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Asthma Update

Thomas C. Bent, MD, FAAFP

Infant, Child and Adolescent Course


Thomas C. Bent, MD
Associate Clinical Professor
Department of Family Medicine
University of California, Irvine

Medical Director
Laguna Beach Community Clinic
Declaration of Interest
Dr. Bent declares that he is not a member
of an advisory board or speakers’ panel for
any pharmaceutical company.
Learning Objectives
• Understand the 10 Key Clinical Activities
for Quality Asthma Care
• Manage Asthma with a step-wise
approach
• Educate patients in self-monitoring and
self-management
Burden of Suffering
• 15 Million Americans with Asthma
• 5000 Deaths per year
• 500,000 Hospitalizations per year
• 2,000,000 ER visits per year
• Cost of Care: $6 Billion
Definition of Asthma
• 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.
• Recurrent episodes of wheezing, breathlessness, chest
tightness, and cough.
• Reversible airflow obstruction, either spontaneously
or with treatment.
• Increased bronchial hyperresponsiveness to a
variety of stimuli.
Information Taken From
National Asthma Education and Prevention Program (NAEPP). Expert Panel Report
2: Guidelines for the Diagnosis and Management of Asthma. National Heart, Lung,
and Blood Institute (NHLBI), National Institutes of Health (NIH). April 1997.
Components of Asthma
• Reversible Airway Obstruction
• Airway Hyper reactivity
• Airway Inflammation
Airway Pathology in Asthma
Permissions for this slide not granted.
Role of Inflammation and
Bronchoconstriction in Asthma
Permissions for this slide not granted.
Key Clinical Activity 1:
Establish Asthma Diagnosis
• History
• Physical Exam
• Spirometry

Information Taken From


Key clinical activities for quality asthma care: recommendations of the National Asthma
Education and Prevention Program.
Website:
www.guidelines.gov/summary/summary.aspx?doc_id=3734&nbr=2960&string=asthma
Symptoms
• Cough
• Wheezing
• Dyspnea
Physical Exam
• Prolonged expiratory phase
• Diffuse wheezing
• Tachypnea
• Intercostal retractions
Spirometry
• >12% improvement in FEV 1 after
treatment with short-acting bronchodilator
or short course of oral corticosteroids
Differential Diagnosis
• Upper airway obstruction due to foreign
body or tumor
• Bronchitis/bronchiolitis/pneumonia
• COPD
• Vocal Cord dysfunction
• CHF
• GERD
Key Clinical Activity 2:
Classify Severity of Asthma
• Mild Intermittent
• Mild Persistent
• Moderate Persistent
• Severe Persistent
Mild Intermittent Asthma
• Symptoms no more than twice weekly
• Brief exacerbations
• Nocturnal asthma no more than twice monthly
• Asymptomatic with normal lung function
between episodes
• FEV1 and Peak Flow no less than 80% of
predicted
• Peak Flow variability less than 20%
Mild Persistent Asthma
• Symptoms greater than twice weekly but no
more than once daily
• Exacerbations may affect activity
• Nocturnal symptoms more than twice monthly
• FEV1 and Peak Flow no less than 80% of
predicted
• Peak Flow variability from 20 to 30 %
Moderate Persistent Asthma
• Daily symptoms
• Daily use of Rescue meds
• Exacerbations affect activity
• Nocturnal symptoms more than once weekly
• Exacerbations occur at least twice a week and
may last for days
• FEV1 or Peak Flow between 60 and 80% of
predicted
• Peak Flow variability greater than 30%
Severe Persistent Asthma
• Continuous symptoms
• Limited physical activity
• Frequent exacerbations
• Frequent nocturnal symptoms
• FEV1 or Peak Flow less than 60% of
predicted
• Peak Flow variability greater than 30%
Key Clinical Activity 3:
Schedule Routine Follow-Up Care
• Review medication use
• Review Peak Flow records
• Demonstrate inhaler, spacer and Peak
Flow meter technique
• Review self-management plan
Key Clinical Activity 4:
Assess for Referral to Specialty
Care
Indications for Consultation or
Co-management
• Life-threatening exacerbation
• Poor response to initial management
• Unclear diagnosis
• History suggests occupational factors,
environmental inhalant or an ingested
substance
Indications for Consultation or
Co-management
• Initial diagnosis of severe persistent asthma
• Patient requires continuous oral corticosteroid
therapy
• Patient requires more than two courses of oral
corticosteroids in one year
• Patient requires additional diagnostic testing
Key Clinical Activity 5:
Control Asthma Triggers
• Tobacco Smoke!!!
• Dust Mites
• Cockroaches
• Cats
• Dogs
• Laughing or crying
Key Clinical Activity 6:
Treat or Prevent Comorbid
Conditions
• Allergic Rhinitis
• Sinusitis
• GERD
• Drug sensitivities
– Beta Blockers
– Aspirin
– NSAIDs
• Flu and Pneumonia Vaccines
Key Clinical Activity 7:
Prescribe Medications According to
Severity
Treatment of Mild Intermittent
Asthma
• Short-acting “Rescue” bronchodilator
• No Daily controller medication is needed
Treatment of Mild Persistent
Asthma
• “Rescue” Bronchodilator
• Daily “Controller” Medication
– Inhaled Corticosteroid (ICS)
– Leukotriene modifier
– Cromolyn
– Sustained release theophylline
Evidence Based Practice
Recommendation
Inhaled Corticosteroids are more effective
than anti-leukotriene agents and should
remain first line in monotherapy for
persistent asthma.

