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No matter what anybody says… Breathing is ALWAYS a good time!

No matter what anybody says… Breathing is ALWAYS a good time!. 2012 London Olympics. What percent of the host city team (England) members suffer from asthma?. 3% 10% 25% 49% No Info – HIPPA Violation.

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No matter what anybody says… Breathing is ALWAYS a good time!

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  1. No matter what anybody says… Breathing is ALWAYS a good time!

  2. 2012 London Olympics What percent of the hostcityteam (England) members suffer from asthma? • 3% • 10% • 25% • 49% • No Info – HIPPA Violation

  3. London 2012 Olympics: A quarter of Team GB suffer from exercise-induced asthma 25%

  4. Pediatric AsthmaSan Antonio 2012 David Renner, PA-C, BMS AAPA-AAI Mercy Allergy and Asthma Clinic Springfield, Missouri drenner.ommr@yahoo.com

  5. Asthma • Definition • “Asthma is an eosinophilic, desquamative bronchitis that can result in irreversible lung disease.” • Our emphasis: Diagnosis, Treatment and what’s new

  6. Asthma • suspected if: • historical description of symptoms with or without the disease • appropriate response to asthma medication • diagnostic if: • documentation of reduced airflows and reversibility (PFT testing – Pre and Post)

  7. Asthma Masqueraders Recurrent “Croup” “Reactive Airways” “Twitchy Airways” Recurrent Viral Colds Bronchitis Exercise Induced Cough Cystic Fibrosis “Allergic” Asthma

  8. Airflow Measurements • Peak flows • Quick to respond to treatment/ highly variable • FEV1 • Indicate larger airway function • Mid-flows (MEFR or FEF 25-75) • Very slow to recover/ highly variable • Indicate smaller airway involvement

  9. Pulmonary Assessment • Peak flow meters are an important tool for emergent evaluation and home monitoring • Spirometry should be measured in asthma throughout childhood to document the growth of the pulmonary system • Repeated spirometry also documents the loss of pulmonary function with continued disease activity throughout adult life

  10. Can we alter the progression of the asthma disease?

  11. Common Presentation • Recurrent chest symptoms • chronic cough or phlegm, especially causing arousal from sleep or paroxysmal to emesis • recurrent bronchitis (chest colds) • exertion-related SOB, cough, or wheeze • chest symptoms around smoke, cold air, laughter, crying

  12. Symptom Questionnaire General chest questions: • Breathing problems after sports • Cough problems more than others • Breathing problems in cold air General allergy questions: • Sneeze near someone else’s pets • Itchy/puffy eyes in Spring or Fall

  13. Coughing versus Wheezing

  14. Transient Wheezers • Early daycare/ higher # of siblings • Negative family history of Asthma • Second-hand smoke exposure • No evidence of allergy • Usually resolve in childhood

  15. Continued Wheezers TWO GROUPS: • Non-atopic – Usually have smaller airways that never recover “normal” values • Atopic – Those with family history and evidence of specificperennial allergy

  16. Common Asthma Triggers • Upper respiratory tract infection (esp viral) • Exercise/Hyperventillation • Irritants (smoke/air pollution) • Emotions • Gastroesophageal reflux • Allergens

  17. Perennial Allergy • Common cause of chronic rhinitis and asthma • Unidentifiable by the patient due to chronicity of exposure • Often due to house pet and there is a tremendous sub-conscious effort to deny possibility

  18. Dust Mites… Control Measures Allergy Shots

  19. Cat saliva / oils Control Measures Allergy Shots

  20. Increasing Incidence of Allergy • Increasing about 5 % per year, having doubled in the past 15 years • Predominant theory: The Hygeine Hypothesis • Immunizations prevent viral burden and T-suppressor activity • Cleaner home environments reduce bacterial and fungal exposures

  21. The “cure” for the Hygiene Theory?

  22. Saliva versus Fur / Skin dander

  23. Options to Treat Environmental: Avoidance, Barriers Medications: ICS, LABA, SABA, LTRA, etc Immunotherapy: SLIT vs SCIT Dietary: Certain foods, weight loss

  24. Environmental Assessment • Should identify a specific allergy, or not • Suggest allergy evaluation if seasonal without the need of screening RAST • Suggest perennial RAST panel for those without seasonal history • Dust mite, cat, dog, cockroach and alternaria

  25. Allergy and Asthma • Development of allergy pre-school appears critically linked to the development of life-long asthma • House dust mite allergy • Cat • Cockroach • Alternaria

  26. RAST Interpretation • RAST classes are scaled 0 to 5 • RAST results of 0-1 are insignificant • RAST results of 2 may suggest future sensitivity and disease • RAST results of 3 or greater are usually clinically significant

  27. Environmental Controls • Dust Mite - Dust mite barriers, HEPA vacuums and dehumidification • Cat or Dog – Elimination from the home • Cockroach – Preventive insecticide and cleanliness • Mold – Repair of any water damage and dehumidification

  28. Cat vs. Dog The big difference…

  29. Treatment of Asthma • Acute medications (“Rescue”) • Preventive medications (“Controllers”) On the horizon – 24 hours LABA • Role of Education...

