10/6/2014. Tommy s Story: An Overview of Asthma Mangement. Disclosure. Objectives for this talk.

Transcription

1 Tommy s Story: An Overview of Asthma Mangement Clifton C. Lee, MD, FAAP, FHM Associate Professor of Pediatrics Chief, Pediatric Hospital Medicine Children s Hospital of Richmond at VCU Disclosure Obviously, I have no financial disclosures However, I can tell you.. Objectives for this talk. Overview of asthma management Monitoring of symptoms and lung function Patient education Controlling triggers factors and comorbid conditions Pharmacologic therapy Emergency department management Discuss various pharmacologic agents used in acute management 1

2 This is Tommy! This is also Tommy. Goals of Asthma Treatment Reduce impairment Reduce risk 2

3 Reduce Impairment Freedom from frequent asthma symptoms Minimal need ( 2 days per week) of inhaled SABAs Few nighttime awakenings ( 2 nights per month) Optimization of lung function Maintenance of normal daily activities Asthma care satisfaction Reduce Risk Prevent recurrent exacerbations and need for ED or inpatient care Prevent reduce lung growth in child and loss of lung function in adults Optimization of pharmacotherapy with minimal or no adverse effects Monitoring Patients with Asthma 3

4 Symptom Assessment Assessment of impairment Has your asthma awakened you at night or in the early morning? How often have you been needing to use your relief medication to relieve symptoms of cough, shortness of breath, or chest tightness? Have you needed any unscheduled care for your asthma? Have you been able to participate in school/work and recreational activities? If you are measuring your peak flow, has it been lower than your personal best? Have you had any side effects from your asthma medications? Symptom Assessment Assessment of risk Have you taken oral steroids for your asthma in the past year? Have you been hospitalized for your asthma? If yes, how many times have you been hospitalized in the past year? Have you been admitted to the intensive care unit or been intubated because of your asthma? Do you currently smoke cigarettes or exposed to tobacco smoke? Monitoring Pulmonary Function 4

5 Peak Expiratory Flow Rate (Peak Flow) Useful indicator of airflow obstruction Repeated measurements are useful May not be accurate for first time users Home monitoring is helpful with patients with moderate to severe asthma Periodic checks on the use of the peak flow meter Normal range: % of personal best value Patient Education Patient Education Enable patients/parents to become active partners Effectiveness of direct one on one education Decreases hospitalizations Improves daily function Improves patient/parent satisfaction 5

6 Pharmacologic Treatment Categories of Asthma Severity Intermittent Mild persistent Moderate persistent Severe persistent 6

7 Intermittent Mild persistent Moderate persistent Severe persistent Symptoms 2 days/week >2 days/week but not daily Nighttime awakenings SABA use for symptom control Interference with normal activity Lung function 2 times/month 2 days/week Daily 3 4 times/month >1 time/week but not nightly >2 days/week but not daily Daily Throughout the day Often 7 times/week Several times per day None Minor limitation Some limitation Extremely limited FEV₁ >80% predicted FEV₁/FVC >85% FEV₁ up to 80% predicted FEV₁/FVC >80% FEV₁ 60 79% predicted FEV₁/FVC 75 80% FEV₁ <60% predicted FEV₁/FVC <75% How about Tommy? Wheezes 3 days/week Awakens with coughing 4 times/month Uses albuterol MDI 3 times/week Very little limitation with football practice Intermittent Mild persistent Moderate persistent Severe persistent Symptoms 2 days/week >2 days/week but not daily Nighttime awakenings SABA use for symptom control Interference with normal activity Lung function 2 times/month 2 days/week Daily 3 4 times/month >1 time/week but not nightly >2 days/week but not daily Daily Throughout the day Often 7 times/week Several times per day None Minor limitation Some limitation Extremely limited FEV₁ >80% predicted FEV₁/FVC >85% FEV₁ up to 80% predicted FEV₁/FVC >80% FEV₁ 60 79% predicted FEV₁/FVC 75 80% FEV₁ <60% predicted FEV₁/FVC <75% 7

8 Back to Tommy. His only medication is albuterol MDI PRN (usually before practice and games) Recently his asthma symptoms have been more noticeable Only been hospitalized once (not PICU or intubations) Last ED visit was 6 months ago and received steroids but none since Should his medication regimen change? Should Tommy see a Specialist? When to refer Experienced life threatening asthma exacerbation Required hospitalization or more than 2 bursts of oral steroids/year Child >5 years requires step 4 care or higher Child <5 requires step 3 care of higher Asthma not controlled after 3 6 months of active therapy Unresponsive to therapy Uncertain diagnosis of asthma Management complication (nasal polyps, chronic sinusitis, allergic rhinitis) Additional diagnostic tests are needed (skin testing, bronchoscopy, PFTs) Candidate for allergen immunotherapy (allergy shots) 8

