The unified Airway

1. A CPMC Regional CME Event The unified Airway - An Integrated Approach Saturday October 1, 2011

2. Asthma Management: How to Initiate, Maintain, andTaper Therapies Benson Chen, MD San Francisco Critical Care Medical Group

3. Disclosures Own stock in Pfizer and Eli-Lilly

4. Scope of the Problem

5. Outline of Discussion • Asthma Presentation and Work-up • Treatment Paradigm • Pearls

6. Presenting Symptoms Atypical chest pain / pressure Dyspnea at rest or with exertion Cough Inability to take a deep breath Wheezing

7. Other Conditions that Present Like Asthma Congestive heart failure Pulmonary hypertension Vocal cord dysfunction / laryngeal asthma Intra-thoracic endotracheal mass or stenosis Lymphoma Tracheomalacia ASTHMA – DIFFERENTIAL DIAGNOSIS

8. Asthma - Evaluation Detailed history Symptoms Cough, dyspnea, chest pain Frequency and timing of symptoms Diurnal or nocturnal Number of episodes per day, week, month Positional effect on symptoms May suggest reflux or post-nasal drip exacerbating asthma or as the etiology of symptoms Environmental change associated with onset of symptoms Associated symptoms Chest pain, lower extremity edema, weight loss, fevers, night sweats Smoking history Substance abuse history Diet pill use

9. Asthma - Evaluation Physical Exam Vital signs BP, tachycardia, tachypnea, hypoxemia at rest or with exertion Polyphonic wheezing Tracheal wheezing / stridor Jugular venous distention Prominent P2 Neck asymmetry / mass Barrel chest Lower extremity edema Digital clubbing Hypertrophic osteoarthopathy

10. Asthma - Evaluation Pulmonary Function Testing Spirometry Flow-volume Loop Lung Volume DLCO

11. Asthma - Evaluation CXR – if history and physical are suggesting alternative diagnoses Evidence of hyperinflation Increased retrosternal space Flattened diaphragms on lateral view Interstitial markings Cystic or bullous lung disease Cardiomegaly Pleural effusion Mediastinal and or hilar adenopathy

12. Initiating Treatment - Goals Maximize symptom control Minimize side effects of treatment Minimize unnecessary administration of medication Minimize need for systemic steroids

13. Initiating Treatment – Severity Assessment Determine severity of symptoms objectively Symptoms Dyspnea, exertional limitation, wheezing, cough, nocturnal awakenings Frequency of symptoms Daily vs. weekly vs monthly

14. Initiating Treatment – Extrinsic Trigger Assessment Assess for potential environmental allergens Dust Mold / mildew Pet exposures Strong scents/fumes Perfume, cologne, deodorant, soap, shampoo, laundry detergent Smoke Tobacco, incense, fireplace Bedding Carpeting

15. Initiating Treatment – Intrinsic Trigger Assessment To consider assessing for potential intrinsic pro-inflammatory conditions Indolent infections Atypical mycobacteria, fungal Airway fungal colonization ABPA Parasitic infections IgE elevation Churg Strauss Hypereosinophilia syndrome

16. Initiation of Treatment – Step Up Approach Stepping Up Benefits Avoids over treatment Avoids potential side-effects related to unnecessary therapies Avoids potentially unnecessary exposure to LABA Avoids potential long-term over-treatment Drawbacks Requires frequent contact with patient in the office or by phone to monitor adequacy of treatment response May delay alternative diagnostics / diagnoses if symptoms are not related to asthma May delay complete relief of symptoms

17. Stepping Up - Initial therapy dependent upon severity of patient’s presenting symptoms Intermittent Asymptomatic between episodes Symptoms < 2 days/week Nighttime awakenings < twice/month No limitation in normal activities Mild Persistent Symptoms > 2 days/week but not daily Nighttime awakenings 3 – 4 times/month Minor limitation in normal activities Moderate Persistent Daily symptoms Nighttime awakenings > once per week but not nightly Some limitation in normal activities Severe Persistent Symptoms throughout day Nighttime awakenings almost or nightly Extreme limitation in normal activities

18. Stepping Up – Initial treatment recommendations Intermittent SABA (short acting beta agonist, e.g. albuterol) prn Mild persistent Low dose inhaled steroid Moderate persistent Low dose inhaled steroid + LABA (long acting beta agonist, e.g. salmeterol) Medium dose inhaled steroid Severe persistent Medium dose inhaled steroid + LABA High dose inhaled steroid + LABA

19. Treatment Follow-Up: Reassessment Reassess response to treatment in 2 to 6 weeks Adjust medication regimen accordingly Step up or down with goal of achieving symptom level of “Intermittent Asthma” on the fewest medications and at the lowest doses tolerated Step down once symptoms have been under control for at least 3 months

20. Additional Treatment Considerations Non-pharmaceutical interventions Extrinsic allergen control Hypoallergenic bedding Dust mite cover for mattress Pet removal Smoking cessation Intrinsic immunostimulatory control Evaluating for atypical mycobacterial infections Evaluating for allergic bronchopulmonaryaspergillosis or other fungal colonizing agents

21. Additional Treatment Considerations Additional pharmaceutical interventions Omalizumab Monoclonal IgG antibody that inhibits IgE binding to receptors on mast cells and basophils Alternative agent in patients with severe persistent asthma and evidence of an extrinsic allergic component – dust mites, cockroaches, dogs, cats Leukotriene antagonists Cough variant asthma Asthma with allergic rhinitis Alternative agent in patients with mild, moderate, or severe persistent asthma

22. Pearls • “Wheezing is not always asthma” • Asthma management is more than just inhalers • Identify and address potential environmental triggers • Identify and address potential intrinsic triggers • Medical management of asthma • Risk stratify to determine initial treatment • Step-up treatment • Be willing to step-down therapy

23. Take Home Points • ENVIRONMENT • RISK STRATIFY • REASSESS • STEP-UP • STEP-DOWN