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Asthma: Co-Existing and Co-Morbid Conditions

Asthma: Co-Existing and Co-Morbid Conditions. Richard F. Lockey, M.D. Division of Allergy and Immunology Department of Internal Medicine University of South Florida College of Medicine and James A. Haley Veterans’ Medical Center Tampa, Florida. Learning Objectives.

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Asthma: Co-Existing and Co-Morbid Conditions

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  1. Asthma: Co-Existing and Co-Morbid Conditions Richard F. Lockey, M.D. Division of Allergy and Immunology Department of Internal Medicine University of South Florida College of Medicine and James A. Haley Veterans’ Medical Center Tampa, Florida

  2. Learning Objectives At the completion of this presentation, the participant should be able to: • Have knowledge of co-existing and co-morbid conditions of asthma • Understand that asthma cannot be properly treated unless these conditions are addressed

  3. Food Rhinosinusitis a. Allergic b. Non-allergic c. Infectious d. Nasal polyposis e. Other Gastroesophageal Reflux Disease (GERD) Vocal Cord Dysfunction (VCD) Obesity Osteopenia and Osteoporosis Psychological Problems Churg-Strauss Disease Sleep Apnea Pregnancy COPD versus Asthma Eczema Smoking Cessation Infection (Vaccination) Bronchiectasis and Cystic Fibrosis Exercise-Induced Asthma Others- Endocrine, Conjunctivitis,Congestive Heart Failure, Pulmonary Embolism, Medications Primary Ciliary Dyskinesia

  4. Introduction • Asthma is perhaps the most treatable of all chronic diseases. • For optimal outcomes, co-existing and co-morbid conditions must be identified and treated. • Co-morbid conditions and their diagnosis and treatment should be included in asthma guidelines

  5. Questions for patients with asthma (children and adults as appropriate) • History + ask and think about co-morbid conditions • Complete physical examination 3. Spirometry and flow volume loop, as necessary 4. Risk factors for various co-morbid conditions (almost everyone has risk factors) 5. Psychological profile

  6. Questions for patients with asthma (children and adults as appropriate) 6. Sleep profile • Weight assessment • Smoking (drinking and drug) assessment 9. Diet – appropriate calcium and vitamin D. Exercise (walk 1.5 miles) or stand (1.5 hours) 10. Dexa bone scan? 11. Rhinoscopy, as indicated 12. Vaccination assessment 13. Others as necessary

  7. Risk factors for exacerbation of difficult-to-treat asthma 39 had 3 severe exacerbations/yr 136 subjects 29 had 1 severe exacerbation/yr Brinke , et al. Eur Respir J 2005; 26: 812.

  8. Conclusions Odds ratio (OR) associated with 3 exacerbations a) severe sinus disease, OR 3.7 b) GERD, OR 4.9 c) URIs, OR 6.9 d) Psychological dysfunction, OR 10.8 e) Obstructive sleep apnea, OR 3.4 All patients with frequent exacerbations had 1/5 while 52% had 3/5 Brinke , et al. Eur Respir J 2005; 26: 812.

  9. Risk Factors for Fatal Asthma >> Social history - Low socioeconomic status or inner-city residence - Illicit drug use - Major psychosocial problems >> Co-morbidities - Cardiac disease - Other chronic lung disease - Chronic psychiatric disease -Adapted from NIH/NHLBI National Asthma Education and Prevention Program. Expert Panel Report 3: guidelines for the diagnosis and management of asthma: Clinical practice guidelines. Bethesda (MD): 2007 -Guilbert T et al.In Middleton 7th ed. Allergy: Principles and Practice, 2009, p 1323

  10. Rhinosinusitis

  11. Rhinosinusitis (Allergic, Nonallergic, Infectious) and Asthma Incidence and Association 1. Rhinitis (all kinds) linked to sinusitis (rhinosinusitis) and to nasal polyps – all of which are co-morbid conditions of asthma 2. Up to 70% of patients with asthma also present with rhinosinusitis. Annesi-Maesano I. Allergy 1999;54 (suppl) 7-13

