR-3) • UNLESS OTHERWISE NOTED, ALL EBM RECOMMENDATIONS ARE FROM COCHRANE

  3. CASE # 1 • 45 Y.O. W MALE C/O COUGH X 3 ½ WEEKS; DAILY, MOSTLY NOCTURNAL

  4. CASE # 1 • Which of the following is NOT in your top 5 differential diagnoses? • A. Post URI Inflammation • B. Post Nasal Drip • C. Allergies • D. Asthma • E. Sinusitis

  5. THE DIFFERENTIAL OF CHRONIC COUGH • POST URI INFLAMMATION • PND • ALLERGIES • ASTHMA • SINUSITIS • GERD • WHAT DO YOU WANT TO DO?

  6. OUR CASE • HX. • P.E.

  7. 2. Which of the following is a valid criterion for diagnosing asthma? • A. Wheezing on physical exam • B. Spirometry • C. Symptomatology • D. Sound of the cough

  8. PFTs

  9. 3. Which of the following PFT parameters is MOST likely to be below normal in a patient with asthma? • A. FVC • B. FEV1 • C. TLC • D. FRC

  10. OUR CASE • HIS PFTs : • PARAMETER % PREDICTED • FVC 89 • FEV1 78

  11. 4. OUR CASE • We can now diagnose this patient with asthma. • A. True • B. False

  12. REVERSIBILTY OF DEFECT • FEV1 OR PEFR NEEDS TO IMPROVE BY AT LEAST 12%;

  13. THIS MEANS YOU HAVE TO DO PFTs • @ INITIAL ASSESSMENT • AFTER TREATMENT & SX STABILZE • DOCUMENTS “NORMAL” AIRWAY FXN • A MINIMUM OF Q 1-2 YEARS AFTER THAT • WITH EACH EXACERBATION • ‘C’ REC

  14. SPIROMETRY & PEFRs ARE TO ASTHMA AS BLOOD PRESSURE IS TO HYPERTENSION

  15. 5. How many stages of asthma severity are there? • A. 3 • B. 4 • C. 5 • D. 6

  16. STAGING THE SEVERITY OF ASTHMA • INTERMITTENT • MILD PERSISTENT • MODERATE PERSISTENT • SEVERE PERSISTENT

  17. INTERMITTENT • SX NIGHT SX LUNG FXN < 2/WK < 2/MO FEV1 or PEF > 80%

  18. MILD PERSISTENT • SX NIGHT SX LUNG FXN • >2/WK BUT > 2/MO FEV1 or PEF > 80% < 1/DAY EXACERBATIONS MAY AFFECT ACTIVITIES

  19. MODERATE PERSISTENT • SX NIGHT SX LUNG FXN DAILY > 1/WK >60% & <80% DAILY USE OF INHALED BETA- AGONIST EXACERBATIONS > 2/WK & AFFECT ACTIVITIES

  20. SEVERE PERSISTENT • SX NIGHT SX LUNG FXN CONTINUAL FREQUENT <60% FREQUENT EXACERBATIONS LIMITED PHYSICAL ACTIVITY

  21. OUR CASE • HOW DO YOU WANT TO TREAT THIS PATIENT & WHY?

  22. 6. According to EPR-3, how many age categories are there when considering treatment for asthma? • A. 2 • B. 3 • C. 4 • D. 5

  23. 7. According to EPR-3, how many STEPS are there when considering treatment for asthma? • A. 3 • B. 4 • C. 5 • D. 6

  24. EPR-3 • Assess severity before starting Rx • Assess control to guide RX adjustments • 3 age categories for treatment • 6 steps in management to individualize treatment

  25. 8. How many known pathophysiologic dysfunctions are in the pathogenesis of Asthma? • A. 1 • B. 2 • C. 3 • D. 4

  26. Asthma Pathophysiology Smooth muscle dysfunction Airway inflammation Airway remodeling Adapted from Bousquet et al. Am J Respir Crit Care Med. 2000;161:1720-1745.

  27. Asthma Pathophysiology Smooth muscle dysfunction • Exaggerated contraction • Increased smooth muscle mass • Increased release of • inflammatory mediators Adapted from Bousquet et al. Am J Respir Crit Care Med. 2000;161:1720-1745.

  28. BRONCHOCONSTRICTION 10 Minutes After Allergen Challenge Before

  29. SMOOTH MUSCLE HYPERPLASIA

  30. Asthma Pathophysiology Acute response Chronic inflammatory response • Bronchial hyperreact ivity • Mucosal edema • Airway secretions • Increased inflammatorycell numbers • Epithelial damage Adapted from Bousquet et al. Am J Respir Crit Care Med. 2000;161:1720-1745.

  31. Inflammatory Cells in Lung Tissue E = Epithelium BM = Basement Membrane Laitinen et al. J Allergy Clin Immunol. 1992;90:32-42.

