Learning Objective. Asthma. Discuss the pathophysiology, clinical presentation, diagnosis, and treatment of Asthma 2/22/2017

Transcription

1 Marianne Curran, PA C 3/1/17 Learning Objective Discuss the pathophysiology, clinical presentation, diagnosis, and treatment of Definition many variations Chronic Disorder with Reversible (Intermittent & Recurring) Airflow Obstruction, Bronchial Hyperresponsiveness with underlying inflammation +/ with Shortness of Breath, cough, wheezing 1

2 Why is this Important? Statistics ~17 20 million U.S. Adults have asthma ~6 7 million U.S. Children, most common chronic disease in children 2.o million ER visits with asthma S/S ~3,500 deaths in 2010 from asthma Anatomy Review Review of Lung Anatomy 2

3 Think of 3 things: Airway Hyper Responsiveness Inflammation Airflow Obstruction Review of Lung Anatomy 3

4 Demographics Can be anyone Urban > Rural population Higher in minority populations rates in black children increased 50% from 01 to 09 ~1/2 develop > age of 10 ~1/2 will have remission in adulthood If develop as an adult, rarely goes into remission Cause = Unknown Genetic factor(s) present Allergy plays a central role Inflammation 1 st Lead to Hyperresponsiveness Bronchconstriction Mucus hypersecretion Airway edema 4

5 Presentation Wide range from mild to severe Can be intermittent and non specific Episodic shortness of breath with/without wheezing, cough (usually worse at night), sputum production To Dx need symptoms of the above + reversible expiratory airflow obstruction Can look like many other conditions DDx: Other pulmonary diseases; emphysema, chronic bronchitis, bronchiectasis Chronic rhinosinusitis Vocal cord dysfunction (VCD) Cystic Fibrosis Heart Failure Pulmonary Embolism Foreign Body in the airway Obesity GERD Upper Respiratory Tract infection History 5

6 History Age at onset Exacerbation details; how frequent, duration, limitations Patterns; time of day, time of week, etc look for triggers Family history Current medications Smoker? now or in the past? Past medication history (ACEI) h/o Allergic manifestations Number/freq. of ER visits Ever been hospitalized with asthma attack Ever been on a ventilator due to asthma attack Triggers can be inhaled or systemic antigens Smoke Perfumes Dust Animals Other pollutants Cold air, dry air Exercise Illness History ROS: General Skin HEENT Pulm Cardiac 6

7 Physical exam No abnormal signs or many if in acute phase Wheezing especially during expiratory phase Prolonged expiratory phase Accessory respiratory muscles Active expiration Increase AP diameter = Barrel chest Diaphoretic, tachycardia, elevated respiration rate Samter s syndome Nasal Polyps 3. Sensitivity to NSAIDs...almost always a Board question Important to educate these patients to avoid NSAIDs Studies: Spirometry (Spiro) is the gold standard Easy but is effort dependent Fast Inexpensive Serial studies helpful Baseline get one 7

8 Studies: Spirometry cont. FEV1: Forced Expiratory Volume in 1 second Decreased in Normal > 80% FVC: Forced Expiratory Volume Normal > 80% FEV1/FVC Ratio: This is what you use to determine obstruction Less than 70% = obstructive process Spiro Spiro 8

9 Spiro Spirometry cont. DO A POST Studies: cont. Labs Serum IgE CXR Bronchial challenge aka Bronchoprovocation testing Allergy testing Peak Expiratory Flows (PEF) > Pulse oximetry Arterial Blood Gas (ABG) for acute settings CPFT 9

10 Classification of asthma severity Spirometry results Frequency of symptoms Nighttime symptoms Frequency of Rescue Inhaler use ADLs Classification of asthma severity Mild intermittent Mild persistent Moderate persistent Severe persistent Classification of asthma severity Mild intermittent: Occasional symptoms 2/wk Asymptomatic & normal pulm. function (aka spirometry) between exacerbations Exacerbations brief (few hrs to few days) Nocturnal symptoms 2/month Use of rescue inhaler 2/week Mild persistent: Symptoms > 2/week, but <1/day Exacerbations may affect activities Nocturnal symptoms > 2/month Use of rescue inhaler > 2 days/week (not daily) FEV1 80% predicted 10

11 Classification of asthma severity Moderate persistent: Daily symptoms; interfere with activities Exacerbations 2/week; may last days Nocturnal symptoms > 1/week Daily use of rescue inhaler FEV1 60% predicted, but < 80% predicted Severe persistent: Continual symptoms daily Limited physical activities Nocturnal symptoms usually nightly Frequent exacerbations Frequent nocturnal symptoms FEV1 < 60% predicted Treatment Most important aspect... EDUCATION 11

12 Patient Education To achieve optimal status: ADLs Rescue Inhaler use Nocturnal symptoms Normal/or as normal as you can get it lung functions on serial spirometry Maintenance medication: lowest doses/combination possible to achieve the above (ideally no side effects) Reduce ER visits Reduce oral corticosteriod use Patient Education Avoid triggers If they have allergies to dust, mites, smoke, pets, environmental items Treat allergies: Consider immunotherapy/allergy shots Timing of Rescue inhaler PEFs: Stepping up/down in their treatment plan When to obtain treatment, seek ER How to take their medications especially inhalers Other items to avoid: NSAIDs, ASA, non selective B blocker NOOOOO smoking, avoid 2 nd hand smoke Yearly flu vaccine Treatment Medications Two main categories Quick relief Rescue, taken as needed Goal is to promptly reverse airflow obstruction & relieve symptoms Examples: short acting B2 agonists, anticholinergics Long term Control, taken daily to maintain Examples: long acting B2 agonists, corticosteroids, leukotriene modifiers, theophylline 12