  12. Rhinosinusitis (Allergic, Nonallergic, Infectious) and Asthma Incidence and Association 3. Allergic rhinitis can be a precursor of asthma 4. Deterioration of rhinitis symptoms negatively impacts bronchial responsiveness and conversely adequate management of rhinitis improves asthma 5. Chronic sinus disease may be linked to severe asthma Bachert C et al. In: Middleton 7th ed. Allergy: Principles and Practice, p 991

  13. Rhinosinusitis (Allergic, Nonallergic, Infectious) and Asthma Incidence and Association 6. Postulated that perennial allergic and non-allergic rhinitis rather than seasonal rhinitis predisposes to “sinusitis” 7. Controlling infectious sinusitis may decrease asthma medication needs Moss MH et al. In: Middleton 6th ed. Allergy: Principles and Practice, 2003, p 1225

  14. Nasal Polyps and Asthma • Nasal polyps unusual in atopic patients • 40 – 80% of aspirin-exacerbated asthma subjects have nasal polyps and 15% of polyp patients have aspirin-exacerbated asthma • Nasal polyps in 37 – 48% of patients with cystic fibrosis (some patients have concomitant asthma) • Bronchial hypersensitivity exists in many patients with polyps Bachert C et al. In: Middleton 7th ed. Allergy: Principles and Practice, p 991

  15. Gastroesophageal Reflux Disease (GERD)

  16. Atypical symptoms of GERD Chest pain Hoarseness Chronic cough Sore throat Wheezing 80% of subjects with asthma may have GERD Throat clearing (feels like “cotton- ball” which cannot clear) Globus Laryngospasm Dental erosion -Mujica et al. Postgrad Med 1999 -DeVault et al. Am J Gastroenterol 1999

  17. Symptoms of GERD in Childhood • Regurgitation especially after eating • Signs of esophagitis (irritability, arching, choking, gagging, feeding aversion) Symptoms resolve in most by 12-24 mo • Older children abdominal and chest discomfort • Also, stridor, obstructive apnea, or lower airway disease Orenstein S et al. Nelson 17th ed., 1217

  18. Prevalence of GERD in Children • Abnormal pH probes common and many such patients have no clinical symptoms Chiquette et al. J Asthma 2002;39:135 Khoshoo et al. Chest 2003;123:1008 Sheikh et al. Pediatr Pulmonol 1999;28:181

  19. Cochrane Data Base Review of GERD Treatment for Asthma in Adults and Children (2006) 12 randomized controlled trials of Rx for GERD in adults and children 2 independent reviewers Interventions included proton pump inhibitors (6), H2 receptor antagonists (5), surgery and conservative management (1) Temporal relationship in 4 trials found between asthma and GERD Anti-reflux Rx did not consistently improve lung function, asthma symptoms, nocturnal asthma and medication use Conclusion: No overall improvement but subgroups may gain benefit; albuterol use may be decreased

  20. GERD and Chronic Rhinosinusitis • Upper respiratory symptoms frequent among subjects with symptomatic GERD Dx’d by esophageal study • GERD associated with chronic rhinosinusitis in children and adults -Theodoropoulos DS et al. Am J Resp Crit Care Med 2001;164:72-6 -Barbero GJ. Otolaryngol Clin North Am 1996;29:27-38 -Phipps CD et al. Arch Otolaryngol Head Neck Surg 2000;126:831-6 -Ulualp SO et al. Am J Rhinol 199;13:197-202 -DiBaise et al. Ann Int Med 1998;1291078-83

  21. Vocal Cord Dysfunction (VCD)

  22. Vocal Cord Dysfunction (VCD) Definition of VCD Paradoxical adduction (closure) of the vocal cords/ folds during inspiration and/or early expiration “Irritable larynx syndrome” Episodic laryngeal dysfunction triggered by irritant exposures or can occur spontaneously with variable clinical manifestations: chronic cough, frequent throat-clearing, globus pharyngeus, choking episodes, dysphonia, masquarades as asthma; exercise–induced asthma, or complicates asthma -Mikita JA, et al., All Asthma Proc 2006;27:411. -Bahrainwala AH, et al., Curr Opin Pulm Med 2001;7:8. -Byrd RP, et al., Postgrad Med 2000;108:37. -Balkissoon R, In: Nonallergic Rhinitis, Baraniuk JN, Shusterman D (eds): Informa Healthcare USA, Inc., New York, pp. 411, 2007.