9 Tommy is going to the ED!! Case Presentation 6 year old male with history of mild intermittent asthma 24 hour history of coughing, wheezing, chest tightness Symptoms began after football game Albuterol inhaler 2 4 puffs every 2 hours without relief Started on Flovent MDI 2 weeks ago and compliant 9

10 What do you do??? Initial Assessment Rapid cardio pulmonary assessment Avoid delays in treatment NEVER delay oxygen supplementation for any child in distress Detailed history and complete examination AFTER initial stablization Assessment: History Characteristics of child s symptoms Onset, duration, severity of symptoms Verify potential risk factors Medication use Family history Social history 10

11 Assessment: Examination General appearance Vital signs Respiratory rate: best indicator Pulses paradoxus: >20 mm Hg Accessory muscle use Mental status I:E ratio Assessment: Ancillary Data Pulse oximetry: The fifth vital sign Non invasive Poor sensitivity/specificity in predicting outcome Peak expiratory flow monitoring Effort depedent <60% of predicted indicates severe obstruction ABG, CXR Management Correct hypoxemia Reverse airway obstruction Treat the inflammatory response Provide OXYGEN Improves tissue oxygenation Reduces pulmonary vasocontriction Facilitates bronchodilation 11

12 Treatment Options Β adrenergic agonist Anticholinergics Corticosteroids Magnesium Methylxanthines Leukotriene modifiers Heliox Mechanical ventilation SABA (Short Acting Beta Agonist) Mainstay of emergent treatment Albuterol most widely used Nebulizer vs. inhaler Continuous delivery (CAT) MDI vs. Nebulizer MDI: acceptable alternative Advantages: decreased cost, reduced administration time in ED, portability Can be used in infants (need a mask on the end of the spacer) 12

13 MDI vs. Nebulizer MDI with spacer vs. nebulizer Randomized, double blind, placebo controlled 60 children (1 4 years) No significant differences in clinical score, RR, O₂ saturation MDI group: greater reduction in wheezing, fewer admissions, lower mean cost Mandelberg A et al. Is Nebulized Aerosol Treatment Necessary in the Pediatric Emergency Department? Comparison with a Metal Spacer Device for Metered Dose Inhaler. Chest 2000;117: Continuous Delivery Similar outcomes and side effect profiles with continuous vs. intermittent nebulized delivery Less labor intensive Ensures the goal of 3 treatments within the first hours of care Young children may not tolerate wearing a facemask for long periods of time Product Albuterol via nebulizer Dose 0.15 mg/kg/dose (minimum 2.5mg, maximum 5mg/dose) every minutes for 3 doses, then mg/kg (maximum 10 mg) every 30 minutes to 4 hours as needed Continuous albuterol therapy Albuterol MDI with spacer 0.5 mg/kg/hr (maximum 20mg/hr) by large volume nebulizer. Dose may also be determined based upon body weight: 5 10 kg: 7.5 mg/hr 10 20kg: mg/hr >20 kg: 15 mg/hr 4 8 puffs every minutes for 3 doses, then every 1 4 hours as needed (minimum 2 puffs/dose, maximum 8 puffs/dose) 13

14 Systemic β adrenergic Agonist Indications Severe respiratory distress Fail to respond to standard therapy Epinephrine Terbutaline Epinephrine 0.01 mg/kg IM or SC (1:1000 concentration) Maximum 0.4 mg/dose or 0.4 ml Can repeat every minutes for 3 doses Arrhythmias, tachycardia, hypertension, headaches, hyperglycemia, hypokalemia, nausea, vomiting Terbutaline 0.01 mg/kg SC or IM Maximum 0.25 mg/dose Can repeat every 20 minutes for 3 doses IV loading dose: 10 mcg/kg Infusion rate: 0.4 mcg/kg/min titrated up to 3 6 mcg/kg/min Paradoxical bronchoconstriction 14

