ASTHMA By Dr Aguilera. Definition: Chronic inflammatory disorder of the respiratory airways which...

ASTHMAASTHMA

By Dr AguileraBy Dr Aguilera

Definition:Definition:

• Chronic inflammatory disorder of the Chronic inflammatory disorder of the respiratory airways which includes 3 respiratory airways which includes 3 componentscomponents– bronchial hyperresponsiveness to a variety of bronchial hyperresponsiveness to a variety of

stimuli (i.e. allergens, respiratory viruses, stimuli (i.e. allergens, respiratory viruses, environmental exposures and others)environmental exposures and others)

– reversible airflow obstructionreversible airflow obstruction– associated with recurrent episodes of associated with recurrent episodes of

respiratory symptoms (i.e. most commonly respiratory symptoms (i.e. most commonly wheezing, SOB, chest tightness and cough)wheezing, SOB, chest tightness and cough)

PathophysiologyPathophysiology

• Asthma has 2 mechanisms of reaction:Asthma has 2 mechanisms of reaction:– Allergen induced bronchoconstriction Allergen induced bronchoconstriction

• IgE mediated responseIgE mediated response mast cell stimulation mast cell stimulation mediators mediators releasedreleased

– Other stimuli induced bronchoconstrictionOther stimuli induced bronchoconstriction• Inflammatory mediated responseInflammatory mediated response inflam cell stimulation inflam cell stimulation

neuro/hormonal reflexes in the lungsneuro/hormonal reflexes in the lungs

• Both cause edematous swelling of airway Both cause edematous swelling of airway wallswalls hyperresponsiveness and ultimately hyperresponsiveness and ultimately airflow obstruction, which can occur in minutes, airflow obstruction, which can occur in minutes, hours, days or weekshours, days or weeks

Epidemiology: 2000Epidemiology: 2000

• Prevalence is increasingPrevalence is increasing• 17 million patients with asthma in the US17 million patients with asthma in the US• Age: Age:

– >18 yrs = 11 million (62%)>18 yrs = 11 million (62%)– 2-17 yrs = 6 million (38%)2-17 yrs = 6 million (38%)

• Race: Race: – 8.9 million Caucasian (52%)8.9 million Caucasian (52%)– 3.5 million Latino (21%)3.5 million Latino (21%)– 3.3 million African American (19%)3.3 million African American (19%)– 1.3 million other (8%)1.3 million other (8%)

• Gender: Male 42%, Female 58%Gender: Male 42%, Female 58%

Morbidity and MortalityMorbidity and Mortality

• Most often associated with failure to appreciate Most often associated with failure to appreciate severity of exacerbation by pt and/or provider:severity of exacerbation by pt and/or provider:– Deaths: > 5,000/year but decreasing overall since Deaths: > 5,000/year but decreasing overall since

1990, probably due to better management from PCP1990, probably due to better management from PCP– Hospitalizations: 466,000 in 2000Hospitalizations: 466,000 in 2000

• 5% required ICU 5% required ICU

• ED Visits: ED Visits: – 1.9 million in 20001.9 million in 2000– females 2X > than malesfemales 2X > than males– the 11the 11thth most common diagnosis most common diagnosis– 20-30% of these required hospitalization20-30% of these required hospitalization

Morbidity and Mortality Morbidity and Mortality Cont’dCont’d• Costs: > $6 billion/year Costs: > $6 billion/year

– average annual cost/pt with attack =$600 average annual cost/pt with attack =$600 compared with $170 with no attackcompared with $170 with no attack

– cost includes the 3 million lost workdays in cost includes the 3 million lost workdays in the US per yearthe US per year

• Important Note:Important Note: Most ED visits, and Most ED visits, and therefore, hospitalizations are preventable. therefore, hospitalizations are preventable. A useful practice is to assume that every A useful practice is to assume that every exacerbation is potentially fatal.exacerbation is potentially fatal.

