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Rachael Ali-Permell, BS, RT, RRT-NPS, ACCS,AE-C

Manager Respiratory Therapy Department Bayhealth Milford Memorial Hospital, Delaware

Faculty

Quinones Healthcare Seminars, LLC

Asthma & COPD Management

}  During the 1930s to 1950s, asthma was known as one of the holy seven psychosomatic illnesses.

}  Asthma was described as psychological, with treatment often involving, as its primary component, psychoanalysis. A child's wheeze was seen as a suppressed cry for his or her mother.

}  Psychoanalysts thought that patients with asthma should be treated for depression. This psychiatric theory was eventually refuted and asthma became known as a physical condition.

}  Asthma, as an inflammatory disease, was not really recognized until the 1960s when anti-inflammatory medications started being used.

}  An estimated 18.8 million American adults suffer from asthma.

}  Current data shows adult asthma led to an estimated 14.2 million lost days of work.

}  The annual direct health-care cost of asthma is approximately $50.1 billion; indirect costs (e.g. lost productivity) add another $5.9 billion, for a total of $56.0 billion dollars.

Centers for Disease Control and Prevention: National Center for Health Statistics, National Health Interview Survey Raw Data,

}  By 1973, less than six years after the introduction of Virginia Slims, the rate of 12-year-old girls who had started smoking increased by 110 percent.

}  COPD is the 4th leading cause of death worldwide, yet 75% of those affected remain untreated

}  The World Health Organization estimates 600 million people worldwide have COPD.

}  COPD is projected to be the third leading cause of death by 2020 with only heart disease and cerebrovascular disease accounting for more deaths. Lung cancer, stomach cancer and HIV will be the 5th, 8th and 9th most common causes of death respectively.

}  Higher prevalence rates for COPD are found in men than in women globally reflecting historic gender differences in smoking behavior.

}  COPD is known by many alternative names. ◦  Emphysema ◦  Chronic Bronchitis ◦  Chronic Obstructive Bronchitis ◦  Chronic Airflow Limitation ◦  Chronic Airflow Obstruction ◦  Chronic Airways Obstruction ◦  Chronic Obstructive Airways Disease ◦  Chronic Obstructive Lung Disease ◦  Non-Reversible Obstructive Airways Disease ◦  Alpha-1 antitrypsin

}  Asthma ◦  Onset early in life (childhood/adolescence) ◦  Symptoms vary widely from day to day ◦  Symptoms worse at night/early morning ◦  Allergy, rhinitis and/or eczema present ◦  Family history ◦  Air flow limitations:

  Reversible ◦  1st line maintenance treatment:

  Inhaled corticosteroids

}  COPD ◦  Onset in Mid-life (~40 yrs old) ◦  Symptoms slowly progressive ◦  History of tobacco smoking ◦  Occupational exposure ◦  Indoor/outdoor air pollution ◦  Air flow limitations:

  Partially reversible ◦  1st line maintenance treatment:

  Inhaled long-acting bronchodilator

COPD

v  Measures of assessment and monitoring, obtained by objective tests, physical examination, patient history and patient report, diagnose and assess the characteristics and severity of asthma and monitor whether asthma control is achieved and maintained

v  Education for a partnership in asthma care

v  Control of environmental factors and comorbid conditions that affect asthma

v  Pharmacologic therapy

Lets Talk About ASTHMA !!!

v  Wheezing—high-pitched whistling sounds when breathing out—especially in children.

v  History of any of the following:

Cough, worse particularly at night

Recurrent wheeze

Recurrent difficulty in breathing

Recurrent chest tightness

v  Symptoms occur or worsen in the presence of:

Exercise

Viral infection

Animals with fur or hair

House-dust mites (in mattresses, pillows, upholstered furniture, carpets)

Mold

Smoke (tobacco, wood)

Pollen

Changes in weather

Strong emotional expression (laughing or crying hard)

Airborne chemicals or dusts

Menstrual cycles

v  Symptoms occur or worsen at night, awakening the patient.

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v  Hyperexpansion of the thorax, especially in children; use of accessory muscles; appearance of hunched shoulders; and chest deformity.

v  Sounds of wheezing during normal breathing, or a prolonged phase of forced exhalation (typical of airflow obstruction). Wheezing may only be heard during forced exhalation, but it is not a reliable indicator of airflow limitation.

The Expert Panel recommends spirometry measurements:

v  FEV1, forced expiratory volume in 6 seconds (FEV6), FVC, FEV1/FVC—before and after the patient inhales a short-acting bronchodilator should be done for patients which the diagnosis of asthma is being considered, including children ≥5 years of age (EPR⎯2 1997).

v  These measurements help to determine whether there is airflow obstruction, its severity, and whether it is reversible over the short term (Bye et al. 1992; Li and O'Connell 1996).

