Asthma

1. Asthma

2. Definition • Asthma is an inflammatory disorder manifested by a clinical syndrome of episodic dyspnea, wheeze, and cough with reversible airflow obstruction and bronchial hyperresponsiveness.

3. Expert Panel Report 2:Four Components ofAsthma Management • Measures of Assessment and Monitoring • Control of Factors Contributing to Asthma Severity • Pharmacologic Therapy • Education for a Partnership in Asthma Care

4. Component 1: Measures of Assessment and Monitoring • Two aspects: • Initial assessment and diagnosis of asthma • Periodic assessment and monitoring

5. Initial Assessment and Diagnosis of Asthma • Determine that: • Patient has history or presence of episodic symptoms of airflow obstruction • Airflow obstruction is at least partially reversible • Alternative diagnoses are excluded

6. Initial Assessment andDiagnosis of Asthma (continued) • Methods for establishing diagnosis: • Detailed medical history • Physical exam • Spirometry to demonstrate reversibility

7. Initial Assessment andDiagnosis of Asthma (continued) Does patient have history or presence of episodic symptoms of airflow obstruction? • Wheeze, shortness of breath, chest tightness, or cough • Asthma symptoms vary throughout the day • Absence of symptoms at the time of the examination does not exclude the diagnosisof asthma

8. Initial Assessment andDiagnosis of Asthma (continued) Is airflow obstruction at least partially reversible? • Use spirometry to establish airflow obstruction: • FEV1 < 80% predicted; • FEV1/FVC <65% or below the lower limit of normal • Use spirometry to establish reversibility: • FEV1 increases >12% and at least 200 mL after using a short-acting inhaled beta2-agonist

9. Initial Assessment andDiagnosis of Asthma (continued) Are alternative diagnoses excluded? • Vocal cord dysfunction, vascular rings, foreign bodies, other pulmonary diseases

10. Bronchoprovocation Testing • Methacholine Challenge • Exercise Induced Bronchospasm • Increased sensitivity • Decreased specificity • Very high negative predictive value

11. Methacholine Challenge • Increasing doses of methacholine given by inhalation • Repeated spirometry performed • Decrement of FEV1 by 15% is diagnostic of bronchial hyperreactivity at dose < 4 mg/ml. • 4-16 mg/ml is considered by most to be borderline • Clinical interpretation in requires correlation with symptoms.

12. Classification of Asthma Severity: Clinical Features Before Treatment Days With Nights With PEF or PEF Symptoms Symptoms FEV1 Variability Step 4 Continuous Frequent 60% 30% Severe Persistent Step 3 Daily 5/month 60%-<80% 30% Moderate Persistent Step 2 3-6/week 3-4/month 80% 20-30% Mild Persistent Step 12/week 2/month 80% 20% Mild Intermittent Footnote: The patient’s step is determined by the most severe feature.

13. Periodic Assessment and Monitoring • Teach all patients with asthma to recognize symptoms that indicate inadequate asthma control. • Patients should be seen by a clinicianat least every 1 to 6 months.

14. Monitoring Symptoms • Symptom history should be based ona short (2 to 4 weeks) recall period • Symptom history should include: • Daytime asthma symptoms • Nocturnal wakening as a result ofasthma symptoms • Exercise-induced symptoms • Exacerbations

15. Monitoring Lung Function: Spirometry • Spirometry is recommended: • At initial assessment • After treatment has stabilized symptoms • At least every 1 to 2 years

16. Monitoring Lung Function: Peak Flow Monitoring It is unclear whether peak flow monitoring is better than symptomatic monitoring in all patients. Consider whether patients with moderate-to-severe persistent asthma should: • Have a peak flow meter and learn to monitortheir peak flow • Do daily long-term monitoring or short-term(2 to 3 weeks) monitoring • Use peak flow monitoring during exacerbations

17. Monitoring Lung Function: Peak Flow Monitoring (continued) Patients should: • Measure peak flow on waking before taking a bronchodilator • Use personal best • Be aware that a peak flow <80% of personal best indicates a need for additional medication • Use the same peak flow meter over time

18. Monitoring Quality of Life/Functional Status • Periodically assess: • Missed work or school due to asthma • Reduction in usual activities due to asthma • Sleep disturbances due to asthma • Change in caregiver activities due tochild’s asthma

19. Monitoring Pharmacotherapy • Monitor: • Patient adherence to regimen • Inhaler technique • Frequency of inhaled short-actingbeta2-agonist use • Frequency of oral corticosteroid “burst” therapy • Side effects of medications