Risk factors for death from Risk factors for death from AsthmaAsthma

• Past history of sudden, severe exacerbationsPast history of sudden, severe exacerbations• Prior intubationPrior intubation• Prior admission to ICUPrior admission to ICU• More than 2 hospitalizations in past yearMore than 2 hospitalizations in past year• More than 3 ED visits in the past yearMore than 3 ED visits in the past year• Recent use/withdrawal from systemic steroidsRecent use/withdrawal from systemic steroids• Comorbid conditionsComorbid conditions• Difficulty perceiving severity of disease (more Difficulty perceiving severity of disease (more

common in males)common in males)

Asthma Attack EvolutionAsthma Attack Evolution

• Two different pathogenic scenarios involved:Two different pathogenic scenarios involved:– Airway inflammation predominant:Airway inflammation predominant:

• pts show a progressive deterioration over 6 hours, days or pts show a progressive deterioration over 6 hours, days or weeks (slow onset attack). weeks (slow onset attack).

• The prevalence is 80-90% in adults and usually assoc with The prevalence is 80-90% in adults and usually assoc with infectious causes.infectious causes.

• Have a slower therapeutic response Have a slower therapeutic response

– Bronchospasm predominant:Bronchospasm predominant:• Pts present with a sudden onset attack over minutes to 3-6 Pts present with a sudden onset attack over minutes to 3-6

hrs (asphyxic or hyperacute attack). hrs (asphyxic or hyperacute attack).

• Usually associated with allergens, exercise and stress.Usually associated with allergens, exercise and stress.

• Have a more rapid and complete responseHave a more rapid and complete response

DiagnosisDiagnosis

• Usually cannot be done in the first visitUsually cannot be done in the first visit

• History and Physical examHistory and Physical exam– Classic triadClassic triad

•Cough, SOB and wheezeCough, SOB and wheeze

•Not all that wheezes is asthma and not all Not all that wheezes is asthma and not all asthma wheezes.asthma wheezes.

•Presence of wheezing is a poor predictor of Presence of wheezing is a poor predictor of airflow obstruction, therefore need to use other airflow obstruction, therefore need to use other findingsfindings

– Vital signs, RR, mentation, accessory muscle useVital signs, RR, mentation, accessory muscle use

Diagnosis Cont’dDiagnosis Cont’d

• Pulmonary Funtion TestingPulmonary Funtion Testing– Peak Expiratory Flow Rate (PEFR)Peak Expiratory Flow Rate (PEFR)

• Measured by age and heightMeasured by age and height– Spirometry with bronchodilator evaluationSpirometry with bronchodilator evaluation

• FEV1, FVC and FEV1/FVC ratioFEV1, FVC and FEV1/FVC ratio– > 80% predicted borderline obstruction> 80% predicted borderline obstruction– 60-80% mild obstruction60-80% mild obstruction– 40-60% moderate obstruction40-60% moderate obstruction– <40% severe obstruction<40% severe obstruction

• Serial testing over timeSerial testing over time– Bronchoprovocation testing with methacholineBronchoprovocation testing with methacholine

• Same deal as with exercixe stress testing in anginaSame deal as with exercixe stress testing in angina

Diagnosis Cont’dDiagnosis Cont’d

• CXRCXR– Only on initial evaluationOnly on initial evaluation– Can see flattened diaghrams from Can see flattened diaghrams from

hyperinflationhyperinflation

• Blood testsBlood tests– nonenone

• Allergy testingAllergy testing– Allergy skin testAllergy skin test– Blood radioallergosorbent test (RAST)Blood radioallergosorbent test (RAST)