Infants and Children v  Upper airway diseases

Allergic rhinitis and sinusitis

v  Obstructions involving large airways

Foreign body in trachea or bronchus

Vocal cord dysfunction

Vascular rings or laryngeal webs

Laryngotracheomalacia, tracheal stenosis, or bronchostenosis

Enlarged lymph nodes or tumor

v  Obstructions involving small airways

Viral bronchiolitis or obliterative bronchiolitis

Cystic fibrosis

Bronchopulmonary dysplasia

Heart disease

v  Other causes

Recurrent cough not due to asthma

Aspiration from swallowing mechanism dysfunction or gastroesophageal reflux

v  Adults COPD (e.g., chronic bronchitis or emphysema)

Congestive heart failure Pulmonary embolism

Mechanical obstruction of the airways (benign and malignant tumors) Pulmonary infiltration with eosinophilia

Vocal cord dysfunction

}  Symptoms: How many days in the past week have you experienced chest tightness, cough, shortness of breath, or wheezing?

}  Nighttime awakenings: How often due you wake up at night with chest tightness, cough, shortness of breath, or wheezing?

}  Rescue inhaler use: How many times in the last week have you used your rescue inhaler?

}  FEV1: What is your current lung function measured with spirometry? Unlike the other above symptoms, your FEV1 will not be readily available at home; you will need to ask your doctor when pulmonary function tests are performed.

Intermittent Mild Persistent Moderate Persistent Severe Persistent

Symptoms 2 or less days per week More than 2 days per week Daily Throughout the day

Nighttime Awakenings

2 X's per month or less 3-4 X's per month

More than once per week but not nightly Nightly

Rescue Inhaler Use 2 or less days per week More than 2 days per week, but not daily Daily Several times per day

Interference With Normal Activity None Minor limitation Some limitation Extremely limited

Lung Function FEV1 >80% predicted and normal between exacerbation

FEV1 >80% predicted FEV1 60-80% predicted FEV1 less than 60% predicted

Classification Therapy Step

Intermittent Step 1

Mild Persistent Step 2

Moderate Persistent Step 3 or 4

Severe Persistent Step 5 or 6

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(MaxAir)

Breath Actuated MDI

(Tornalate)

(Xopenex)

(Atrovent)

v  Patient education, including a written asthma action plan to guide patient self-management of exacerbations at home, especially for patients who have moderate

or severe persistent asthma and any patient who has a history of severe exacerbations

v  A peak-flow-based plan may be particularly useful for patients who have

difficulty perceiving airflow obstruction and worsening asthma.

v  Recognition of early signs of worsening asthma and taking prompt action. v  Appropriate intensification of therapy by increasing inhaled short-acting beta2-agonist

(SABA) and, in some cases, adding a short course of oral systemic corticosteroids.

v  Removal or withdrawal of the environmental factor contributing to the exacerbation.

v  Prompt communication between patient and clinician about any serious deterioration in

symptoms or peak flow, decreased responsiveness to SABAs, or decreased duration of effect.

GREEN ZONE : 80-100% Denotes good control. Continue long-term control medications (of prescribed)

YELLOW ZONE: 50-79%

SOB, chest tightness, cough, wheeze or inability to do usual activities

Asthma is getting worse. Take quick reliever and increase meds if directed by physician

Medication: dose and frequency

RED ZONE: < 50% Significant SOB, quick relief medications do not help, cannot do normal activities or symptoms are same or worse after 24 hours.

Add or increase quick-relief medications and contact doctor now. If no improvement call 911 and go to emergency room.

v  Oxygen to relieve hypoxemia in moderate or severe exacerbations. v  SABA to relieve airflow obstruction, with addition of inhaled ipratropium bromide in

severe exacerbations.

v  Systemic corticosteroids to decrease airway inflammation in moderate or severe

exacerbations or for patients who fail to respond promptly and completely to a

SABA v  Consideration of adjunct treatments, such as intravenous magnesium sulfate or heliox,

in severe exacerbations unresponsive to the initial treatments listed above.

v  Monitoring response to therapy with serial measurements of lung function.

v  Preventing relapse of the exacerbation or recurrence

v  referral to follow up asthma care within 1–4 weeks; v  an ED asthma discharge plan with instructions for medications prescribed at

discharge v  increasing medications or seeking medical care if asthma worsens; v  review of inhaler techniques whenever possible; and consideration of initiating

inhaled corticosteroids (ICSs).

v  Characterized by increased airway resistance, pulmonary hyperinflation, and increased dead space. All of these factors lead to increased work of breathing.

v  Increased work v  The normally passive process of expiration becomes active in an attempt by the patient to force the inspired

gas out of their lungs. In addition, there is increased inspiratory work caused by high airway resistance and hyperinflation. Airway resistance is increased by turbulent gas flow.

v  If treatment with bronchodilators and corticosteroids does not reduce work of breathing quickly enough, ventilatory failure can occur.

