Respiratory Update

Asthma: Causes, Monitoring and Treatment

Presented by Cynthia Fouts, June, 2012

Learning ObjectivesAfter viewing this presentation, the learner will be able to:understand the two major classifications of asthma

list ways to decrease the patient’s exposure to asthma triggers

coach the patient in performing peak flow measurements

write an asthma plan

classify asthma severity

choose correct management techniques based on severity.

Background:Asthma used to be viewed as a condition that a

person gets, is treated, and suffers no lasting damage.

Recent studies have shown that each asthma exacerbation leaves airway damage behind.

In addition to physical damage, asthma exacerbations result in loss of productivity (both for adults at work and children in school).

Asthma sufferers also report that asthma affects their activities and enjoyment of life

Asthma Types:There are two major types of asthma:

Intrinsic – also known as nonallergic or nonatopic

Extrinsic – also known as allergic or atopic

IntrinsicEtiology – elusiveUsually occurs after 40 years of ageNon-specific stimuli:

Infections Cold Air Exposure Exercise Esophageal Reflux Emotional Stress Pollutants Food Additives, Food Preservatives

Extrinsicclearly associated with exposure to a specific

antigenic agentType I anaphylactic hypersensitivity reactionIgE-mediated allergic reactionFamily relatedUsually appears in childrenHypersensitivity immune response causes the

disease by causing acute and chronic inflammation

Decreasing exposure to triggers:Tobacco smoke

Quit if smokerSmoke-free environments (car & house)

Dust mitesEncase mattress in special dust-mite free coverEncase pillow in special dust-mite free cover or wash

every week in hot water or cool water/bleachReduce indoor humidity to <60%Do not sleep on cloth covered cushions or furnitureRemove carpets from bedroom and from concreteStuffed toys

Keep out of the bed Wash weekly in hot water or cool water/bleach

Decreasing triggers, cont’d.Animal Dander

Keep animal with fur out of the homeKeep pet out of bedroom and keep door closedRemove carpet and cloth-covered furniture

CockroachKeep all food out of the bedroomKeep food and garbage in closed containersUse poison baits, traps and powders instead of

sprays

Decreasing triggers, cont’d.Vacuum cleaning

Try to get someone else to come in and do the vacuuming once or twice a week

If do it yourself, use a mask, central vac system or vacuum with a HEPA filter

Indoor moldFix leaky faucets and pipesClean moldy surfacesDehumidify basements

Decreasing triggers, cont’d.Pollen and Outdoor Mold

Keep windows closed during peak allergy seasonsStay inside during midday and afternoonTalk to doctor about anti-inflammatory meds before

allergy season startsSmoke, Strong Odors and Sprays

If possible do not use wood burning stove, kerosene heater, fireplace, or any unvented heater

Stay away from new paint, new carpet, hair spray, perfumes

Decreasing triggers, cont’d.Exercise or Sports

Check air quality index and avoid outside activity when air pollution or pollen levels high

Warm up before exercisingShould be able to be active without symptoms; if not

talk to dr. about taking meds before activity to prevent symptoms

Other triggersAvoid Sulfites in foods – beer or wine, shrimp, dried

fruit, processed potatoesCold air – cover mouth and nose with scarfOther meds – tell doctor about all meds you are taking

Daily monitoringAll asthma patients should use a peak flow

meter to monitor their daily symptoms.A peak flow meter is a small hand-held device

which measures the speed which a patient can exhale.

Measurement is in Liters/minute.Easy to use – even children who can follow

simple directions can use it.Many times a peak flow meter will show a

decrease in flow before the patient feels an increased shortness of breath.

Peak Flow Meters – different styles

How to Use a Peak Flow MeterHave patient in upright positionInstruct to place mouthpiece into their mouth but

do not obstruct the opening with their tongueFirmly seal lips around mouthpieceTake a big breath inBLAST out the breath – hard and fast!!!Note readingReset meter to zeroRepeat process twice more and record the best

reading

Asthma Zone Management SystemThis system is a process of daily monitoring using a peak flow meter, daily recording of results, and treatment based on those results.

