Asthma

1. Asthma Rita All NUR 652 Primary Care ICD 9 codes: 493.00 Extrinsic asthma, unspecified 493.90 Asthma, unspecified, without mention of status asthmaticus 493.92 Asthma, unspecified, with acute exacerbation

2. Asthma- Definition • Asthma is a chronic, reversible, inflammatory airway disease • Characteristics include bronchoconstriction that is reversible, airway edema and hyperresponsiveness • Recurrent bouts of breathlessness and wheezing, chest tightening, and cough (can be worse at night) • Can be highly unpredictable, from mild attack to complete airway obstruction leading to death.

3. Asthma- Classification 4 major classifications : Based on daily activity, symptom occurrences, use of rescue inhaler, and FEV levels • Intermittent- no daily medication needed, rescue inhaler only • There is no interference with daily activity • Symptoms may occur 2 or less days a week, with awakening from sleep 2 or less nights a month • Rescue inhaler used 2 or less days a week • Normal forced FEV between bouts, and greater than 80% during episodes

4. Asthma- Classification • Mild persistent- One daily control med needed- low dose inhaled corticosteroid, cromolyn, leukotriene modifier • There is minor interference with daily activity • Symptoms may occur 2 or more days a week, but not daily, with awakening from sleep 3-4 nights a month • Rescue inhaler used 2 or more days a week • Greater than 80% FEV between and during episodes

5. Asthma- Classification • Moderate persistent- inhaled beta2 agonist PRN, daily control medication- combination inhaled medium dose corticosteroid with long acting bronchodilator; cromolyn; leukotriene modifier. • There is some interference with daily activity • Symptoms may occur daily, with awakening from sleep at least 1 night a week, but not every night • Rescue inhaler used daily • 60-80% FEV between and during episodes

6. Asthma- Classification • Severe persistent- inhaled beta2 agonist PRN, multiple daily control medication- combination inhaled high dose corticosteroid with long acting bronchodilator; cromolyn; leukotrienemodifier, may need long term corticosteroids. • There is major interference with daily activity • Symptoms occur throughout the day, with awakening from sleep every night • Rescue inhaler used several times a day • Less than 60% FEV between and during episodes

7. Asthma- Pathophysiology Inflammatory cell infiltration Sub basement fibrosis Mucous hypersecretion Epithelial injury Smooth muscle hypertrophy Angiogenesis Airflow obstruction and bronchial responsiveness

8. Asthma Pathophysiology

9. Asthma- Etiology • Caused by extrinsic (environmental) and intrinsic (stress) triggers causing spontaneous remittance or exacerbation. • Genetic predisposition- IgE mediated response to aeroallergens (atopy)- strongest identifiable risk factor for asthma. • 3 principle triggers: • Allergens and environmental factors- • Molds, animal dander, pollen, dust, smoke, beta-blockers, or aspirin containing products, temperature changes • Infections- URI’s, RSV • Psychological factors- stress • Also can be caused by certain drugs : Betablockers, aspirins, new evidence suggests a Tylenol connection (Soferman, et al, 2013) • obesity, reflux • Inflammation allows for hyper-reactivity of the bronchi, limiting airflow, causing the symptoms of wheezing, chest tightness, cough and difficulty breathing

10. Incidence Affects 5-10% of population 7 million children, one of the most common childhood chronic diseases, highest in 5-17 years old 30 million Americans, 300 million globally and growing More common in boy youths More common in adult women, African American African Americans have a higher rate of mortality, possibly due to access of care, low income, compliance with treatment plans (Halterman, et al, 2011) Increase in prevalence, hospitalization, and death in the past 20 years 5500 deaths annually due to asthma in the US

11. Clinical findings • Accurate history very important • May be normal • General appearance: • Signs of respiratory distressor use of accessory muscles • Rhinitis • Nasal polyps • Swollen turbinates • Wheezing • Prolonged expiratory phase • Cough • Shortness of breath

12. Differential Diagnosis- Children • Upper Airway • Allergic rhinitis • Sinusitis • Airway Obstruction • Foreign body aspiration • Vocal cord dysfunction • Vascular ring/ laryngeal web • Laryngotracheomalacia • Airway obstruction from lymph nodes or tumor • Small airway obstruction • Viral bronchiolitis (up until age of 2- most common RSV) • Recurrent cough • GERD • Aspiration

13. Differential Diagnosis- Adults COPD CHF PE Tumor Pulmonary infiltration with eosinophilia Medications such as ACE inhibitors Vocal cord dysfunction

14. Social/ Environmental Considerations • Adolescents have a poor rate of compliance • Those with mild symptoms are least like to get ongoing preventative care, have an action plan, or know what to do or when to initiate therapy when symptoms occur • Chronic illness self image issues • Those that are uninsured or have lack of access to quality of healthcare will have poorer outcomes • Cost of medication: • Albuterol $50 • Pulmicort $175 • Flovent $170 • Singlair $185

15. Laboratory Tests Labs: not necessary, but may show eosinophilia, or elevated IgE, ABG’s to determine hypoxemia. Spirometry: Normal testing doesn’t rule out asthma. Measures forced vital capacity and forced expiratory volume in 1 sec. A reduced ratio of fev1/fvc with reversibility of 12% after bronchodilator use establishes diagnosis. Bronchoprovocation with use of methacholine, histamine, cold air, or exercise is the only definitive diagnostic test. Peak expiratory flow rates cannot determine diagnosis

16. Management/ Treatment Guidelines- Non pharmacologic Identification of triggers Controlling exposures Identify those at risk for reaction to aspirins or NSAIDS, beta- blockers, avoid exposure Food allergies and sulfites in food can precipitate symptoms Daily monitoring of peak expiratory flow record it on a record with any symptoms Written instructions including crisis plan

17. Management/ Treatment guidelines- Pharmacologic • First line: • Short acting beta agonist • Quick relief of symptoms, and prevent exercise induced asthma • Albuterol, xopenex, alupent, maxair • Use with aerochamber or spacer for increased efficacy with decreased side effects as compared to neb treatments. • Anticholinergic agents • Ipratropium bromide (atrovent), used in combination with SABA for acute treatment • Systemic corticosteroids • Can be used in all patients with acute asthma exac. • In mod to severe asthma as adjunct • Prednisolone 1-2 mg/kg/d for 7 days in adults and 3 days for children.