  23. VCD Diagnostic Criteria Paradoxical inspiratory adduction of anterior 2/3 vocal folds on laryngoscopy ± Posterior diamond-shaped glottic gap Variable extrathoracic obstruction on flow volume loops posterior anterior

  24. Spirometry and Flow Loop FEV1 (88% of predicted), no bronchodilator response. Flattened inspiratory loop

  25. Vocal Cord Dysfunction (VCD) National Jewish Health 95 subjects with asthma and/or VCD a. 42 had VCD alone b. 53 had VCD with asthma c. 28% had been intubated d. Misdiagnosed with asthma for average of 4.8 yrs e. “Very sick patients” with VCD Newman AB et al. Am J Resp Crit Care Med 1995;152:1382

  26. Psychosocial Problems

  27. Psychosocial Problems • Stress is linked to many diseases – asthma is no exception • Stress may alter immune system in direction of Th2 response • Depression particularly dangerous – especially for severe asthma • Psychological problems are particularly dangerous for a patient with severe asthma Bloomberg GR, Chen E. Immunol Allergy Clin N Am 2005;25,83

  28. Psychosocial Problems • Stress associated with increased prevalence of asthma • Stress associated with increased exacerbations • ? whether asthmatic children have significantly more total anxiety disorders, lower self-esteem, greater functional impairment, past school problems, past psychiatric illnesses, and familial stress -Guilbert T et al.In Middleton 7th ed. Allergy: Principles and Practice, 2009, pp 1319-1343 -Wright RJ et al. Am J Respir Crit Care Med 2002;165:358-365 -Sandberg S et al. Lancet 2000;356:982-987

  29. Asthma and Sleep Apnea

  30. Asthma and Sleep Apnea Definition Obstructive Sleep Apnea Syndrome (OSAS) is: 1. Complete or partial collapse of the upper airways during sleep with consequent cessation of breathing despite ongoing respiratory effort plus coexistent daytime somnolence 2. Coexistent daytime somnolence (disabling) -Staevska MP, Baraniuk JN. Rhinitis and Sleep Apnea. In: Baraniuk J, -Shusterman D (eds). Nonallergic Rhinitis, 2007, Informa Healthcare, New York, 449-472

  31. Asthma and Sleep Apnea Adult Symptoms At least one of the following 3 observations: • Patient complaints of unintentional sleep episodes during wakefulness, daytime sleepiness, unrefreshing sleep, fatigue, or insomnia • Patient wakes up at night with breath holding, gasping, or choking • Bed partner observes symptoms of loud snoring and/or breathing interruptions - Staevska MP, Baraniuk JN. Rhinitis and Sleep Apnea. In: Baraniuk J, Shusterman D (eds). Nonallergic Rhinitis, 2007, Informa Healthcare, New York, 449-472

  32. Asthma and Sleep Apnea Symptoms - Children • The caregiver reports snoring and/or labored or obstructed breathing during sleep. • The caregiver observes at least one of the following: - Paradoxical inward rib cage motion during inspiration movement arousals - Diaphoresis - Neck hyperextension during sleep - Excessive daytime sleepiness, hyperactivity, or aggressive behavior - Slow rate of growth - Morning headaches - Secondary enuresis Staevska MP, Baraniuk JN. Rhinitis and Sleep Apnea. In: Baraniuk J, Shusterman D (eds). Nonallergic Rhinitis, 2007, Informa Healthcare, New York, 449-472

  33. Asthma and Sleep ApneaPrevalence of Obstructive Sleep Apnea-Hypopnea (OSAH) in Severe versus Moderate Asthma • 23 of 26 (88%) with severe asthma, 15 of 26 (58%) with moderate asthma, 8 of 26 (31%) controls without asthma had apnea-hypopnea index ≥ 15 events/hour Using more restrictive criteria, 50% severe, 23% moderate, and 12% (control) of subjects had obstructive sleep apnea (OSA) • No correlation between severity of sleep-disordered breathing and asthma severity Julien JY et al. J Allergy Clin Immunol 2009;124:371-6

  34. Asthma and Sleep Apnea • Risk of sleep apnea increases with nasal obstruction, large adenoids and tonsils, and elongated face. • Rhinitis appears to increase the risk of obstructive sleep apnea. 3. Many other risk factors associated with sleep apnea include obesity, gastroesophageal reflux, endocrine problems, and others.