Classification of AsthmaClassification of AsthmaStageStage Daytime Daytime

symptomssymptomsNighttime Nighttime SymptomsSymptoms

PEFRPEFR

of of predictedpredicted

FEV1FEV1

of of predictedpredicted

Mild Mild Intermittent Intermittent

AsthmaAsthma

< 2x/wk< 2x/wk < 2 < 2 nights/wknights/wk

>80% >80% <20%<20%

Mild Mild Persistent Persistent AsthmaAsthma

> 2x/wk, > 2x/wk, but <1x/daybut <1x/day

> 2 > 2 nights/monights/mo

>80%, but >80%, but fluctuates fluctuates

>20%>20%

20-30%20-30%

Moderate Moderate Persistent Persistent AsthmaAsthma

Daily SxDaily Sx > 1 > 1 night/wknight/wk

60% - 80%60% - 80% >30%>30%

Severe Severe Persistent Persistent AsthmaAsthma

ContinualContinual Frequent Frequent

4-7x/wk4-7x/wk< 60%< 60% >30%>30%

Overall ManagementOverall Management

• 4 key component to success4 key component to success– Patient MonitoringPatient Monitoring– Controlling TriggersControlling Triggers– PharmacotherapyPharmacotherapy– Patient EducationPatient Education

Overall Management cont’dOverall Management cont’d

• MonitoringMonitoring

– Peak Expiratory Flow Rate (PEFR) can be used to follow impact of Peak Expiratory Flow Rate (PEFR) can be used to follow impact of change in therapy upon lung fxn and/or to assess severity of change in therapy upon lung fxn and/or to assess severity of attack, attack, NOTNOT to detect presence of airflow obstruction to detect presence of airflow obstruction• Measurement is highly dependent on users techniqueMeasurement is highly dependent on users technique• Measure with patient standing and should be a evening trialMeasure with patient standing and should be a evening trial• Record best of 3 triesRecord best of 3 tries• Pts should have device at home, however, to establish a baselinePts should have device at home, however, to establish a baseline• Encouraged to be used at least by pts with mod-severe diseaseEncouraged to be used at least by pts with mod-severe disease• Mixed data on whether or not home monitoring is beneficialMixed data on whether or not home monitoring is beneficial

– For the future:For the future:• Sputum Eosinophilia as a marker for treatmentSputum Eosinophilia as a marker for treatment• Exhaled nitric oxide as a way to predict airway inflammation and Exhaled nitric oxide as a way to predict airway inflammation and

asthmatic controlasthmatic control

Overall Management Cont’dOverall Management Cont’d

• Controlling Trigger FactorsControlling Trigger Factors– Identify and avoid triggersIdentify and avoid triggers– They vary from person to person and time to time (for They vary from person to person and time to time (for

females most commonly have exacerbations in premenstrual females most commonly have exacerbations in premenstrual phase)phase)

– Generally fall into 6 categories:Generally fall into 6 categories:• 1. Allergens (pollen), 2. Irritants (air pollutants), 3. Respiratory 1. Allergens (pollen), 2. Irritants (air pollutants), 3. Respiratory

infections (viruses), 4. Physical activity, 5. Chemicals (foods and infections (viruses), 4. Physical activity, 5. Chemicals (foods and drugs) and 6. Emotional stress. These are the main ones drugs) and 6. Emotional stress. These are the main ones identified clinicallyidentified clinically

– Allergic rhinitis, chronic sinusitis, polyposis, GERD, menses, Allergic rhinitis, chronic sinusitis, polyposis, GERD, menses, and pregnancy are others that may also contribute to and pregnancy are others that may also contribute to exacerbationsexacerbations

– Once identified: a.) avoid the trigger, b.) limit exposure if Once identified: a.) avoid the trigger, b.) limit exposure if cannot be completely avoided, c.) take an extra dose of cannot be completely avoided, c.) take an extra dose of bronchodilator before exposure, but careful with exceeding bronchodilator before exposure, but careful with exceeding normal amountsnormal amounts


• Pharmacologic TherapyPharmacologic Therapy– This is the mainstay of management in This is the mainstay of management in

most patients with asthma, and varies most patients with asthma, and varies with type and severity of asthma.with type and severity of asthma.