18. Management/ Treatment guidelines- Pharmacologic • Second line (for long term control): • Inhaled corticosteroids- preferred long term therapy for persistent asthma and during pregnancy (flovent, pulmicort) • Long acting beta agonists- not to be used alone, or severe outcomes including death may occur. Salbutamol or Formoterol • Combination products- preferred in moderate persistent asthma, if inhaled corticosteroids alone are not helpful (advair) • Leukotriene receptor agonists- not preferred for mild persistent. Singulair • Lipoxygenase pathway inhibitor- Alternative, not preferred for adjunctive treatment in adults. • Theophylline- not preferred as adjunt to inhaled corticosteroids • Cromolyn sodium and nedocromil are alternatives, but not preferred • Immunodilators- Adjunctive therapy, Omalizumab- for allergies and severe persistent

19. Complications Atelectasis Pneumonia Pneumomediastinum Pneumothorax Medication specific side effects/adverse reactions Respiratory failure Death

20. Follow up Step down therapy gradually, visits in 1-6 months depending on symptoms and response to treatment Review short term and long term goals Review daily self management plan Medication adjustment based on symptoms

21. Counseling/ Education Smoking cessation Prevention of second hand smoke exposure Removal or modification of allergens/ irritant triggers in living space Allergen immunotherapy Treat allergic rhinitis Use of inhalers with aerochambers When to use rescue inhaler (role of medications) Flu vaccine annually

22. Asthma action plan • Asthma action plan • Self monitoring of symptoms • Self monitoring of peak flow measurements • When to call provider • When to go to emergency room

23. Asthma Treatment Plan

24. Consultation/ Referral • Referral to allergist or pulmonologist if: • Unclear if true asthma • Additional patient education needed • If other diagnoses exist: Rhinitis, GERD, Sinusitis, OSA • If bronchoprovocation or skin testing is needed • For consideration of immunotherapy or anti- IgE therapy • Poorly controlled asthmatics with moderate to severe persistent asthma or multiple ECC visits

25. Multiple choice questions • 1. What drug class is the most effective rescue therapy for acute asthma symptoms? • Short acting beta agonist • Anticholinergic agent • Systemic corticosteroids • Inhaled corticosteroids 2. Which is not a commonly associated condition of asthma? • Obesity • Allergic Rhinitis • Eczema • Diabetes

26. Multiple choice questions • 3. Which is not an environmental risk factor for asthma? • Genetic predisposition • Viral infections • Tobacco smoke • Animal dander 4. The physical exam on a patient with asthma: • May be normal • May show accessory muscle use • Eczema may be present • All of the above

27. Multiple choice questions • 5. Which test would be appropriate for diagnosis of asthma? • Spirometry • CBC • Bronchoprovocation • Peak expiratory flow rates 6. Which person would be least likely to be diagnosed with asthma? • African American Male age 6 • Caucasian male aged 70 • African American female aged 48 • 2 year old caucasian boy with recent RSV

28. Multiple choice questions • 7. A 7 year old asthmatic male is questioned about his asthma control. His mom reports he only requires his inhaler once weekly, and is rarely awakened by symptoms at night. Which class of asthma would he fall into based on info provided? • Mild persistent • Intermittent • Moderate persistent • Severe persistent 8. What result may be found on a blood test for an asthmatic patient? • low WBC count • Elevated potassium • Elevated IgE • Low sed rate

29. Multiple choice questions • 9. Which would not be found in a patient with Severe persistent asthma? • Symptoms throughout the day • Use of albuterol inhaler several times of day • Mild limitations to daily activity 10. Which statement regarding asthma is true? • Chronic, reversible airway disease • Chronic, irreversible airway disease • Acute, intermittent, airway disease

30. References Burns, C. (2013). Pediatric Primary Care (5th ed.) Philadelphia: Elsevier Saunders. Dunphy, L. (2011). Primary Care (3rd ed.). Philadelphia: FA Davis and Co. Domino, F. (2013). The 5 Minute Clinical Consult 2014 (22nd ed.). Philadelphia: Lippincott Williams & Wilkins. Halterman, J. S., Riekert, K., Bayer, A., Fagnano, M., Tremblay, P., Blaakman, S., & Borrelli, B. (2011). A pilot study to enhance preventive asthma care among urban adolescents with asthma. Journal of Asthma, 48(5), 523-530. Juel, C. T. B., & Ulrik, C. S. (2013). Obesity and Asthma: Impact on Severity, Asthma Control, and Response to Therapy. Respiratory care, 58(5), 867-873. Melén, E., & Pershagen, G. (2012). Pathophysiology of asthma: lessons from genetic research with particular focus on severe asthma. Journal of internal medicine, 272(2), 108-120. Rosenthal, E. (2013, October 13). Paying til it hurts. New York Times. Retrieved from http://www.nytimes.com/2013/10/13/us/the-soaring-cost-of-a-simple-breath.html. Tapp, H., Hebert, L., & Dulin, M. (2011). Comparative effectiveness of asthma interventions within a practice based research network. BMC health services research, 11(1), 188. UTD (2013). Asthma treatment guidelines. Retrieved from http://www.uptodate.com/