Asthma Management A Stepwise Approach Disclosure - None Jane Cooper, RN, FNP- BC, CORLN University of Missouri Health Care Depart. of Otolaryngology Head and Neck Surgery Columbia, Missouri Objectives Review definition and diagnosis of asthma Discuss the 4 components of asthma management Regular monitoring airflow measurements Control of environmental triggers and comorbid conditions Medication Take correctly Patient education partnership Examine the 2007 NAEEP Guidelines for Stepwise Approach Review asthma medications Discuss asthma management in the ENT patient. Prevalence of Asthma According to CDC and Prevention, an estimated 7.1 million children ( 9.5%)have asthma, making it the most common pediatric chronic illness in America. 1. Leading cause of school absenteeism. Average 30 kids in classroom, 3 will have asthma. Number of adults in the U.S. with asthma is 18.9 million or 8.2%. 2. WHO estimates 235 million people worldwide suffer from asthma. 1. CDC and Prevention. Healthy Youth: Asthma. http://www.cdc.gov/healthyouth/asthma. Accessed July 29,2013 2. Http://www.cdc.gov/nchs/fastats/asthma.htm Accessed July 29, 2013. Increasing Globally Sharp increase in the global prevalence, morbidity, mortality, and economic burden associated with asthma over the last 50 years, mostly in children, as the most common chronic disease. The increase parallels the increase of atopic diseases worldwide. Probably due to urbanization of communities. Braman,SS. Asthma Guidelines in Day-To-day Practice. Pulmao RJ 2012;21(2):70-75. Costs Treating asthma patients under the age of 18 costs an estimated 3.2 billion per year. Asthma causes 12.8 million lost school days in kids yearly. Children from low income families have a higher prevalence of asthma and are 3 times more likely to have acute exacerbations leading to ED visits. Adults lose 14.5 million work days yearly due to asthma. Centers of Disease Control and Prevention. FastStats: Asthma. www.cdc.gov/nchs/faststats/asthma.htm. Accessed August 10, 2013. 1
Asthma Guidelines The asthma guidelines were first published in 1991 by the National Heart, Lung, and Blood Institute (NHLBI) and National Asthma Education and Prevention Program (NAEPP). Updated in 1997, 2002 and 2007. The Guidelines provide medically evidenced best practice methodology for treating asthma. Despite guidelines, asthma has continued to be challenging to manage. There are discrepancies between what providers prescribe and teach and the care patients receive. Asthma is often under diagnosed and inappropriately treated. Rance,KarenUnderstanding and Implementing the New NHLBI Asthma Guidelines. J for Nurse Practitioners. 2008; April 254-261. 2007 Guideline Changes New Emphasis On Monitoring asthma control as goal for therapy. Distinguish between asthma Severity and monitoring asthma Control. Provider should gauge impairment and risk as two components in determining the Level of Asthma Control. Multifaceted approaches to Pt education and to control environmental factors and co-morbid conditions that affect asthma. (allergy, reflux etc) Changes in managing asthma long term. (Step up and down) Step down medications after 3 months of stability Changes to treatment for managing asthma exacerbations. Rance, Karen GINA Global Initiative for Asthma Global strategy to provide a roadmap for improved allergy care. 1. Use objective measures, such as spirometry to diagnose and monitor response to treatment. 2. Provide advice for effective environmental control. 3.Use the step-up approach for pharmacological therapy. 4.Develop a partnership of care with patient or caregiver. Global Strategy for asthma management and prevention. (GINA) Updated 2012. www.ginasthma.org Asthma is Chronic inflammatory disorder of the airways Episodic and reversible airflow obstruction Airway Hyper -Responsiveness Subsequent narrowing of small airways Common Symptoms Wheezing, Cough, Shortness of breath and chest discomfort http://www.google.com/imgres?q=asthma+pictures&sa=x&rls=com.microsoft:enus&biw=1680&bih=840&tbm=isch&tbnid=ok5calqcxgh5lm:&imgrefurl=http://www.medicinenet.com/asthma_pictures_slideshow/article. htm&docid=heerkcqyomsomm&imgurl=http://images.medicinenet.com/images/slideshow/asthma-s3-bronchiolesnormal.jpg&w=493&h=335&ei=covxucsihypgragahigqbw&zoom=1&iact=rc&dur=156&page=2&tbnh=140&tbnw=206&start=44&ndsp=49 &ved=1t:429,r:52,s:0,i:249&tx=133&ty=49 2