  32. Asthma Pathophysiology Airway remodeling • Cellular proliferation • -smooth muscle cells • -mucous glands • Increased matrix protein deposition • Basement membrane thickening • Angiogenesis Adapted from Bousquet et al. Am J Respir Crit Care Med. 2000;161:1720-1745.

  33. WHAT ARE THE THERAPEUTIC TARGETS? Smooth muscle dysfunction Airway inflammation • lnflammatory cell infiltration/activation • Mucosal edema • Cellular proliferation • Epithelial damage • Basement membrane thickening • Bronchoconstriction • Bronchial hyperreactivity • Hyperplasia/Hypertrophy • Inflammatory mediator release Symptoms/Exacerbations Adapted from Bousquet et al. Am J Respir Crit Care Med. 2000;161:1720-1745.

  34. ASTHMA: GOALS OF THERAPY • Control chronic and nocturnal symptoms • Maintain normal activity levels, including exercise • Maintain near-normal pulmonary function • Prevent acute episodes of asthma • Minimize emergency department (ED) visits and hospitalizations • Avoid adverse effects of asthma medications Guidelines for the Diagnosis and Management of Asthma. 1997. NIH Publication No. 97-4051.

  35. TREATMENT • 40 – 50% ARE NOT FOLLOWED CORRECTLY • ‘A’ REC • WRITTEN ACTION PLANS IMPROVE THIS BY A CLINICALLY SIGNIFICANT AMOUNT • ‘B’ REC

  36. THE TREATMENT OF ASTHMA DETERMINED BY CATEGORY OF ASTHMA; A STAGED RESPONSE : • INTERMITTENT • MILD PERSISTENT • MODERATE PERSISTENT • SEVERE PERSISTENT START HIGH AND BACK OFF ‘B’ REC New: 6 steps for the 4 stages

  37. EPR-3’s 6 steps • Step 1 – Intermittent • Step 2 – Mild Persistent • Step 3 – Moderate Persistent • Step 4 – Moderate Persistent • Step 5 – Severe Persistent • Step 6 – Severe Persistent

  38. Stepwise treatment: Ages > 12 years • Step 1 : SABA PRN • Step 2 : Low dose ICS • Step 3 : Low dose ICS & LABA or medium dose ICS • Step 4 : Medium dose ICS & LABA • Step 5 : High dose ICS & LABA; consider Xolair if allergies • Step 6 : High dose ICS & LABA & oral steroids; consider Xolair if allergies

  39. INTERMITTENT • NO DAILY MED NEEDED • USE SHORT-ACTING BETA-AGONIST PRN SX. • EDUCATE : • ASTHMA • MDI USE • SELF MANAGEMENT • ACTION PLAN • ENVIRONMENTAL CONTROL MEASURES

  40. MILD PERSISTENT • A CONTROLLER MED : • INHALED STEROID IS PREFERRED • A CROMONE MAY SUFFICE IN SOME • UNCOMMON: LTM • RARE: THEOPHYLLINE • RESCUE MED : • INHALED BETA-AGONIST • EDUCATION

  41. MODERATE PERSISTENT • INCREASE STEROID (MEDIUM DOSE) • ADD LONG-ACTING BETA-AGONIST* • ADD LTM • CONTINUE RESCUE MED & EDUCATION *CONTROVERSIAL

  42. SEVERE PERSISTENT • HIGH DOSE INHALED STEROID • LABA • SYSTEMIC STEROID • LTM • THEOPHYLLINE • RESCUE MED(S) • INTENSIFY EDUCATION • “WHATEVER IT TAKES”

  43. SO OUR PATIENT HAS _____ • AND WE WILL USE WHAT MED(S) FOR HIM? • GO BACK TO HIS SX & PFTs

  44. USE OF MDIs

  45. USE OF MDIs

  46. USE OF MDIs

  47. MUST TEACH MDI USE • TELL • DEMONSTATE • WATCH • ASSESS

  48. TRICKS WITH USING MDIs ? • RINSE MOUTH ‘B’ REC • NEBS VS. CHAMBERS ‘A’ REC

  49. KNOWLEDGE OF AND PRACTICAL SKILLS WITH THE DEVICES 75 67* RT RN 48 MD MeanKnowledgeScore(%) 50 39 25 0 n = 30 n = 30 n = 30 *P<0.0001 vs RN and MD Hanania et al. Chest. 1994;105:111-116.

  50. MEDICAL STAFF’S ABILITY TO EFFECTIVELY DEMONSTRATE PROPER INHALER TECHNIQUES RT 98* 97* 100 RN 82 78 MD 80 69 Mean DemonstrationScore (%) 60* 57 60 40 21 20 12 0 MDI Turbuhaler® MDI + AeroChamber® *P<0.0001 vs RN and MD Hanania et al. Chest. 1994;105:111-116.

More Related