– Relievers vs. ControllersRelievers vs. Controllers•Fast actingFast acting Slow acting Slow acting

•Relieve bronchospasmRelieve bronchospasm Controls inflammation Controls inflammation

•Stops symptomsStops symptoms Prevents symptoms Prevents symptoms

•Take PRNTake PRN Take everyday Take everyday


– Mild Intermittent AsthmaMild Intermittent Asthma: (refer to prior slide): (refer to prior slide)• Includes exercise induced asthmaIncludes exercise induced asthma• Short Acting Inhaled beta-agonists: Albuterol (Proventil, Short Acting Inhaled beta-agonists: Albuterol (Proventil,

Ventolin)Ventolin)– Rapid onset of action, get maximal potency of bronchodilation Rapid onset of action, get maximal potency of bronchodilation

and minimal side effects.and minimal side effects.– Encourage to use 10 minutes prior to exposure to a triggerEncourage to use 10 minutes prior to exposure to a trigger– Meter dose inhalers (MDI’s) are now using ozone-safe Meter dose inhalers (MDI’s) are now using ozone-safe

propellants instead of chlorofluorocarbon (CFC)propellants instead of chlorofluorocarbon (CFC)– Alternate delivery forms have been developedAlternate delivery forms have been developed

Albuterol now comes in powder formAlbuterol now comes in powder form Ipratropium (Atrovent) is Ipratropium (Atrovent) is NOTNOT a good reliever for asthma a good reliever for asthma

• Mast Cell Stabilizers (Cromolyn, Nedocromil)Mast Cell Stabilizers (Cromolyn, Nedocromil)– Have no benefit to relieve immediately asthmatic symptomsHave no benefit to relieve immediately asthmatic symptoms– Limited role in adultsLimited role in adults


– Mild Persistent AsthmaMild Persistent Asthma• All Persistent asthmatics need a controllerAll Persistent asthmatics need a controller

– The assumption behind this recommendation is that regular medication The assumption behind this recommendation is that regular medication use will reduce the frequency of symptoms, improve overall quality of use will reduce the frequency of symptoms, improve overall quality of life and decrease the risk of serious attacks and therefore lower the life and decrease the risk of serious attacks and therefore lower the rate of ED visits and hospitalizationsrate of ED visits and hospitalizations

• Inhaled SteroidsInhaled Steroids– The gold standard against which all other controlling therapy is The gold standard against which all other controlling therapy is

comparedcompared– Decreases mast cell and airway inflammationDecreases mast cell and airway inflammation– Side effects include:Side effects include:

Local effects (thrush, dysphonia, and bad taste) Local effects (thrush, dysphonia, and bad taste) Systemic effects (cataracts, bone loss, increase IOP, growth Systemic effects (cataracts, bone loss, increase IOP, growth

suppression) are dose related, rare and occur particularly in suppression) are dose related, rare and occur particularly in prolonged, high dose usersprolonged, high dose users

– Using a spacer device is recommended in order to maximize Using a spacer device is recommended in order to maximize medication delivery to the lung and minimize oral depositionmedication delivery to the lung and minimize oral deposition

– No advantage to using albuterol immediately prior to inhaled steroid to No advantage to using albuterol immediately prior to inhaled steroid to achieve more lung depositionachieve more lung deposition

– Using an inhaled steroid with a systemic oral steroid is not Using an inhaled steroid with a systemic oral steroid is not contraindicated, but should be limitedcontraindicated, but should be limited

Not All Steroids Are Created Not All Steroids Are Created EqualEqualDrugDrug Low doseLow dose Medium Medium

dosedoseHigh doseHigh dose

Beclomethasone Beclomethasone MDI (Vanceril) 40 MDI (Vanceril) 40 mcgmcg

2-6 pfs/day2-6 pfs/day 16-12 pfs/day16-12 pfs/day >12 pfs/day>12 pfs/day

Budesonide DPIBudesonide DPI

(Pulmacort) (Pulmacort) 200mcg200mcg


Flunisolide MDIFlunisolide MDI

(Aerobid) 250 (Aerobid) 250 mcgmcg


Fluticasone DPIFluticasone DPI

(Flovent)(Flovent)50mcg50mcg

2-6 pfs/day2-6 pfs/day100 mcg100 mcg

6-12 pfs/day6-12 pfs/day250 mcg250 mcg

>12 pfs/day>12 pfs/dayTriamcinolone Triamcinolone MDIMDI

(Azmacort) 100 (Azmacort) 100 mcgmcg



– Moderate Persistent AsthmaModerate Persistent Asthma• Incorporates the mild asthmatic receiving treatment, yet Incorporates the mild asthmatic receiving treatment, yet

remain symptomaticremain symptomatic• Try to find the combination that worksTry to find the combination that works• Long Acting Beta AgonistsLong Acting Beta Agonists