Etiology of Asthma is not clear. Complex disease with many immunological variables. Many different cell types ( dendritic, T cells, TH1 and TH2) and cytokines ( IL-4, IL-13 and IL-5) that play critical roles in asthma pathogenesis. http://www.nlm.nih.gov/medlineplus/magazine/issues/fall11/articles/fall11pg4.html Asthma Pathways Diagnosis Clinical Evaluation Detailed history Allergy exposure: Home, school, work environment Smoke and chemical exposure Smoking ( active and passive) Viral infections Diagnosis Asthma Triggers Clinical picture - cough, SOB, wheezing etc.. Spirometrywith flow volume loops or PFTs give information on breathing patterns. Evidence of obstructive breathing, improved with use of bronchodilator. + Bronchodilator response: FEV1 increased by 200 ml + 12% OR FVC increased by both 200 ml + 12%. Exhaled nitric oxide (if high can indicate inflammation) Allergy Evaluation- Skin prick test or lab Chest X-ray Lab CBC with diff (Eosinophils), IgE, sweat chloride/genetic tests for CF, Vitamin D 3
Food Allergy Asthma Triggers Milk Egg Peanut Tree Nuts Wheat Soy Shellfish Fish Most Allergic Foods Asthma Management asthmainstitute.pitt.edu 341 409- The University of Pittsburgh AsthmaInstitute - Tobacco smoke Smoke from wood stoves and fireplaces Perfume Cleaning Products Air pollution Nail and hair products Regular monitoring of symptoms and lung function Control of the environmental triggers and comorbid conditions that contribute to asthma severity Pharmacologic Therapy Patient Education - Partnership Asthma Control TestR 5 questions designed to help a patient describe their symptoms and how they are feeling. 1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at home? All of the time Most of the time Some of the time A little of the time None of the time 1 2 3 4 5 2. During the past 4 weeks, how often have you had shortness of breath? All of the time Most of the time Some of the time A little of the time None of the time 1 2 3 4 5 Kosinsski, M, Bayliss, MS, Turner-Bowker, DM, Fortin,EW. Asthma Quality Control Test: A Users Guide, Lincoln (RI): QualityMetric, Incorporated, 2004. Copyright @2004 QualityMetric. Asthma Control Test 3. In the past 4 weeks, how often did your asthma symptoms (wheezing, cough, SOB, chest tightness or pain) wake you up at night or earlier than usual in the morning? 4 or more 2-3 nights a week once a week Once or twice Not at all nights a week 1 2 3 4 5 4. In the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (Albuterol, Maxair or Primatene Mist)? 3 or more 1-2 times/day 2-3 times/week 1 time week Not at all 1 2 3 4 5 5. How would you rate your asthma control during the past 4 weeks? Not Poorly Somewhat Well Completely controlled controlled controlled controlled controlled 1 2 3 4 5 4
Asthma Control Test Results: 5 to 15 Poorly Controlled 15 to 20 Somewhat Controlled 20 to 25 Controlled A tool to help educate patients and parents. Help raise awareness of how they are doing. Not a diagnostic tool. Ages 12 to adult. Monitoring Asthma Spirometry Measures forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) Reduced Ratios of (FEV1/FVC ) can help determine restriction or obstruction. The 2007 NAEPP (National Asthma Education and Prevention Program) guidelines recommend using spirometryin practices that routinely care for asthma patients. Monitoring Asthma Peak expiratory flow rate (PEFR) Ages 5 to adult Benefits:Inexpensive ($20), convenient can be done at home, useful for detecting changes in asthma control Limitations: Measurements are dependent on the patient s technique. A reduced peak flow reading does not always indicate airway obstruction. The patient establishes a baseline measurement when feeling well personal best. Readings below the range may indicate narrowing of the airway and prompt implementing the Asthma Action Plan Reduce Impairment Freedom from symptoms Minimal need (< 2x per week) of short acting beta agonists (SABAs ) to relieve symptoms. Optimal lung function Maintaining normal ADL. School, work, athletics and exercise Patients and families are satisfied with asthma care UptoDate An Overview of Asthma Management, Author Fanta, Christopher MD Accessed 12/31/12 Asthma Severity First step is to classify severity of the asthma How is asthma classified? Look at 3 factors Reported symptoms over the previous 2-4 weeks Current level of lung function Number of exacerbations requiring the use of oral steroids per year. Four Categories of Asthma Severity Intermittent Mild Persistent Moderate Persistent Severe Persistent NAEPP: Expert Panel Report III: Guidelines for the diagnosis and management of asthma. (NIH publication no 08-4051). Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on July 29, 2013). 5
