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Update on Acute Asthma

Update on Acute Asthma. Carlos Camargo, MD, DrPH Emergency Medicine, MGH Channing Laboratory, BWH Harvard Medical School. www.emnet-usa.org. Outline of Presentation. Background NAEPP guidelines Novel therapies Preventive interventions Summary. Definition of Asthma.

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Update on Acute Asthma

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  1. Update on Acute Asthma Carlos Camargo, MD, DrPH Emergency Medicine, MGH Channing Laboratory, BWH Harvard Medical School www.emnet-usa.org

  2. Outline of Presentation • Background • NAEPP guidelines • Novel therapies • Preventive interventions • Summary

  3. Definition of Asthma • Chronic lung disease characterized by: • Airway narrowing that is reversible (± completely) either spontaneously or with treatment • Airway inflammation • Airway hyper-responsiveness to a variety of stimuli. • Episodic dyspnea with associated wheezing • Heterogeneous group with: • Shortness of breath • Wheezing • Cough ATS. ARRD 1987

  4. NAEPP Guidelines, 1997 • National Asthma Education and Prevention Program (NAEPP) • Classification of chronic asthma: • Mild intermittent asthma • Mild persistent asthma (>2 days/wk, >2 nights/mo) • Moderate persistent asthma • Severe persistent asthma • Inhaled corticosteroids (ICS) are “preferred treatment” for all patients with persistent asthma

  5. Epidemiology • 17 - 27 million Americans (6-10% prevalence) • 10 million office visits + 2 million ED visits + 500,000 hospitalizations + 5,000 deaths • Major cause of school and work absences • At least $12 billion per year • Increasing burden for years ... but now flat (or  )

  6. Asthma Prevalence, 1980-2001 NHIS 2001 * 11.3 * 7.3 * 4.3

  7. Asthma Prevalence, 1980-2001 NHIS 2001 * 11.3 * 7.3 * 4.3

  8. Asthma Mortality, 1980-1999

  9. ED Visits for Asthma, 1992-2000 Visits in thousands NHAMCS Database

  10. MARC • Founded 1996 • Goal: To improve care of acute asthma & other airway disorders • Funded by NIH, industry, foundations • Emergency Medicine Network • www.emnet-usa.org

  11. EMNet Sites(137 US sites) 9/22/04

  12. Potential for Improving Asthma • ED is often used for asthma care • 2 million ED visits per year • Most asthma hospitalizations begin in the ED • Among ED patients (MARC data): • 74% adults (63% children) use ED for all “problem” asthma care • 45% adults (31% children) receive all asthma Rx from ED • With PCP: 63 + 61% for problem care; 24 + 25% for all Rx • High-risk population

  13. ED Patients with Acute Asthma

  14. ED and Hospital Management: Goals • Correct significant hypoxemia • Rapidly reverse airflow obstruction • Decrease likelihood of recurrence NAEPP, 1997

  15. ED and Hospital Management: Initial Treatment Mild-to-Moderate Exacerbation (PEF > 50%) • Oxygen to achieve O2 sat > 90% • Inhaled  2-agonist by MDI or neb, up to 3 in 1st hr • Oral corticosteroid if no immediate response or if patient recently took oral corticosteroid NAEPP, 1997

  16. ED Treatment, 1992-1999 ED Treatment, 1992-1999 90% 80% 70% Antiasthmatic Corticosteroid 60% Antimicrobial %Usage 50% 40% 30% 20% 10% 0% 1993 1994 1995 1996 1997 1998 1999 National Center for Health Statistics, CDC

  17. Systemic Steroids at Discharge P for trend <0.001

  18. ED and Hospital Management:Initial Treatment (continued) Severe Exacerbation (PEF < 50%) • Oxygen to achieve O2 sat > 90% • Inhaled high-dose 2 -agonist and anticholinergic by neb q 20 minutes or continuously for 1 hour • Oral corticosteroid NAEPP, 1997

  19. ED and Hospital Management:Initial Treatment (continued) Impending or Actual Respiratory Arrest • Intubation and mech ventilation with 100% O2 • Nebulized 2-agonist and anticholinergic • IV corticosteroid • Admit to hospital intensive care NAEPP, 1997

  20. 2002 Update on Selected Topics • Antibiotics not recommended for acute asthma • ICS are preferred treatment for children of all ages with persistent asthma • ICS + long-acting -agonist is the preferred treatment for moderate or severe persistent asthma in individuals age 6 and older NAEPP, 2002

  21. Dual Therapy with ICS + LABA (weeks)

  22. Dual Therapy with ICS + LABA (days)

  23. Novel Therapies in the ED • IV magnesium • Heliox • IV leukotriene modifiers www.emnet-usa.org

  24. IV Mg for Acute Asthma – Admit Rate

  25. Heliox for Severe Acute Asthma – PEF

  26. IV Montelukast for Acute Asthma – FEV1

  27. ED-Initiated Preventive Interventions • High-risk population • Use of ED for “problem asthma” care + asthma Rx • What interventions are feasible in the ED setting? • Examples from MARC: • ICS initiation at discharge from ED • Asthma education programs • Bridging the gap between ED & primary asthma care

  28. Initiation of ICS at Discharge *

  29. ICS after the ED -- Relapse at 20-24 Days

  30. Prevention of Repeat ED Visits

  31. 2.0 1.5 1.0 Rate Ratio of Asthma Death 0.5 0.0 1 0 2 4 6 8 10 12 MDIs of Inhaled Corticosteroids per Year Prevention of Fatal Asthma Suissa & Ernst, JACI 2001.

  32. National Asthma Educator Certification Board Mission Statement To promote optimal asthma management and quality of life among individuals with asthma, their families and communities, by advancing excellence in asthma education through the Certified Asthma Educator process. www.naecb.org

  33. Follow-up with PCP • Philadelphia study • randomized trial, 1 center, n=178 • $25 intervention (free meds, taxi vouchers, 48-hr call) • f/u with PCP: usual care (29%) vs. intervention (46%), p=0.02 RR=1.6 (95%CI, 1.1-2.4) • EMF Center of Excellence Award • Recently completed RCT at 9 EMNet sites • 1 month: 50% increase in PCP follow-up (ACEP 2001) Baren et al, Ann Emerg Med 2001

  34. Follow-up with PCP • Philadelphia study • randomized trial, 1 center, n=178 • $25 intervention (free meds, taxi vouchers, 48-hr call) • f/u with PCP: usual care (29%) vs. intervention (46%), p=0.02 RR=1.6 (95%CI, 1.1-2.4) • EMF Center of Excellence Award • Recently completed RCT at 9 EMNet sites • 1 month: 50% increase in PCP follow-up (ACEP 2001) • 6 and 12 months: no diff in clinical outcomes … (ACEP 2002) • Next steps … facilitated referral to specialists?

  35. Summary • Asthma epidemiology • NAEPP guidelines • 1997: O2 prn, inhaled ß-agonist + antichol, systemic steroids • 2002: ICS for children of all ages with persistent asthma ICS + LABA for age 6+ with moderate-severe persistent • Novel treatments – severe exacerbations only • Prevention at all clinical encounters! • Start ICS at ED discharge … consider ICS + LABA • Asthma education (brief) … consider outpatient session • Arrange continuing care … consider referral to specialist

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