Charting Peak Flow & ZonesYou will note on the preceeding example of a Peak Flow Chart that there were green, yellow, and red columns. These columns represent the 80-100%, 50-80%, and <50% zones of the patient’s personal best. The personal best is the best of two weeks of measurements made during a time when the patient’s asthma is well controlled.

Written Action PlanWritten asthma action plans include two important elements:

Daily management

Recognition and handling worsening symptoms

Daily ManagementMonitoring with a peak flow meter

Recording of peak flow measurement

What medications to take every day; when and how to take them

Recognition and Handling Worsening SymptomsWhat symptoms and PF measurements

indicate worsening asthma (yellow zone)What medications to take in response to these

signs and symptomsWhat symptoms and PEF measurements

indicate the need for urgent medical attention (red zone)

Emergency telephone numbers for the physician, ED, and person or service to transport the patient rapidly for medical care

Classification of Asthma Severity – Mild IntermittentSymptoms Nocturnal

SymptomsDaily Meds for Long Term Control

Medication for Quick Relief

Symptoms no more frequent than twice a week.Asymptomatic and with normal PF between exacerbations.Exacerbations brief (hours to days).Intensity of Exacerbations varies.

No more frequent than twice monthly

No daily medications

Short-acting inhaled β2-agonistUse more than twice weekly may indicate the need to initiate long-term therapy

Classification of Asthma Severity – Mild PersistentSymptoms Nocturnal

SymptomsDaily Meds for Long Term Control

Medication for Quick Relief

Symptoms more frequent than twice weekly but less than once per day.Exacerbation may affect activity.

More frequent than twice monthly

Once-daily medication:Antiinflammatory agent (low-dose corticosteroid, cromolyn)orSustained-release theophyllineNOTE: Leukotriene modifiers may be considered for pts at least 12 yr old.

Short-acting inhaled β2-agonistDaily use or increasing use may indicate the need to additional long-term therapy

Classification of Asthma Severity – Moderate PersistentSymptoms Nocturnal

SymptomsDaily Meds for Long Term Control

Medication for Quick Relief

Daily SymptomsDaily use of inhaled, short-acting β2-agonistExacerbations affect activity.Exacerbations at least twice weekly and may last for days.

More frequent than once weekly.

One or two daily med:Antiinflammatory agent (medium-dose inhaled glucocorticoid)and/orMedium-dose inhaled glucocorticoid plus long-acting bronchodilator

Short-acting inhaled β2-agonistDaily use or increased use indicates need for additional long-term therapy

Classification of Asthma Severity – Severe PersistentSymptoms Nocturnal

SymptomsDaily Meds for Long Term Control

Medication for Quick Relief

Continual symptoms.Limited physical activity.Frequent exacerbations.

Frequent Two daily medications:Antiinflammatory agent (high-dose inhaled glucocorticoid)andLong-acting bronchodilator (inhaled or oral β2-agonist or theophylline)

Short-acting inhaled β2-agonistDaily use or increased use indicates need for additional long-term therapy

Treatment RegimenNote that the medications ordered for a

patient are associated with the severity rating of their asthma.

It is important to educate the patient on the correct administration of MDI’s and DPI’s to ensure adequate intake of the medications.

It is possible to control almost all asthma with medication and avoidance of triggers.

BibliographyDes Jardins, T. and Burton, G. (2006). Clinical Manifestations and Assessment of Respiratory Disease. St. Louis, Mo: Mosby Elsevier. pg. 197-206.

Guidelines for the Diagnosis and Management of Asthma (EPR-3). (2007) National Heart Lung and Blood Institute. Retrieved from http://www.nhlbi.nih.gov/guidelines/asthma/index.htm

Measuring Your Peak Flow Rate. (2012) American Lung Association. Retrieved from http://www.lung.org/lung-disease/asthma/living-with-asthma/take-control-of-your-asthma/measuring-your-peak-flow-rate.html

National Asthma Control Initiative. (2008) National Heart Lung and Blood Institute. Retrieved from http://www.nhlbi.nih.gov/health/prof/lung/asthma/naci/index.htm