Intermittent Asthma Daytime asthma sxsoccur 2 or less days per week 2 or less night time awakenings per month Use of short-acting beta agonists (SABA) < 2x per week Normal activity between exacerbations FEV1 readings are normal (80% or higher of predicted nomal) between exacerbations. Rx - SABA Step 1 for starting treatment Mild Persistent Sxs> 2x per week, but less than daily Use of SABA > 2x week, but not daily Nocturnal awakenings 3-4 x per month Mild interference with activities Spirometry within normal range Use of oral steroids 2 or more times a year Rx Low dose ICS or montelukast(singulair), Cromolyn Step 2 for starting treatment Moderate Persistent Daily asthma sxs Nocturnal awakenings > once a week Daily need of SABA Decrease in normal activity FEV1 -between 60-80% of predicted FEV1/FVC below normal Use of oral steroids > 2x year Step 3 for starting treatment Severe Persistent Have one or more Asthma sxs throughout the day Nightly awakenings Need for SABA several times daily Normal activity is extremely limited FEV1 < 60% of predicted Step 3 (age 0-4) Step 3 or 4 (5-11) Step 4 or 5 (> 12) Assessing Control Classifying Asthma Severity Ages 12 - Adult Well Controlled Not Well Controlled Very Poorly Controlled Maintain current step Consider step down if well controlled for at least 3 months Step up 1 step and reevaluate in 2-6 weeks For side effects, consider alternative treatment Consider short course of oral corticosteroids Step up 1-2 steps and reevaluate in 2 weeks For side effects consider alternative treatment options 6
Assessing Asthma Control - Ages 12 - Adult Managing Asthma ages 12 to Adult Managing asthma ages 12 to adult http://pulmonarycriticalcare.med.wayne.edu/asthma-program.php Short Acting Beta-2 Agonists -SABA Potent bronchodilator Dilates the bronchial smooth muscle. Medication of choice for intermittent asthma, exercise induced bronchoconstriction and a rescue medication. Dose: Prevention and treatment: 2 inhevery 4-6 hrs, can decrease to 1 inh. Prevention of EIB: > 4 yr Give 2 inh15 minutes before exercise. Quick relief of symptoms Onset 10-15 min Adverse Reactions: Nervousness, tremor, HA, cough, tachycardia, GI upset, dizziness, hyperactivity, throat irritation, insomnia. Albuterol ProAir HFA Proventil HFA, Ventolin HFA MDI are 90 mcg. Solution for inh0.5% 0.083% VoSpire ER (tablets) 4 mg 8 mg tabs Dose: Adults: 4 8 mg every 12 hours. Max. 32 mg/day Child: age 6 on up. 4mg every 12 hours, max 24 mg/day Asthma Exacerbation For asthma exacerbations requiring an ER visit albuterol remains the drug of choice If the person has good technique of the MDI, 2 6 puffs using a spacer or Aerochambermask. Repeat after 20 minutes up to 3 doses then every one to four hours as needed. 7
SABA continued Levalbuterol Xopenex Solution (nebulizer) Ages 6-11 yrs. 0.31mg by neb Tid > 12 yrs. 0.63mg Tidcan increase to 1.25 mg Levalbuterol- Xopenex HFA 45 mcg MDI Not recommended for children < 4 yrs. > 4 yrs 2 inhevery 4-6 hrs, or 1 inhevery 4 hrs allergyasthmatech.com 300 290-Facts About AsthmaPrevention - Allergy AsthmaTech Adverse reactions: Single -isomer of albuterol, similar side effects. Giving Asthma Medicationsto a Child: Some Great Videos Craig... drcraigcanapari.com There is no significant difference between albuterol or levalbuterol in efficacy, safety or prevalence of adverse side effects. Use should be reserved for those with known adverse effects from albuterol. Uptodate.com/content/beta-agonists-in asthma-acute administration and prophylactic use. Accessed 7/18/13 SABA continued Pirbuterol- Maxair Autohaler 200mcg per inhalation breath actuated MDI Age 12 to Adult Dose is 1-2 inhevery 4-6 hours Max of 12 inhper day Not studied for use in severe asthma exacerbation LABA Long-acting beta agonists have a long lipophilic side chain that increases the duration of binding the drugs to the adrenergic receptor. Causes a longer duration of action Salmeterol and formoterol Used with ICS for those with moderate or severe asthma not controlled with ICS alone. Have an additive