Heliox v  helium has a lower density and a higher viscosity than nitrogen and oxygen.

v  heliox convert turbulent flow into laminar flow, thereby decreasing airway resistance and work of breathing.

Pressure control mode Low Tv and RR; Prolong Exp Time; Shorten Insp Time

v  Pressure to achieve Tidal volume: 6-8 mL/kg (using ideal body weight) v  Respiratory rate: 11-14 breaths/minute v  FiO2: 100% v  PEEP: 0-5 cm H2O

Goal: obtaining PH above 7.2 and Pplat under 30 cm H2O Saturation > 88% Monitoring for Hyperinflation The ventilated patient with asthma must be monitored for persistent or worsening hyperinflation. Hyperinflation can be measured by: Auto-PEEP : represents the lowest average alveolar pressure during the respiratory cycle. Measured using an end-expiratory hold. values >15 cm H2O indicative of hyperinflation. Auto-PEEP can also be detected by examining the flow tracings. Expiratory flow that continues at the onset of inspiration indicates that breath stacking (hyperinflation) is occurring. Plateau pressure (Pplat): recommended method to monitor patients for hyperinflation and injurious airway pressures. The average end-inspiratory alveolar pressure. Pplat is measured using an end-inspiratory pause. Values > 30 cm H2O indicate hyperinflation and excessive airway pressures.

v 

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Measurement of intrinsic positive end-expiratory pressure.

Mechanism of dynamic hyperinflation in the setting of severe airflow obstruction.

History and Assessment v  A 12-year-old girl with a history of asthma came to the emergency department because she

had acute shortness of breath and wheezing associated with an upper respiratory tract infection. Her only asthma medication was albuterol as needed; montelukast therapy had been stopped 2 weeks earlier. Despite 3 back-to-back treatments with nebulized albuterol and ipratropium, she remained symptomatic and was admitted to the hospital. Intravenous administration of methyl-prednisolone was started in the emergency department.

v  Despite continued bronchodilator and corticosteroid therapy, the patient’s condition worsened, and she required increasing amounts of supplemental oxygen. A sample of blood for arterial blood gas analysis was obtained while she breathed oxygen via a simple face mask at a rate of 12 L/min. The results were as follows: pH 7.23; Paco2 61 mm Hg; and Pao2 84 mm Hg. The patient was lethargic, was breathing at a rate of 60 to 70 breaths per minute, had tachycardia, and had pulsus paradoxus as indicated by pulse oximetry.5 Her chest was quiet on auscultatory examination.

Treatment and Management v  While preparing for intubation she was given heliox from a premixed H-cylinder (80% helium,

20% oxygen) via a nonrebreather mask at a rate of 10 L/min, Nasal administration of oxygen at a rate of 2 L/min was required to keep her oxygen saturation greater than 90%.

v  Arterial blood gas analysis of a blood sample obtained 25 minutes after the initiation of heliox revealed the following: pH 7.36, Paco2 46 mm Hg, and Pao2 57 mm Hg.

v  Plans for intubation were put on hold, and intensive pharmacological therapy continued, including intravenous terbutaline.

v  Frequent treatment with nebulized bronchodilators was given via a sidearm port of the nonrebreather mask; the nebulization was powered by heliox gas at a flow rate of 6 L/min from a second oxygen flowmeter (actual flow, 11 L/min), as suggested by Hess et al.6

Outcome v  The patient had progressive improvement in vital signs, level of consciousness, and

oxygenation. After 5 hours of heliox therapy, she was returned to breathing a mixture of nitrogen and oxygen. She continued to improve, and she was discharged from the hospital 2 days later.