20. Component 2: Control of Factors Contributing to Asthma Severity • Assess exposure and sensitivity to: • Inhalant allergens • Occupational exposures • Irritants: • Indoor air (including tobacco smoke) • Air pollution

21. Component 2:Control of FactorsContributing to Asthma Severity(continued) • Assess contribution of other factors: • Rhinitis/sinusitis • Gastroesophageal reflux • Drugs (NSAIDs, beta-blockers) • Viral respiratory infections • Sulfite sensitivity

22. Work-Aggravated and Occupational Asthma:Evaluation Recognize the potential for workplace-related symptoms: • Sensitizers (e.g., isocyanates, plant oranimal products) • Irritants or physical stimuli (e.g., cold/heat,dust, humidity) • Coworkers have similar symptoms

23. Work-Aggravated andOccupational Asthma:Evaluation(continued) Recognize patterns of symptoms in relation to work exposures: • Improvement during vacations or days off(may take a week or more) • Symptoms may be immediate (<1 hour), delayed (most commonly, 2 to 8 hours after exposure), or nocturnal • Initial symptoms may occur after high-level exposure (e.g., spill)

24. Work-Aggravated andOccupational Asthma:Evaluation(continued) Document work-related airflow limitation • Serial charting for 2 to 3 weeks (2 weeks at work andup to 1 week off work as needed to identify or excludework-related changes in peak expiratory flow): • Record when symptoms and exposures occur • Record when a bronchodilator is used • Measure and record peak flow every 2 hours while awake • Immunologic tests • Refer for further confirmatory evaluation(e.g., bronchial challenges)

25. Control Other Factors That Can Influence Asthma Severity • Rhinitis • Intranasal corticosteroids are most effective • Sinusitis • Promote drainage; antibiotics for complicating acute bacterial infection • Gastroesophageal reflux • Medications; no food before bedtime; elevate head of bed • Influenza vaccine annually

26. Control Other Factors ThatCan Influence Asthma Severity(continued) • Viral infections • Annual influenza vaccination • Aspirin/nonsteroidal anti-inflammatory drugs (NSAIDs) • Ask adult patients about sensitivity • Counsel avoidance for those with sensitivity, severe asthma, or nasal polyps

27. Control Other Factors That Can Influence Asthma Severity(continued) • Sulfite-containing foods/beverages • All patients should avoid • Non-selective (especially) beta-blockers • All patients should avoid

28. Component 3:Pharmacologic Therapy • Asthma is a chronic inflammatory disorderof the airways. • A key principle of therapy is regulation of chronic airway inflammation.

29. Component 3: Pharmacologic Therapy Environmental risk factors (causes) INFLAMMATION Airway Airflow hyperresponsiveness limitation Precipitants Adapted with permission from Stephen T. Holgate, M.D., D.Sc. Symptoms • Asthma is a chronic inflammatory disorder of the airways. • A key principle of therapy is regulation of chronic airway inflammation.

30. Inhaled Medication Delivery Devices • Metered-dose inhaler (MDI) • Dry powder inhaler (DPI) • Spacer/holding chamber • Spacer/holding chamber and face mask • Nebulizer

31. Overview ofAsthma Medications • Daily: Long-Term Control • Corticosteroids (inhaled and systemic) • Cromolyn/nedocromil • Long-acting beta2-agonists • Methylxanthines • Leukotriene modifiers

32. Overview of Asthma Medications (continued) • As-needed: Quick Relief • Short-acting beta2-agonists • Anticholinergics • Systemic corticosteroids

33. Inhaled Corticosteroids • Most effective long-term-control therapy for persistent asthma • Small risk for adverse events at recommended dosage • Reduce potential for adverse events by: • Using spacer and rinsing mouth • Using lowest dose possible • Using in combination with long-acting beta2-agonists • Monitoring growth in children

34. Inhaled Corticosteroids(continued) • Benefit of daily use: • Fewer symptoms • Fewer severe exacerbations • Reduced use of quick-relief medicine • Improved lung function • Reduced airway inflammation

35. Estimated Comparative Daily Dosages of InhaledCorticosteroids for Adults Drug Low Dose Medium Dose High Dose Beclomethasone 168 - 504 mcg 504 - 840 mcg > 840 mcg Budesonide DPI 200 - 400 mcg 400 - 600 mcg > 600 mcg Flunisolide 500 - 1,000 mcg 1,000 - 2,000 mcg >2,000 mcg Fluticasone 88 - 264 mcg 264 - 660 mcg > 660 mcg Triamcinolone 400 - 1,000 mcg 1,000 - 2,000 mcg >2,000 mcg