effect with ICS when combined Not used in monotherapy. Leukotriene Receptor Antagonist LTRA Leukotrienes(LTC4, LTD4 and LTRA) are strong bronchoconstrictors and pro-inflammatory agents. Found in nasal secretions, sputum and bronchoalveolarlavage fluid in asthma patients Can be used in addition to ICS for daily treatment of persistent asthma in kids > 1 yr. Orin mild persistent asthma as step down therapy from ICS. Montelukast- Singulair Approved for ages > 1 yrfor asthma and 6 months or greater for rhinitis. Dosages: 4 mg granules or chewable tab ages 1-5 5 mg chewable tab ages 6-14 10 mg 15 and older Adverse Effects: URI, fever, cough, headache, pharyngitis, abdominal pain, diarrhea 8
What does the evidence show? Compared to placebo: A randomized DB study for children ages 2-5 years with intermittent asthma triggered by viral infections. 270 children in each group and given placebo or montelukast for one year. Results: Those on montelukast had 32% less asthma exacerbations (from 2.3 to1.6) and decreased used of ICS. Compared to ICS: Many studies for adults and children have shown ICS to be more effective than LTRAs in treating asthma for most patients. Two comparison studies of fluticasone and montelukast in children aged 6-14, reported fewer asthma attacks, increased pulmonary measures, and less nighttime symptoms with those using fluticasone only. Intermittent Use LTRA More information needed to confirm if taking montelukast at the onset of increased asthma or URI symptoms can be encouraged for children with intermittent asthma. Summary: Consider using montelukast in addition to a ICS for persistent asthma. Or when stepping down from ICS in mild persistent asthma. www.uptodate.com/contents/chronic-asthma-in children - accessed July, 2013. Inhaled Corticosteroids - ICS For long term asthma control If night awakenings are > 1x week Use of oral steroids > 2x a year Limitations of normal activity Addition of ICS prevents loss of lung function Increase quality of life Decreases risk of severe exacerbations ICS Adverse Reactions- Most Common Headache Rhinitis URI Pharyngitis Oral symptoms with MDI Increased asthma symptoms In young children average 1.1cm reduction in rate of growth in first year of Rx. A temporary, not a progressive slowing. PEAK STUDY (Prevention of Early Asthma in Kids) monitored 285 kids over 2-3 years. ICS Pulmicort budesonide Flexhaler (dry pwd) inhaler Respules ( susp) QVAR beclomethasone MDI ICS Alvesco ciclesonide (MDA) age 12 > Asmanex mometasone (dry pwd) age 4 > Flovent fluticasone ( MDI, dry pwddiskus) age 4> 9
Combined ICS + LABA Fluticasone/salmeterol Advair age 4 > DPI 100 mcg/ 50 mcg 250 mcg/ 50 mcg 500 mcg/ 50 mcg 45 mcg-21mcg MDI 115 mcg-21mcg 230 mcg-21mcg Mometasone/formoterol Dulera Adults MDI 100 mcg/5 mcg 200 mcg/5mcg Budesonide/formoterol Symbicort Adults MDI 80 mcg/4.5 mcg 160 mcg/4.5 mcg ICS + LABA Use when asthma symptoms not adequately controlled on a medium or higher dose of asthma-controller medications. Likely Moderate persistent asthma Step 3 on the Asthma Rx Guidelines Anti-IgE Therapy Omalizumab Xolair Approved for ages 12 and up in the U.S. In other countries used down to age of 6. Used to treat moderate to severe asthma that is not well controlled with standard medications. IgElevel of 30 to 700 IU/ml, + allergen skin test or IgEto a perennial allergen. Dose is given SQ every 2-4 weeks. Response rate is 30 50% Minimum of a 12 week Rx is needed to reach efficacy. Before Adding More Meds: ICE Inhaler technique Check patient's technique. Compliance Ask when and how much medication the patient is taking. Environment Ask patient if something in his or her environment has changed. Is there environmental tobacco smoke in the home? Find out about cotinine levels, which can help track exposure to tobacco smoke and its toxic constituents using a saliva, blood or urine test. You may also want to consider an alternative diagnosis. Assess patient for presence of other upper respiratory disease. Adapted from the Practical Guide for the Diagnosis and Management of Asthma, NIH Publication, August 2007, National Institutes of Health, National Heart, Lung and Blood Institute Cost Comparison of Asthma Medications Article: Cost Effective Asthma Treatments for Uninsured or Underinsured Pediatric Patients by KarlenE. Luthy, DNP, FNP, EmilianneDougall, MS, FNP and Renea L Beckstrand, PhD, CCRN