  30. Distribution of Asthma Hospital Admissions by Month 12% 10% 8% 6% 4% 2% 0% Jan Feb March April May June July Aug Sept Oct Nov Dec n=29,430 Data on file, GlaxoSmithKline. Pendergraft et al. J Allergy Clin Immunol. 2003; 111 (2):S267. [abstract]

  31. Asthma ICU Admissions as a Percent of Monthly Asthma Hospitalizations n=2,976 Data on file, GlaxoSmithKline. Pendergraft et al. J Allergy Clin Immunol. 2003; 111 (2):S267. [abstract]

  32. US deaths due to asthma1,2 Year Deaths Due to Asthma Since 1997 • Number of deaths due to asthma has declined.3 • More patients receive formal disease education.3 • Hospitalization rates overall have remained stable.3 Deaths, No. 1. American Lung Association. Trends in Asthma Morbidity and Mortality. July 2006. 2. CDC. National Vital Statistics Reports. Deaths: Preliminary Data for 2004. 2006. 3. NAEPP, NHLBI, NIH. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. August 2007.

  33. Controllers • Anti-inflammatory agents: • Oral corticosteroids (“OCS”) • Inhaled corticosteroids (“ICS”) • Leukotriene receptor antagonists (“LTR”) • Miscellaneous: • Long-acting beta-agonist (“LABA”) • Cromolyn, nedocromil, and theophylline

  34. Current Use ofAnti-Inflammatory Medication Anti-inflammatory (past year) >4 Canisters of Reliever Medication (past year) 60 48 46 50 40 34 29 Proportion of Individuals (%) 28 26 30 23 * * 20 20 14 13 10 0 Mild Intermittent Mild Persistent Moderate Severe Total Persistent Persistent Short-term Symptom Burden * P<0.01 for difference between intermittent and persistent asthma. Adams et al. J Allergy Clin Immunol. 2003;112:445-450.

  35. Rules of “2” New Classification: “Intermittent” only

  36. New Classification: “Persistent”

  37. Is It Time for aParadigm Shift in Asthma? Asthma26 million in US1 Persistent92.7% Mild Intermittent7.3% Mild 15.4% Moderate/Severe77.3% 1. Mannino, et al. MMWR. 2002;51(SS-1):1–13. Adapted from Fuhlbrigge, et al. Am J Respir Crit Care Med. 2002:160:1044-1049.

  38. The Development of Guidelines Has Evolved With Our Understanding of Asthma 1991 Expert Panel Report (EPR): Guidelines for the Diagnosis and Management of Asthma issued 2007 NAEPP (EPR-3) updated guidelines issued 2002 Updates of selected topics (EPR-update) 1989 First expert panel convened 1997 EPR-2 issued 2006 GINA guidelines published 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 EPR-3 Recognition that natural course of asthma does not appear to be altered by current antiinflammatory treatments; increased focus on asthma control; emphasis on individualized treatment EPR-1 Asthma highlighted as an inflammatory disease EPR-2 Importance of early recognition/intervention recognized NAEPP, NHLBI, NIH. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. August 2007.

  39. Asthma Remains a Public Health Issue Young children experience a disproportionate number of hospitalizations (2004)1,4 Asthma prevalence in the United States1–3 Adults,>18 y Total US Population, % Children,4 y Year Number of Hospitalizations per 10,000 US Population 1. NAEPP, NHLBI, NIH. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. August 2007. 2. CDC, NCHS. cdc.gov/nchs/about/major/nhis/released200703.htm. June 2007. 3. CDC. MMWR. 2001;50:682–686. 4. CDC, NCHS. cdc.gov/nchs/products/pubs/pubd/hestats/ashtma03-05/asthma03-05.htm. Accessed October 2, 2007.

  40. Classifying Asthma Severity Impairment aEIB=exercise-induced bronchoconstriction. Adapted from NAEPP, NHLBI, NIH. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. August 2007.

  41. Classifying Asthma Control Impairment aACQ values of 0.76–1.4 are indeterminate regarding well-controlled asthma. Adapted from NAEPP, NHLBI, NIH. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. August 2007.

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