36. Long-Acting Beta2-Agonists • Not a substitute for anti-inflammatory therapy • Not appropriate for monotherapy • Beneficial when added to inhaled corticosteroids • Not for acute symptoms or exacerbations

37. Short-Acting Beta2-Agonists • Most effective medication for relief of acute bronchospasm • More than one canister per month suggests inadequate asthma control • Regularly scheduled use is not generally recommended

38. Leukotriene Modifiers • Mechanisms • 5-LO inhibitors • Cysteinyl leukotriene receptor antagonists • Indications • Long-term-control therapy in mildpersistent asthma • Improve lung function • Prevent need for short-acting beta2-agonists • Prevent exacerbations • Further experience and research needed • Do not replace inhaled corticosteroids • Not for monotherapy

39. Stepwise Approach to Therapy: Gaining Control 1. Start high and step down. 2. Start at initial level of severity; gradually step up. STEP 4 Severe Persistent 2 STEP 3 1 Moderate Persistent STEP 2 Mild Persistent STEP 1 Mild Intermittent

40. Stepwise Approach to Therapy for Adults and Children >Age 5: Maintaining Control • Step down if possible • Step up if necessary • Patient education and environmental control at every step • Recommend referral to specialist atStep 4; consider referral at Step 3 STEP 4 Multiple long-term-control medications, includeoral corticosteroids STEP 3 > 1 Long-term-control medications STEP 2 1 Long-term-control medication: anti-inflammatory STEP 1 Quick-relief medication: PRN

41. Indicators of PoorAsthma Control • Step up therapy if patient: • Awakens at night with symptoms • Has an urgent care visit • Has increased need for short-acting inhaled beta2-agonists • Uses more than one canister of short-acting beta2-agonist in 1 month

42. Indicators of Poor Asthma Control (continued) • Before increasing medications, check: • Inhaler technique • Adherence to prescribed regimen • Environmental changes • Also consider alternative diagnoses

43. Step 1 Treatment for Adults and Children >5: Mild Intermittent • Daily Long-Term Control • Not needed • Quick Relief • Short-acting inhaledbeta2-agonist PRN • Increasing use, or use more than 2x/week, may indicate need for long- term-control therapy • Intensity of treatment depends on severity of exacerbation STEP 1

44. Step 2 Treatment for Adults and Children >5: Mild Persistent • Daily Long-Term Control • Anti-inflammatory • Inhaled corticosteroid (low dose) or • Cromolyn or nedocromil STEP 2

45. Step 3 Treatment for Adults andChildren >5: Moderate Persistent • Daily Long-Term Control • Inhaled corticosteroid (low-to-medium dose) AND • Long-acting bronchodilator (long-acting beta2-agonist OR • Inhaled corticosteroid (medium dose) • IF NEEDED, increase to: • Inhaled corticosteroid (medium-to-high dose) andlong-acting bronchodilator • Consider referral to a specialist STEP 3

46. Step 4 Treatment for Adults andChildren >5: Severe Persistent • Daily Long-Term Control • Inhaled corticosteroid (high dose) AND • Long-acting bronchodilator • Long-acting inhaledbeta2-agonist OR • Sustained-release theophylline OR • Long-acting beta2-agonist tablets AND • Oral corticosteroid, long term • Recommend referral to a specialist STEP 4

47. Step 2-4 Treatment for Adults andChildren >5: Severe Persistent(continued) • Quick Relief • Short-acting inhaled beta2-agonist PRN • Daily or increasing use indicates need for long-term control therapy • Intensity of treatment depends on severity of exacerbation STEP 4

48. Managing Exercise-Induced Bronchospasm (EIB) • Anticipate EIB in all patients • Teachers and coaches need to be notified • Diagnosis • History of cough, shortness of breath, chest pain or tightness, wheezing, or endurance problemsduring exercise • Conduct exercise challenge OR have patientundertake task that provoked the symptoms • 15% decrease in PEF or FEV1 is compatible with EIB

49. Managing Exercise-Induced Bronchospasm (EIB) (continued) • Management Strategies • Short-acting inhaled beta2-agonists used shortly before exercise last 2 to 3 hours • Salmeterol may prevent EIB for 10 to 12 hours • Cromolyn and nedcromil are also acceptable • A lengthy warmup period before exercise may preclude medications for patients who can tolerate it • Long-term-control therapy, if appropriate

50. Management of Asthma Exacerbations • Inhaled beta2-agonist to provide prompt relief of airflow obstruction • Systemic corticosteroids to suppress and reverse airway inflammation • For moderate-to-severe exacerbations, or • For patients who fail to respond promptly and completely to an inhaled beta2-agonist