Information Taken From


Ducharme FM, Di Salvo F. Anti-leukotriene agents compared to inhaled corticosteroid
management of recurrent and/or chronic asthma in adults and children. The
Cochrane Database of Systemic Reviews 2004,Issue 1
Website: www.cochrane.org/cochrane/revabstrAB002314.htm
Evidence Based Practice
Recommendation
For patients requiring inhaled corticosteroids,
starting with a moderate dose is equivalent to
starting with a high dose and down-titrating.

Information Taken From


Powell H, Gibson PG. High dose versus low dose inhaled corticosteroid as initial starting dose
for asthma in adults and children. The Cochrane Database of Systemic Reviews 2003,
Issue 4 Website: www.cochrane.org/cochrane/revabstr/AB004109.htm
Treatment of Moderate Persistent
Asthma
• “Rescue” Bronchodilator
• Controller Meds:
– ICS (low to medium dose) and
– Long acting Bronchodilator
Alternative Treatment for Moderate
Persistent Asthma
• Increase ICS within medium-dose range

Or

• Low to medium dose ICS and either


leukotriene modifier or theophylline
Treatment of Severe Persistent
Asthma
• “Rescue” Bronchodilator
• “Controller” meds:
– ICS (high dose) and
– Long acting Bronchodilator and
– Oral corticosteroids (if needed)
Key Clinical Activity 8:
Monitor use of Beta2-Agonist
Drugs
• One canister should last one month
• Review dosage instructions and inhaler
technique at follow up visits
• Modify daily controller therapy in response
to change in beta2-agonist usage
Key Clinical Activity 9:
Develop a Written Asthma
Management Plan
• Include written instructions on recognizing
signs and symptoms of worsening asthma
• on medication type, dose and frequency
• On recognizing when to seek medical care
• Plans can be based on symptoms or peak
flow readings
Key Clinical Activity 10:
Provide Routine Education on
Patient Self-Management
• Basic facts about Asthma
• Concept of “Rescue” and “Controller”
meds
• Environmental controls
• Inhaler technique
• Peak Flow self-monitoring
• Concept of self-management
Evidence Based Practice
Recommendation
Self-management education combined
with usual care is more effective than
usual care alone.

Information Taken From


www.cochrane.org/colloquia/abstracts/ottawa/P-164.htm
Goals of Treatment
• Prevent chronic or troublesome symptoms
• Maintain near normal pulmonary function
• Maintain normal activity levels
• Prevent exacerbations and minimize urgent
care/ER visits and hospitalizations
• Provide optimal pharmacotherapy with minimal
adverse effects
• Meet patients’ and families’ expectations
TM

Asthma In America Survey


Permissions for this slide not granted.
Please visit http://www.asthmainamerica.com/aaa_index.html for
complete results of the Asthma in America Survey.
TM

Asthma In America Survey


Permissions for this slide not granted.
Please visit http://www.asthmainamerica.com/aaa_index.html for
complete results of the Asthma in America Survey.
TM

Asthma In America Survey


Permissions for this slide not granted.
Please visit http://www.asthmainamerica.com/aaa_index.html for
complete results of the Asthma in America Survey.
TM

Asthma In America Survey


Permissions for this slide not granted.
Please visit http://www.asthmainamerica.com/aaa_index.html for
complete results of the Asthma in America Survey.
TM

Asthma In America Survey


Permissions for this slide not granted.
Please visit http://www.asthmainamerica.com/aaa_index.html for
complete results of the Asthma in America Survey.
Practice Based Disease
Management
• Patient education
• Physician education
• Flow sheets
• Action plan templates
• Urgent care/ER guidelines
• Outcomes measurements
Laguna Beach Community Clinic
Asthma Monitor Sheet

Name_________________________________Chart #__________DOB____/____/____
Diagnoses 1___________________2__________________3__________________

Date / / / / / / / / / /
Peak Flow
Rescue MDI&Freq
Albuterol
Asthma Severity
COPD/History
PreventiveMDI/MEDS
ICS
LA BetaAg
Leukot. Inhib
MC Stabilizers
SA BetaAg
Oral Steroids
Theophylline
Antihistamines
Flu Vaccine
PT Monitor Peak Flow
Tobacco ETS
Tobacco Use/Smoke
Best PEFR
Lost Days (30)
SymptomFreeDays (14)
Acute Asthma Educ
Asthma Plan
Self Management Goal
Triggers
Asthmatic Educ. Appt.
Smoking Avoidance
Counseling
PT. Demonstrated
Proper Use of MDI
TX Plan Reviewed
Environmental
Guideline Given

Diagnosis Made Base On 1.HX/SX________2. Spirometry_________3. Other________

Asthma Mild Intermit SX<2X/WK________ Mild Persistent SX>2X/WK BUT NOT EVERY DAY_________
Severity Mod Persistent DAILY SX________ Sever Persistent CONTINUAL SYMP / FEV < 60%____________
Criteria

ED Visits Within 6 months ____ ____ ____ ____ Hospitalization_____ _____ Intubation______
Pneumonia Vaccine ____ ____ ____ ____ Initial CXR______2nd______ Initial PPD____
Summary
• Step wise approach is meant to assist, not
replace, clinical decision making required to
meet individual patient needs
• Classify severity
• Gain control quickly
• Minimize use of short acting beta agonists
• Provide education on self management and
environmental control
Thank You!