Am J Crit Care January 2003 vol. 12 no. 1 28-30 Jeffrey M. Haynes, RRT, RPFT, Ronald J. Sargent, CRT and Elizabeth L. Sweeney, CRT

v  Bronchial thermoplasty is a treatment in which the smooth muscle of the smaller airways in the lungs are directly treated with a heat probe, resulting in mild intentional scarring reducing the amount of airway smooth muscle and decreasing the airways ability to constrict and opening of the airways.

v  Treatment, does not involve surgery, performed with a flexible bronchoscope that goes through

the nose and into the airways. v  Patients are typically given medication to make them relax and in some cases put to sleep. v  With the bronchoscope in the lungs, a thin wire with a heat probe (150 degrees F) on the tip is

passed beyond the tip of the bronchoscope and heat applied to the walls of the airways for 10 seconds.

v  This is repeated in nearby airways thereafter, covering about a third of lungs in each

treatment. v  The entire procedure is repeated 3 weeks later and again 3 weeks after that.

For patient 18 and older Patients with Severe-Persistent Asthma Study (Massachusetts Lung & Allergy, PC. Aghassi . P, and colleagues) Significant benefits: 32% reduction in asthma attacks 84% reduction in emergency room visits for Respiratory symptoms 66% reduction in days lost from work, school and or daily activities 73% reduction in hospitalizations for Respiratory symptoms Potential Downside: Period immediately after treatment: Temporary increase in frequency and worsening of respiratory related symptoms, (typically within a day of procedure and resolved within seven days of standard asthma care) Adverse Events: Pneumonia, bleeding, bronchial obstructions, acute bronchitis, bronchospasm infection, Blood tinged sputum, sore throat. After receiving Bronchial Thermolasty patients can still suffer asthma attacks but the severity may significantly be reduced

Massachusetts Lung & Allergy, PC. Aghassi . P, and colleagues

Airflow obstruction may be caused by all or some of the following: v  Excessive secretions partially blocking the airways.

v  Edematous thickening of the walls decreasing the diameter of the airways.

v  With emphysema the normally elastic alveolar walls becoming over-distended and collapsing inward, narrowing the airways.

v  Chronic respiratory acidosis : Hypoventilation in COPD involves multiple mechanisms, including decreased responsiveness to hypoxia and hypercapnea, increased Ventilation-perfusion mismatch leading to increased dead space ventilation, and decreased diaphragm function secondary to fatigue and hyperinflation

The top two causes of COPD exacerbation: v  bacterial or viral lung infections and air pollution.

v  Studies have found that smoking, lack of a pulmonary rehabilitation program, improper use of an inhaler and poor adherence to a drug therapy program are all associated with more frequent episodes of COPD exacerbation.

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Modified British Medical Research Council (mMRC) Dyspnea Questionnaire

Measures Health Status impairment in COPD

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v  Oxygen Therapy

v  Glucocorticosteroids (oral, IV and/or inhaled medications that treat inflammation) v  Blocking the production of substances that trigger allergic and inflammatory actions v  Interference with white blood cell function yields a side effect of increased susceptibility to infection.

v  Antibiotics (if an underlying bacterial infection exists) v  Bacterial, Strep, MRSA

v  Sputum Analysis v  Infection (antibiotics)

v  Bronchodilators

v  Airway Clearance Techniques v  Breathing/coughing, PEP, Oscillatory,

v  Ventilatory support – Non-Invasive (BIPAP) or Invasive(Intubation/ Mechanical Ventilation)

An arterial blood gas (ABG) sample typically shows that the patient has low oxygen levels (hypoxia) and high carbon dioxide levels (hypercapnia) NIV avoids many of the risks associated with intubation less likelihood of aspiration fewer nosocomial infections such as pneumonia Patients are more comfortable Do not require paralysis or sedation, Compared to intubation NIV is substantially less expensive for both the patient and the hospital. 


v  There have been several important meta-analyses regarding the use of NIV in COPD. Show that NIV is of value in treating acute exacerbations of COPD.1

v  Study patients have decreased: v  Hospital mortality v  Intubation rates v  Length of stay

v  Economic evaluation noted a cost savings of $3244 for each patient treated with NIV vs. mechanical ventilation.

NIV should be applied as soon as indicated to achieve maximum benefit. In one study, the success rate was 93% when NIV was used early in the course of hospital treatment, while the success rate was only 63% when standard medical therapy was used before NIV.2 Crit Care Med 2000;28:2094-2102.(Meta-analysis and economic evaluation of treatment)1

Chest 1998;114:1636-1642. (Randomized, prospective; 30 adult patients)2

Initiation Of NIV Acute exacerbation of COPD Failure to improve despite oxygen, B-agonists, anticholinergics and steroids

v  CPAP settings: Initially, low pressure (5cmH2O) increase by 2cm as tolerated v  BIPAP settings: Initially, IPAP 8-10 ; EPAP 2-4 Increase as tolerated