Journal of Nurse Practitioners, Vol 8, Issue 8, Sept 2012. Identified studies related to the treatment of pediatric patients with asthma. Used an online pharmacy, drugstore.com to collect cost-related information. Step 1 Recommendation: Albuterol most cost effective for HFA and soln Step 2 Recommendation: Low dose beclomethasone (Qvar) Step 3 Recommendation: Medium-dose beclomethasone + SABA Patient Education Foster a partnership with patient and family. Discuss goals of asthma care Self management education Review actions of medications and potential side effects Written Asthma action plan for daily use and for exacerbation. Know when to use oral steroids, when to call Provider and when to seek emergency care. 10
Asthma ReadyTM Communities Asthma Patient Case Study A Missouri program developed by Ben Francisco, PhD, PNP, AC-E aimed at improving asthma care by educating teachers, school nurses and other pediatric health care professionals. He s spent over 14 years of studying and proving the effectiveness of different types of education on the treatment of kids with asthma. Uses live instruction and web-based lessons to train Missouri s professionals. So far, over 900 persons have been educated. His Four main messages about Asthma Education Daily medication can stop asthma. They work only if taken correctly. Airflow measures are critical to know if a child s asthma is under control Environmental factors, such as high allergen areas, are a critical factor that will influence how well a child s asthma is controlled. ENT Considerations Ask about asthma symptoms and level of control Ask about triggers and exposure at home, work and school Test and treat for allergies. Consider reflux Do Spirometry if you treat for allergy. Print out the Asthma guidelines keep handy Know when to refer to Pulmonary or asthma specialist References Center of Disease Control and Prevention. FastStats: Asthma. www.cdc.gov/nchs/faststats/asthma.htm. Accessed 7/28/13 CDC and Prevention, Healthy Youth: Asthma. http://www.cdc.gov/healthy youth/asthma. Accessed July 29, 2013. American Academy of Allergy, Asthma and Immunology. Asthma http://www.aaaai.org/conditions-and-treatments/asthma.aspx. accessed July 29, 2013. National Heart, Lung and Blood Institute. Expert Panel report (EBR3) Guidelines for the diagnosis and management of asthma:section4, managing asthma longtermin children 0-4 yrs of age and age 5-11. http://www.nhlbi.nih.gov/guidelines/asthma/08_sec4_accessed 7/18/2013. National Heart,Lungand Blood Institute. Expert panel report (EPR3): Guidelines for the diagnosis and management of ashtma:sec.3, component 4:medications. http//www. Nhlbi.nih.gov/guidelines/asthma/07_sec3_comp4.pdf. Accessed 7/18/2013. Global Strategy for asthma management and prevention (GINA) updated 2012. www.ginasthma.org/uploads/users files. 7/18/2013. BramanSSAsthma Guidelines in Day-to-day Practice Pulmao RJ 2012;21(2):70-75. References RanceK. Understanding and Implementing the New NHLBI Asthma Guidelines. J Nurs Pract. 2008 : Apr 254-261. LuthyKE, Dougall, E, Beckstrand,R. Cost Effective Asthma Treatments for Uninsured or Underinsured Pediatric Patients. J Nurse Prac 2012:8(8 636-642. Up to Date www.uptodate.com/contents/chronic -asthma-in-children-youngerthan 12 years and An overview of asthma management.accessed 12/31/12. Up to Date www.uptodate.com/contents/beta-agonists-in-asthma-acute administration and prophylactic use. Accessed 7/18/13 Up to Date www.uptodate.con/contents/treatment of moderate persistent asthma in adolescents and adults and treatment of severe asthma in adolescents and adults. Accessed 8/29/13. Asthma Education for missouri. http://www.muhealth.org Accessed 2/14/13. Rank,Met al. Factors associated with decisions to step down asthma medications. J of Allergy and Clinical Immunology. May 2013 Vol.1, Issue 3 pages 312-314. http://www.google.com/imgres?q=university+of+missouri+hospital&sa=x&rls=com.microsoft:enus&biw=1680&bih=840&tbm=isch&tbnid=2lsbzqp6cwy7gm:&imgrefurl=http://editbarry.wordpress.com /2011/07/22/school-choice-hospitalanalogy/&docid=HF1BVpxYUhGSQM&imgurl=http://editbarry.files.wordpress.com/2011/07/newhospital announc.jpeg%253fw%253d506%2526h%253d412&w=506&h=412&ei=fjxxudhafzcjqqgiodwcg&zoom=1&iact=rc&page=2&tbnh=145&tbnw=174&start=38&ndsp=51&ved=1t:429,r:42,s:0,i:212& tx=84&ty=82 11
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