  35. Asthma and Infection (Vaccination)

  36. Influenza • Influenza is a trigger for the development of asthma as well as exacerbates asthma • Influenza infection leads to decline in lung function. It increases the risk of hospitalization and death in patients with COPD • May cause up to 30% of COPD exacerbations/year

  37. Influenza Vaccine • An injectable trivalent, inactivated viral vaccine (TIV) composed of seasonal H3N2, H1N1, and Influenza B • A live attenuated vaccine (LIAV) is also available • Studies show no increase in symptoms after vaccination • Low to medium dose ICS does not affect vaccine responsiveness • High dose ICS does decrease response to Influenza B • Current evidence is conflicting on the effectiveness of influenza vaccination in preventing morbidity and mortality in COPD and asthma • Influenza vaccination is recommended in asthmatics and COPD based upon the known complications of influenza infection CDC. MMWR: Recommendations and Reports 2009;58:1-52 (RR-8)

  38. Streptococcus pneumoniae -Talbot T et al. N Engl J Med 2005;352:2082-90 -Juhn YJ et al. J Allergy Clin Immunol 2008;122:719-23 • Colonization occurs frequently in patients with COPD and asthma and increases the risk for exacerbation as well as invasive disease • Currently, a 23-valent polysaccharide vaccine (PPV-23) is recommended for use in: • Adults ≥ 65 • ≥ 2 years whom are at risk for invasive disease • Revaccination is recommended for: • ≥ 65 if previous dose was given at age < 65 • Patients at risk for invasive disease • Should be given no sooner than 5 years after previous dose

  39. Streptococcus pneumoniae -Talbot T et al. N Engl J Med 2005;352:2082-90 -Juhn YJ et al. J Allergy Clin Immunol 2008;122:719-23 -Jung J et al. J Allergy Clin Immunol 2010;125;217-21 The risk of pneumonia is 11% to 17% in two studies of asthma. The Advisory Committee on Immunization Practices (ACIP) recommends all adults with asthma(19-64 yrs) receive the vaccine for S. pneumoniae (PPV-23).

  40. Pertussis CDC. MMWR: Recommendations and Reports1997;46:1-25(RR-7) CDC. MMWR:Recommendations and Reports 2006;55:1-37 (RR-17) • 5,000-7,000 cases occur each year in the U.S. • Adults can serve as a reservoir for infection of children due to waning immunity • Infection with B. pertussiscan lead to exacerbations of both asthma and COPD • A combination vaccine of tetanus, diphtheria, and pertussis [Adacel (TdaP)] is recommended in these patients as a single dose vaccination for adults age 19-64 • Vaccination has been shown to reduce the number of cases by 44%

  41. Herpes Zoster Reactivation of Varicella Zoster leads to significant morbidity in aging adults, and patients on high dose inhalational or oral steroids (<20mg/day prednisone) may be at higher risk. Zostavax has been shown to reduce the incidence of herpes zoster reactivation by 51.3% and post-herpetic neuralgia by 66.5%. Recommended for all adults (60 and older) as a single dose. Also recommended for all asthmatics and patients with COPD, 60 years and older if on ≤ 20mg/day of prednisone (or equivalent glucocorticosteroid). CDC. MMWR: Recommendations and Reports 2008;57:1-30 (RR-5)

  42. Conclusions • Asthma is perhaps the most treatable of all chronic diseases. • For optimal outcomes, co-existing and co-morbid conditions must be identified and a appropriately treated. • Co-existing and co-morbid conditions should be part of asthma guidelines

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