15 Anticholinergics Ipratropium bromide (Atrovent ) Inhibits bronchoconstriction Decreases mucus production Not systemically absorbed Minimal side effects Administer in conjunction with β₂ agonist Dose: <20 kg = 250 mcg/dose; 20 kg = 500 mcg/dose Combine with albuterol Anticholinergics Ipratropium bromide vs. saline Randomized, double blind, placebo controlled 434 children (2 18 years) Lower admission rate for severe asthma Qureshi F et al. Effect of Nebulized Ipratropium on the Hospitalization Rates of Children with Asthma. N Eng J Med 1998;339:

16 Corticosteroids Diminish airway inflammation Potentiate effectiveness of β₂ agonist Moderate to severe exacerbation Minimal improvement after single β₂ agonist treatment Prednisone or prednisolone PO Methylprednisolone (Solumedrol ) IV Dexamethasone (Decadron ) PO, IV, or IM Corticosteroids IV vs. PO steroids Randomized, double blind, placebo controlled 49 children (18 months 18 years) 2 mg/kg methylprednisolone PO or IV Similar hospital admission rates, RR, O₂ saturation, PEFR, asthma score Barnett PL et al. Intravenous Versus Oral Corticosteroids in the Management of Acute Asthma in Children. Ann Emerg Med 1997;29: Corticosteroids IM dexamethasone vs. PO prednisone Prospective, randomized, investigator blinded trial 32 children (6 months 7 years) 1.7 mg/kg IM dexamethasone or 2 mg/kg/d x 5 days of PO prednisone No significant differences in clinical asthma score or rate of improvement Gries DM et al. A Single Dose of Intramuscularly Administered Dexamethasone Acetate is as Effective as Oral Prednisone to Treat Asthma Exacerbation in Young Children. J Pediatr 2000;136:

17 Product Prednisone or prednisolone Methylprednisolone Dexamethasone Dose 1 2 mg/kg (maximum 60 mg/day) PO for first dose then mg/kg twice daily for subsequent doses for 3 10 day course 1 2 mg/kg (maximum 125 mg/day) IV 0.6 mg/kg (maximum 16 mg/day) PO, IM, or IV Magnesium Sulfate Relaxes smooth muscle by blocking calcium induces muscle contraction Inhibits release of acetylcholine May diminish histamine induced bronchospasm Hypotension, respiratory depression, hypermagnesemia, flushing, nausea, vomiting mg/kg/dose IV over 20 minutes (maximum single dose = 2 grams) Magnesium Sulfate Magnesium vs. placebo Randomized, double blind, placebo controlled 30 children (6 17 years) 40 mg/kg IV (maximum dose of 2 grams) Significant improvement in PEFR, FEV₁, FVC More likely to be discharged in magnesium group Ciarallo, Let al. Higher Dose Intravenous Magnesium Therapy for Children with Moderate to Severe Acute Asthma. Arch Ped Adol Med 2000;154:

18 Theophylline Weak bronchodilator Little or no additional benefit Difficult to titrate Not recommended for routine use in ED Leukotriene Modifiers Montelukast (Singulair ) Potent inflammatory mediator Outpatient therapy No role in acute asthma management Heliox Mixture of helium and oxygen (60:40) Low density gas mixture Decrease airway resistance, obstruction Improve work of breathing Limited use in hypoxic patients 18

19 Heliox Heliox (80:20) vs. room air Randomized, double blind, controlled trial 18 children (16 months 16 years) Heliox at 10L/min by NRB face mask Significant improvement in pulsus paradoxus, WOB, PEFR Kudukis TM et al. Inhaled Helium Oxygen Revisited: Effect of Inhaled Helium Oxygen during the Treatment of Status Asthmaticus in Children. J Pediatr 1997;130: Mechanical Ventilation 1% asthma patients Indications Failure of maximal medical therapy Depressed mental status Severe hypoxia Worsening hypercarbia Respiratory or cardiac arrest Rapid sequence intubation Ketamine: also causes bronchodilatioin Avoid high peak inspiratory pressure No PEEP (minimize barotrauma) What happened to Tommy? Received 3 Duoneb treatments 2 mg/kg dose of Prelone No oxygen requirement Able to be observed for 4 hours post treatments Sent home on 5 days of steroids Follow up with pediatrician next day Continue his Flovent MDI 19

20 So Rapping up Goals of asthma treatment include reducing impairment and risk Asthma education has many benefits including allowing patient/parents to become active partners in care First determine asthma severity to determine the optimal medication regimen If needed, supplemental oxygen is good for you Frequent reassessment is key in acute management in ED Thank You for Your Attention! 20