asthma update edited

8/6/2019 Asthma Update EDITED

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Asthma Update

Thomas C. Bent, MD, FAAFP

Infant, Child and Adolescent Course


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Thomas C. Bent, MD

Associate Clinical Professor

Department of Family Medicine

University of California, Irvine

Medical Director

Laguna Beach Community Clinic


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Declaration of Interest

Dr. Bent declares that he is not a member

of an advisory board or speakers panel forany pharmaceutical company.


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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


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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


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Information Taken FromInformation Taken FromNational Asthma Education and Prevention Program (NAEPP).National Asthma Education and Prevention Program (NAEPP). Expert Panel ReportExpert Panel Report

2: Guidelines for the Diagnosis and Management of Asthma.2: Guidelines for the Diagnosis and Management of Asthma. National Heart, Lung,National Heart, Lung,and Blood Institute (NHLBI), National Institutes of Health (NIH)and Blood Institute (NHLBI), National Institutes of Health (NIH). April 1997.. April 1997.

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, chesttightness, and cough.

Reversible airflow obstruction, either spontaneouslyor with treatment.

Increased bronchial hyperresponsiveness to avariety of stimuli.


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Components of Asthma Reversible Airway Obstruction

Airway Hyper reactivity

Airway Inflammation


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Airway Pathology in AsthmaPermissions for this slide not granted.


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Role of Inflammation and

Bronchoconstriction in AsthmaPermissions for this slide not granted.


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Key Clinical Activity 1:Establish Asthma Diagnosis

History

Physical Exam

Spirometry

Information Taken FromKey clinical activities for quality asthma care: recommendations of the National AsthmaEducation and Prevention Program.

Website:www.guidelines.gov/summary/summary.aspx?doc_id=3734&nbr=2960&string=asthma


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Symptoms Cough

Wheezing

Dyspnea


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Physical Exam Prolonged expiratory phase

Diffuse wheezing

Tachypnea

Intercostal retractions


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Spirometry >12% improvement in FEV 1 after

treatment with short-acting bronchodilatoror short course of oral corticosteroids


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Differential Diagnosis Upper airway obstruction due to foreign

body or tumor Bronchitis/bronchiolitis/pneumonia

COPD

Vocal Cord dysfunction

CHF

GERD


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Key Clinical Activity 2:Classify Severity of Asthma

Mild Intermittent

Mild Persistent

Moderate Persistent

Severe Persistent


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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%


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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% ofpredicted

Peak Flow variability from 20 to 30 %


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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 andmay last for days FEV1 or Peak Flow between 60 and 80% of

predicted

Peak Flow variability greater than 30%


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Severe Persistent Asthma Continuous symptoms

Limited physical activity Frequent exacerbations

Frequent nocturnal symptoms

FEV1 or Peak Flow less than 60% ofpredicted

Peak Flow variability greater than 30%


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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


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Key Clinical Activity 4:Assess for Referral to SpecialtyCare


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Indications for Consultation or

Co-management

Life-threatening exacerbation

Poor response to initial management

Unclear diagnosis

History suggests occupational factors,environmental inhalant or an ingestedsubstance


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Indications for Consultation or

Co-management Initial diagnosis of severe persistent asthma

Patient requires continuous oral corticosteroidtherapy

Patient requires more than two courses of oral

corticosteroids in one year Patient requires additional diagnostic testing


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Key Clinical Activity 5:

Control Asthma Triggers

Tobacco Smoke!!!

Dust Mites

Cockroaches

Cats Dogs

Laughing or crying


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Key Clinical Activity 6:Treat or Prevent Comorbid

Conditions Allergic Rhinitis Sinusitis

GERD

Drug sensitivities

Beta Blockers

Aspirin

NSAIDs

Flu and Pneumonia Vaccines


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Key Clinical Activity 7:Prescribe Medications According to

Severity


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Treatment of Mild Intermittent

Asthma

Short-acting Rescue bronchodilator

No Daily controller medication is needed


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Treatment of Mild Persistent

Asthma

Rescue Bronchodilator

Daily Controller Medication Inhaled Corticosteroid (ICS)

Leukotriene modifier Cromolyn

Sustained release theophylline


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Evidence Based Practice

RecommendationInhaled Corticosteroids are more effective

than anti-leukotriene agents and shouldremain first line in monotherapy forpersistent asthma.

Information Taken FromDucharme FM, Di Salvo F. Anti-leukotriene agents compared to inhaled corticosteroidmanagement of recurrent and/or chronic asthma in adults and children. TheCochrane Database of Systemic Reviews2004,Issue 1

Website: www.cochrane.org/cochrane/revabstrAB002314.htm


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Recommendation

For patients requiring inhaled corticosteroids,

starting with a moderate dose is equivalent tostarting with a high dose and down-titrating.

Information Taken From

Powell H, Gibson PG. High dose versus low dose inhaled corticosteroid as initial starting dosefor asthma in adults and children. The Cochrane Database of Systemic Reviews2003,Issue 4 Website: www.cochrane.org/cochrane/revabstr/AB004109.htm


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Treatment of Moderate Persistent

Asthma


Controller Meds: ICS (low to medium dose) and

Long acting Bronchodilator


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Alternative Treatment for Moderate

Persistent Asthma

Increase ICS within medium-dose range

Or

Low to medium dose ICS and eitherleukotriene modifier or theophylline


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Treatment of Severe Persistent

Asthma


Controller meds: ICS (high dose) and

Long acting Bronchodilator and

Oral corticosteroids (if needed)


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Key Clinical Activity 8:Monitor use of Beta2-AgonistDrugs

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


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Key Clinical Activity 9:Develop a Written AsthmaManagement Plan

Include written instructions on recognizingsigns 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 peakflow readings


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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


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RecommendationSelf-management education combined

with usual care is more effective thanusual care alone.

Information Taken From

www.cochrane.org/colloquia/abstracts/ottawa/P-164.htm


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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


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Asthma In America Survey

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

TM


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Asthma In America SurveyPermissions for this slide not granted.

Please visit http://www.asthmainamerica.com/aaa_index.html for

complete results of the Asthma in America Survey.

TM


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P i B d Di


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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


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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 StabilizersSA 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. DemonstratedProper Use of MDI

TX Plan Reviewed

Environmental

Guideline Given

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

Asthma Mild IntermitSX2X/WK BUT NOT EVERY DAY_________

Severity Mod PersistentDAILY SX________ Sever Persistent CONTINUAL SYMP / FEV < 60%____________

Criteria

ED Visits Within 6 months ____ ____ ____ ____ Hospitalization_____ _____ Intubation______

Pneumonia Vaccine ____ ____ ____ ____ Initial CXR______2nd

______ Initial PPD____


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Summary Step wise approach is meant to assist, not

replace, clinical decision making required tomeet individual patient needs

Classify severity

Gain control quickly Minimize use of short acting beta agonists

Provide education on self management and

environmental control


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Thank You!

asthma update edited

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