– Formoterol (Foradil) and Salmeterol (Serevent)Formoterol (Foradil) and Salmeterol (Serevent) Both have similar characteristics, but Foradil has a faster Both have similar characteristics, but Foradil has a faster

onset of action (5 min vs 20 min)onset of action (5 min vs 20 min) Inhaled meds that have long half lives which allow bid Inhaled meds that have long half lives which allow bid

dosing. No longer in MDI, now in DPIdosing. No longer in MDI, now in DPI Found to be less efficacious than inhaled steroids in Found to be less efficacious than inhaled steroids in

improvement in lung fxn, control of Sx and amt of attacksimprovement in lung fxn, control of Sx and amt of attacks Currently 2Currently 2ndnd line after inhaled steroids, and not recom as line after inhaled steroids, and not recom as

monotherapy for mild asthmamonotherapy for mild asthma Combo therapy (Advair) with inhaled steroid has shown Combo therapy (Advair) with inhaled steroid has shown

more benefit in mod-severe persistent asthma.more benefit in mod-severe persistent asthma.


Leukotriene Receptor Antagonists (LTRA’s)Leukotriene Receptor Antagonists (LTRA’s)

Zafirlukast (Accolate) – bid dosingZafirlukast (Accolate) – bid dosing

Montelukast (Singulair) – qday dosing and therefore is Montelukast (Singulair) – qday dosing and therefore is the favored onethe favored one

also approved for allergic rhinitis.also approved for allergic rhinitis. tolerated well because of low side effect profiletolerated well because of low side effect profile Approved down to age 2Approved down to age 2 Currently positioned 3Currently positioned 3rdrd line, after inhaled steroids line, after inhaled steroids

and long acting beta agonists.and long acting beta agonists. Have a varied response among individuals with Have a varied response among individuals with

asthmaasthma May be used as first line in very mild stage 2 asthmaMay be used as first line in very mild stage 2 asthma May discontinue after 2-3 weeks in “non-responders”May discontinue after 2-3 weeks in “non-responders”


– High-dose inhaled steroidHigh-dose inhaled steroid– Fluticasone 100 -250 mcgFluticasone 100 -250 mcg– Budesonide 200 mcgBudesonide 200 mcg– As the dose of inhaled steroid increases, the likelihood As the dose of inhaled steroid increases, the likelihood

of systemic absorption and potential for significant side of systemic absorption and potential for significant side effects from long term use also increases.effects from long term use also increases.

– Therefore, every effort should be made to reduce the Therefore, every effort should be made to reduce the dose of inhaled steroid, seeking to find the lowest dose dose of inhaled steroid, seeking to find the lowest dose that continues to maintain good control and minimize that continues to maintain good control and minimize the risk of exacerbationsthe risk of exacerbations

– Systemic effects are far less frequent than with Systemic effects are far less frequent than with systemic oral steroidssystemic oral steroids

– Long-acting beta agonistsLong-acting beta agonists– LTRALTRA


– Severe Persistent AsthmaSevere Persistent Asthma• Patients who fail to achieve symptom control despite 2-3 controller Patients who fail to achieve symptom control despite 2-3 controller

medicationsmedications• Long-acting oral bronchodilator (theophylline)Long-acting oral bronchodilator (theophylline)

– Used for its intrinsic anti-inflammatory effect, bronchodilation is Used for its intrinsic anti-inflammatory effect, bronchodilation is considered secondaryconsidered secondary

– Increases ciliary motility, mucus clearance and diaphragmatic motilityIncreases ciliary motility, mucus clearance and diaphragmatic motility– Not tolerated well because of Sfx – nausea, cramps, diarrhea, and Not tolerated well because of Sfx – nausea, cramps, diarrhea, and

insomniainsomnia– Narrow therapeutic index requiring check of serum levelsNarrow therapeutic index requiring check of serum levels

Toxicity can result in seizures and deathToxicity can result in seizures and death 24 hour preparations are preferred (Uniphyl)24 hour preparations are preferred (Uniphyl)

– Currently 4Currently 4thth line, after inhaled steroids, long-acting beta agonists, and line, after inhaled steroids, long-acting beta agonists, and LTRA.LTRA.