◦  Ranges IPAP 4-24 ; EPAP 2-20

Things to consider: v  Proper patient selection v  Proper sizing device (Masking/Headgear) v  Close monitoring of the patient v  Careful attention to patient comfort

When to discontinue NIV in the ED? v  The patient’s oxygenation can be maintained at 90% saturation or better with 4 L/min or less of supplemental

oxygen

v  Respiratory rate is less than 24

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v  Respiratory arrest v  Respiratory rate greater than 35

v  Progressive respiratory distress

v  Loss of consciousness

v  Arterial pH below 7.30 that does not rapidly improve

v  Persistent hypoxia despite supplemental oxygenation v  Bradycardia or significant tachycardia

v  Hemodynamic instability

v  Increasing agitation, lethargy, or confusion

v  Vomiting or increased secretions

Initiation of Invasive Ventilation The decision to intubate should be made immediately if the patient suffers a loss of consciousness, worsening respiratory status, or hemodynamic instability.

}  lung-volume reduction surgery, reduce the size of the lungs by removing about 20-30% of the most diseased lung tissues so that the remaining healthier portion can perform better.

Considerations for surgery include: }  The damage in the lungs must be in an area that is localized (a specific area) and can

be removed .

}  You must be strong enough to have the surgery .

}  You must participate in a pulmonary rehabilitation program.

}  You cannot be a current smoker .

}  Pulmonary rehabilitation a structured program that can

reduce symptoms of COPD. pulmonary rehabilitation program include exercise training, nutrition counseling, and education on special breathing techniques and other means of coping with COPD.

v  Retaining CO2?  Retention: exhalation is not enough to get rid of the carbon dioxide in the lungs.   Pursed Lip Breathing allows for exhaling longer then inhaling and helps to take deeper breaths.

v  COPD who receive excessive supplemental oxygen can develop CO2 retention, and subsequent hypercapnia.

v  Only a blood gas (ABG) can tell you. The CO2 will be greater than 45, sometimes 60 or higher, and the bicarb will be greater than 30. The pH will be normal. A 2 LNC is usually safe for CO2 retainers.

v  Reduction in the hypoxic"drive", a condition called carbon dioxide narcosis. When carbon dioxide levels are chronically elevated, the respiratory center becomes less sensitive to CO2 as a stimulant of the respiratory drive, and the PaO2 provides the primary stimulus for respirations. Administering excess supplemental oxygen can potentially suppress the respiratory center

}  A Certified Asthma Educator: Goals —Teach patients and their family about the pathology of asthma, and help asthmatic patients avoid emergency room visits through proper training of devices and medication use and providing them with an updated asthma action plan. Provide the community with asthma education.

}  Respiratory Clinical Specialist (RCS): The RCS is an advanced RRT position whose duties include facilitating care of the COPD patient with physician rounding, patient/caregiver teaching, defining appropriate care/discharge needs, and case managing those patients with frequent readmissions.

1. The National Heart, Lung, and Blood Institute (NHLBI) Health Information Center is a service of

the NHLBI of the National Institutes of Heal.th. http://www.nhlbi.nih.gov

2. Centers for Disease Control and Prevention, National Center for Health Statistics. CDC Wonder On-line

Database, compiled from Compressed Mortality File 1979-2009 Series 20 No. 2O, 2012.

3. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention.

Behavioral Risk Factor Surveillance System, 2011. Analysis performed by American Lung Association

Research and Health Education using SPSS and SUDAAN software.

4. Use of Heliox to Avoid Intubation in a Child With Acute Severe Asthma and Hypercapnia Am J Crit Care January

2003 vol. 12 no. 1 28-30

5. Ventilator Management of the Intubated Patient With Asthma , Medscape Emergency Medicine; Michael E.

Winters, MD December 13, 2010

6. Levy BD, Kitch B, Fanta CH. Medical and ventilatory management of status asthmaticus. Intensive Care Med.

1998;24:105–117. doi: 10.1007/s001340050530.

7. Keenan SP, Gregor J, Sibbald WJ, et al. Noninvasivepositive pressure ventilation in the setting of severe, acute

exacerbations of chronic obstructive pulmonary disease: More effective and less expensive. Crit Care Med

2000;28:2094-2102.(Meta-analysis and economic evaluation of treatment)

8. Celikel T, Sungur M, Ceyhan B, et al. Comparison of noninvasive positive pressure ventilation with standard

medical therapy in hypercapnic acute respiratory failure. Chest 1998;114:1636-1642. (Randomized, prospective;

30 adult patients)

Thank You !! Questions?