Asthma PowerPoint Presentation

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Asthma Carroll Haymon, M.D. Case Conference April 13, 2011

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Topics for today Making the diagnosis of asthma Using pulmonary function testing Managing asthma, the chronic disease Asthma severity Asthma control Patient education Complicating factors Pharmacologic treatment Ideas for the team

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NOT for today Complicated pathophysiology Management of acute exacerbations Lengthy review of pharmacologic options

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National Asthma Education and Prevention Program: Expert Panel Report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD. National Heart, Lung, and Blood Institute, 2007.

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Many definitions “chronic inflammatory disorder of the airways” Wheezing, breathlessness, chest tightness, and cough, particularly at night. Waxing and waning symptoms due to variable airflow limitation that reverses spontaneously or with treatment. Inflammation causes an increase in airway responsiveness to a variety of stimuli.

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Key concepts Inflammation Airway reactivity Reversibility Waxing and waning Wheeze, cough, shortness of breath

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Wheezing = Asthma? Wheezing in children under 2 is most commonly caused by RSV or Rhinovirus. increased recruitment of inflammatory cells, promotion of cytokine production, enhancement of allergic inflammation, and augmented airways hyperresponsiveness Children who wheeze with these viruses are much more likely to develop asthma later. Chicken or Egg? Host factors?

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Is it asthma? More likely Classic triad Episodic symptoms Characteristic triggers Exercise, allergens, viruses History of atopy Childhood symptoms Less likely No improvement with bronchodilators Onset of symptoms after age 50 20 pack years

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Making the diagnosis Detailed medical history Physical exam focusing on upper respiratory tract, chest, and skin Spirometry in children over 5 and adults Additional studies as needed to exclude alternative diagnoses.

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Pulmonary function tests “critical tools in the diagnosis of asthma” In your office: Peak Expiratory Flow Rates (PEFR, or “peak flows”) Elsewhere: spirometry (FEV1, FVC, and their ratio)

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Do I need spirometry to make the diagnosis of asthma? Yes History and physical are not reliable means of excluding other diagnoses, or of characterizing the status of lung impairment. Pulmonary function reports do not reliably correlate with symptoms, and the two together are needed for disease classification. Peak flows are considered too variable to be accurate for diagnosis. They are more appropriately used for disease monitoring. Children over 5 are usually able to participate. NAEPP guideline. section 3. 2007.

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Which PFT’s? FEV1 FVC FEV1/FVC ratio Reversibility with bronchodilator Total lung volume Diffusion capacity Bronchoprovocation testing

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Interpreting PFT’s First, look at FEV1/FVC ratio This number is REDUCED in asthma or any obstructive airway disease. Then, look at FEV1 This number tells you the severity of the obstruction FEV1 70-99 mild obstruction FEV1 50-69 moderate FEV1 36-49 severe FEV1 <35 very severe Next, look at the response to bronchodilator Increase in FEV1 of 12% (200 mL) or more indicates responsiveness. May be less impressive if FEV1 was already high.

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OK, so it’s asthma… Now what??

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Four components of asthma management Assessment and monitoring to assess severity of disease, and to determine whether asthma control is maintained. Education for a partnership in asthma care. Control of environmental factors and comorbid conditions. Pharmacologic therapy.

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Asthma severity The intrinsic intensity of the disease process Easiest to assess in a patient not on controller medications. Used to guide initial treatment decisions. Must evaluate symptoms, rescue medication use, interference with daily activity, and exacerbations.

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Asthma Control The degree to which the manifestations of asthma are minimized and the goals of therapy are met. Level of asthma control drives decisions to change or maintain therapy. Standardized tools are available Asthma Control Test Childhood Asthma Control Test.

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Assessment of asthma control Reducing impairment Symptoms Activity level Use of rescue meds Near-normal spirometry Reducing risk Exacerbations ED visits/ hospitalizations Prevent loss of lung function

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Asthma responsiveness The ease with which asthma control is achieved by therapy.

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“in the end, symptoms, exacerbations, and quality of life over time are the only measures of asthma control.” (NAEPP guideline)

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Severity and control Remember, a patient could have Severe disease and good control Or Mild disease and poor control

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Four components of asthma management Assessment and monitoring to assess severity of disease, and to determine whether asthma control is maintained. Education for a partnership in asthma care. Control of environmental factors and comorbid conditions. Pharmacologic therapy.

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Patient education Self-monitoring is important to the management of asthma (evidence level A) This can be achieved by symptom monitoring, peak flow monitoring, or a combination. An educated patient can learn to avoid triggers, use medications properly, and implement an “asthma action plan.”

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Four components of asthma management Assessment and monitoring to assess severity of disease, and to determine whether asthma control is maintained. Education for a partnership in asthma care. Control of environmental factors and comorbid conditions. Pharmacologic therapy.

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Like what? Environmental factors Inhaled allergens Respiratory irritants Comorbid conditions Chronic lung disease GERD Obesity OSA Depression Cystic fibrosis

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What about allergy testing? Use selectively Food allergy testing generally not helpful. Animals, mold, cockroaches, dust mites “to formulate proper avoidance strategies.”

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When to refer All referral guidelines are evidence level D. Referral can be to an allergist or a pulmonologist. Local limitations.

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Four components of asthma management Assessment and monitoring to assess severity of disease, and to determine whether asthma control is maintained. Education for a partnership in asthma care. Control of environmental factors and comorbid conditions. Pharmacologic therapy.

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Deciding which meds to use First, determine severity: Intermittent Mild persistent Moderate persistent Severe persistent.

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Deciding which meds to use Next, use step-wise therapy Intermittent: step 1 albuterol Mild persistent: step 2 Low dose inhaled glucocorticoid or leukotriene blockers Moderate persistent: step 3 Low dose inhaled glucocorticoid + long acting beta agonist. Severe persistent: step 4 Higher doses of inhaled glucocorticoid + long acting beta agonist. “Line in the sand”

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Deciding which meds to use Next, assess control Step up or down as needed. “asthma is an inherently variable condition”

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Why aren’t the meds working? Nonadherence Inadequate inhaler technique Ineffective dosing Complicating medical problems Chronic sinusitis, vocal cord dysfxn, GERD, allergies Inappropriate treatment Antibiotics, antitussives, OTC meds Psychosocial factors

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Managing your panel Clarify diagnosis Determine need for updated spirometry Recommend routine visits Consider using standardized tools for assessment of control Focus with your patient on triggers, home monitoring, and comorbid conditions. Emphasize patient education and empowerment.

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Thank you!