• Oral steroidsOral steroids– Want to avoid as much as possible. If going to use, then use in short Want to avoid as much as possible. If going to use, then use in short

spurts or tapering regimensspurts or tapering regimens

Overall Management Cont’dOverall Management Cont’d• Choosing a treatment strategyChoosing a treatment strategy

Start aggressively then step down Start aggressively then step down once controlledonce controlled

Start with a single agent and Start with a single agent and step up until control is step up until control is

achievedachieved

Controls symptoms quicklyControls symptoms quickly May take several months to May take several months to achieve controlachieve control

More side effectsMore side effects Less side effectsLess side effects

Recommended by NIH guidelines Recommended by NIH guidelines for asthma, expert panel report 2for asthma, expert panel report 2

Requires patience and very Requires patience and very close follow-upclose follow-up


• Adjunctive MedicationsAdjunctive Medications– Treating comorbid conditions improves asthma Treating comorbid conditions improves asthma

• AntihistaminesAntihistamines– Treating allergic rhinitis decreases responsiveness to Treating allergic rhinitis decreases responsiveness to

triggerstriggers

• Nasal steroidsNasal steroids– Have been shown to improve symptoms in patients Have been shown to improve symptoms in patients

with both AR and asthmawith both AR and asthma– Some studies indicate benefit in asthma aloneSome studies indicate benefit in asthma alone

• H2 blockers and/or PPI’sH2 blockers and/or PPI’s– Prevalence of GERD in asthmatics ranges from 34-80% Prevalence of GERD in asthmatics ranges from 34-80%

in various studiesin various studies– Improving reflux has been shown to improve controlImproving reflux has been shown to improve control


• Patient EducationPatient Education– Medication MythsMedication Myths

• Nebulizers offer improved medication delivery and are Nebulizers offer improved medication delivery and are referable for more severe asthmaticsreferable for more severe asthmatics

– MDI’s used through a spacer can offer more efficient MDI’s used through a spacer can offer more efficient medication delivery at a fraction of the cost and time medication delivery at a fraction of the cost and time when compared to a nebulizerwhen compared to a nebulizer

• Inhaled steroids increase birth defects or are risky in Inhaled steroids increase birth defects or are risky in pregnancypregnancy

– Recent studies have shown no increase in birth defects or Recent studies have shown no increase in birth defects or decrease in birth weight with the use of any inhaled decrease in birth weight with the use of any inhaled steroidsteroid

Category B or C, except Azmacort = DCategory B or C, except Azmacort = D


• Asthma flow sheet (blue)Asthma flow sheet (blue)– Found on left side of chart, along with Found on left side of chart, along with

diabetic flow sheetdiabetic flow sheet– Convenient tracking of symptoms, peak Convenient tracking of symptoms, peak

flowsflows– There is a cheat sheet on bottom of page There is a cheat sheet on bottom of page

for stagingfor staging– Can write on progress note: “see blue Can write on progress note: “see blue

asthma flow sheet”asthma flow sheet”


• The Asthma Action PlanThe Asthma Action Plan– Helps patients and families understand Helps patients and families understand

complex regimencomplex regimen– The Green Zone (PEFR > 80% predicted)The Green Zone (PEFR > 80% predicted)

•What to do on normal daysWhat to do on normal days

– The Yellow Zone (PEFR 50-80% predicted)The Yellow Zone (PEFR 50-80% predicted)•CautionCaution

– The Red Zone (PEFR < 50%)The Red Zone (PEFR < 50%)•DangerDanger

The EndThe End

ASTHMA By Dr Aguilera. Definition: Chronic inflammatory disorder of the respiratory airways which...

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