13 Medications Delivery options Majority are via Metered Dose Inhalers (MDIs) Nebulization Medications B2 agonists Produce bronchodilation Side effects: Tremor & tachycardia Two types: Short acting Quick relief for acute symptoms; aka Rescue Inhaler Can also use prior to exercise if EIB Rapid onset w/in 5 10 minutes; duration of 3 6 hours Examples: albuterol, levalbuterol, pirbuterol Long acting aka LABA Long term control Onset within minutes; duration of 12 hours Examples: Salmeterol (serevent), formoterol (foradil), Brovana (arformoterol) Treatment Corticosteroids Decrease airway inflammation and hyperresponsiveness Decrease frequency of exacerbations Decrease severity of asthma symptoms Up regulate expression & affinity of B2 receptors in lung Different routes of delivery 13

14 Treatment Inhaled corticosteroids (ICS) Decrease airway inflammation Very effective Better to add a 2 nd long acting med than initially increase dose of ICS Side effects: cough, dysphonia, thrush Examples: fluticasone (flovent), budesonide (pulmicort), beclamethasone (Qvar), Triamcnolone (Azmacort), others NOT a rescue inhaler and NOT to be use as needed Treatment Systemic corticosteroids Can be delivered orally, IV, IM Reduce rate of hospital visits, shorten duration of exacerbations and reduce risk of relapse Typically used for exacerbations or for severe persistent If long term use; TAPER Side effects: Osteoporosis, hyperglycemia, cataracts, weight gain, mood swings, insomnia, suppress hypothalamic pituitary adrenal axis Treatment Combined ICS and long acting beta agonists Combines two medications into one inhaler Examples: Symbicort (budesonide & formoterol), Advair (fluticasone & formoterol), Dulera (mometasone & formoterol) NOT a rescue inhaler and NOT to be use as needed 14

15 Medications Leukotriene modifiers: Allows a decrease in the cellular infiltration of asthmatic bronchial mucosa Side effects: Drowsiness, GI symptoms, headache Example: Singulair (QD) and Zafirlukast/Accolate (BID) Medications Anticholinergic drugs Produces bronchodilator Low side effect profile; dry mouth Typically slower onset than B2 agonists Examples: Atrovent (ipratropium bromide): MDI and solution/svn, short acting Spiriva (tiotrpium bromide): handihaler, long acting Theophylline Produces bronchodilation, increased mucociliary clearance, increased diaphragmatic muscle contraction Side effects; insomnia, GERD, GI symptoms, nausea, tremor (and many drug interactions) Need to measure blood levels watch for toxicity Treatment Misc. Omalizumab/Xolair Reduces sensitivity to allergens used for moderate to severe allergic asthmatics Route: subcutaneous every 2 4 wks (depending on IgE levels & body weight) Side effects: anaphylaxis ptswatched in office after each injection 15

16 Back to our classifications... Mild intermittent Mild persistent Moderate persistent Severe persistent Treatment Mild intermittent: short acting B2 agonists PRN Mild persistent: 1 st line: low dose inhaled corticosteroid (ICS) 2 nd line: long acting B2 agonist, leukotriene modifiers, theophylline Moderate persistent: low dose ICS PLUS one of the other long term control med Severe persistent: high dose ICS plus one of the other long term control meds. Usually need systemic corticosteroids Treatment: Step protocol Step 1: Rescue inhaler as needed Step 2: Low dose ICS Step 3: Low dose ICS & long acting beta agonist OR medium dose ICS Step 4: Medium dose ICS & long acting beta agonist Step 5: High dose ICS & long acting beta agonist Step 6: High dose ICS & long acting beta agonist + oral steroids 16

17 Treatment Monitor these patients More frequent with medication changes More frequent with change in S/S Serial spirometry studies in office Peak Flow monitoring at home Create a formal written action plan based on peak flow changes Special cases Exercise induced asthma Usu. controlled w/short acting B2 agonist minutes prior to exercise Nocturnal asthma Aspirin sensitivity asthma Consider leukotrienes modifiers Pregnancy Pre surgical evaluation Non responders Consider Bronchial Challenge test Consider concomitant conditions that are not optimally treated: GERD VCD Sleep Apnea Chronic rhinitis Chronic sinusitis 17

18 Acute Exacerbation Signs: Tachypnea Tachycardia Tri pod position Difficulty speaking in complete sentences Accessory muscle use O2 90% Hypercapnia Get to it early! How severe? Remove triggers if possible Think ER, think IV steroids Complications: Immediate: Status asthmaticus Acute, life threatening, sustained & severe airway obstruction refractory to treatment. Carbon dioxide retention, hypoxemia and respiratory failure Need ER/hospital Long term if not optimally treated: Airway Remodeling causes Fixed airway obstruction In conclusion Investigate ask questions Lots of treatment/rx options base on severity Can step up and can step down Remove triggers when possible 18

19 Questions EDB24 References 1. Manual of Clinical Problems in Pulmonary Medicine 5 th edition. By Richard A. Bordow

20 Slide 57 EDB24 You should have a slide of your references for each lecture. Emily D Babcock, 2/18/2014