CAPA 2012 Deborah Hellyer MD. Review Asthma – what is it Control is possible What is new? CTS...

ASTHMA

CAPA 2012Deborah Hellyer MD

Objectives

Review Asthma – what is it Control is possible What is new? CTS 2012 Guidelines Special considerations

ASA Triad Occupational Asthma Asthma in Pregnancy Emergency treatment

Asthma

An inflammatory disorder of the airways characterized by paroxysmal or persistent symptoms such as dyspnea, chest tightness, wheezing, sputum production and cough, associated with variable airflow limitation and a variable degree of hyperresponsiveness of airways to endogenous or exogenous stimuli

Asthma Prevalence and Mortality

Source: Masoli M et al. Allergy 2004

Asthma Statistics

2.7 million Canadians have asthma

13% of Ontarians have asthma , 21% of Ontario children aged 0-14 have asthma

39% of people with asthma report limitation in physical activity

Asthma is the # 1 reason for children being hospitalized

Pathology of Asthma

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI, 1995

Normal Asthma

Asthma involves inflammation of the airways

InducersAllergens, chemical sensitizersAir pollution, viruses, occupational exposures

Inflammation

AirwayHyperresponsiveness

Airflow Limitation

SymptomsCough, Wheeze, Chest tightnessDyspnea

TriggersAllergens, exercise, cold air, SO2

particulates

Mechanisms: Asthma Inflammation

Source: Peter J. Barnes, MD

Asthma Inflammation: Cells and Mediators

Symptoms Suggestive of Asthma

Frequent episodes of breathlessness, chest tightness, wheezing or cough

Symptoms worse at night or the early morning Symptoms develop with a viral respiratory tract

infection, after exercise, or to exposure to alloallergens or irritants

Symptoms develop in young children after playing or laughing

Symptoms improve with bronchodilators or corticosteroids

Differential Diagnosis(Wheezing/Cough)

Post infectious Cough Post Nasal Drip COPD Heart Failure Angina Lung Cancer Hyperventilation Syndrome Vocal Cord Dysfunction

Risk Factors Associated the Development of Asthma

Predisposing Factors Atopy Genetics Gender

Causal Factors Indoor Allergens Occupational Sensitizers Outdoor Allergens

Contributing Factors Air Pollution Diet Low Birth Weight Respiratory Infections Smoking

How to Diagnose Asthma?

Supplement history with objective measures in lung function in children over six years of age

Reversible airway obstruction after bronchodilator or

Variable airflow limitation over time or Airway hyperresponsiveness Assessing Allergic Status

Breathing Tests

Spirometry Testing:

lung volumes in/out,

lung flow of air in/out

Peak Flow Monitoring:

lung flow of air in/out

Pulmonary Function Measurement Children (> 6 years) Adults

Preferred spirometry showing reversible airway obstructionReduced FEV1/FVC

AND

Increase in FEV1 after bronchodilator or after a course of controller therapy

Less than lower limit of normal based on age, height and ethnicity

AND

≥ 12%

Less than lower limit of normal based on age, sex, height, ethnicity (<0.75-0.8)

AND

≥ 12% (minimum ≥ 200 ml)

Alternative PEF variabilityIncrease after bronchodilator or course of controller therapy

OR

Diurnal Variation

≥ 20%

OR

Not recommended

60L/min

OR 8% based on twice daily readings > 20% based on multiple daily readings

Alternative Positive Challenge test

Methacholine

OR

Exercise Challenge

PC20 < 4 mg/ml

4 mg/ml – 16 mg/ml borderline

OR

≥ 10-15% decrease in FEV1 post exercise

Diagnosis of Asthma Pulmonary Function Criteria

1Time (sec)Time (sec)

2 3 4 5

FEV1FEV1

VolumeVolume

Normal Subject

Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)

Note: Each FEV1 curve represents the highest of three repeat measurements

Typical Spirometric Tracing

Measuring Airway Responsiveness

Approach to Management

Confirm diagnosis Self management education including:

environmental trigger avoidance, inhaler technique, adherence, action plan

Reliever therapy Daily Controller therapy Regular assessment of asthma control,

including spirometry and PEF

Asthma Management and Prevention Program

Goals of Long-term Management

Achieve and maintain control of symptoms

Maintain normal activity levels, including exercise

Maintain pulmonary function as close to normal levels as possible

Prevent asthma exacerbations Avoid adverse effects from asthma

medications Prevent asthma mortality

Achieve and maintain control of symptoms

Maintain normal activity levels, including exercise

Maintain pulmonary function as close to normal levels as possible

Prevent asthma exacerbations Avoid adverse effects from asthma

medications Prevent asthma mortality

Reducing Exposure to Environmental Tobacco Smoke

Evidence suggests an association between environmental tobacco smoke exposure and exacerbations of asthma among school-aged, older children, and adults.

Evidence shows an association between environmental tobacco smoke exposure and asthma development among pre-school aged children.

Reducing Exposure to House Dust Mites

Use bedding encasements

Wash bed linens weekly Avoid down fillings Limit stuffed animals to

those that can be washed

Reduce humidity level (between 30% and 50% relative humidity per EPR-3)

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI, 1995

Reducing Exposure to Mold

Eliminating mold and the moist conditions that permit mold growth may help prevent asthma exacerbations.

Reducing Exposure to Cockroaches

Remove as many water and food sources as possible to avoid cockroaches.

Exercise

Exercise can cause asthma symptoms …

BUT

Asthma should not usually prevent you from exercising if you:

Keep your asthma under control

Warm-up before and cool-down after exercise

Take a “reliever” medicine 5–10 minutes before exercising, if needed

Irritants - Air Pollution

Air pollution comes from many sources, including vehicles and industry

Highest pollution levels tend to be during the hot humid days of summer

To reduce exposure to air pollution, the following may help:

Reduce outdoor activity when pollution levels are high Keep windows and doors closed when there

are high pollution levels (air conditioning

may be needed when it gets hot)

Allergens - Mould

Moulds can be indoors in damp basements and bathrooms, and outdoors in damp weather

The following can help: Clean mouldy areas well Keep humidity around 35-45% A de-humidifier can help, especially in damp basements Get rid of clutter in the basement, to allow air to move freely Ensure proper water drainage around your home Keep bathroom dry and use fan to remove humidity Seek professional help if indoor mould doesn’t go away or if

there is a lot of mould Limit outdoor activity when outdoor mould levels are high

Allergens - Pollen

Pollens are tiny particles that come off trees, grass and weeds

If you are allergic to pollens, the following may help:

Keep windows and doors closed in home and car during pollen seasons (air conditioner is often needed when it’s hot outside)

After being outside for a long time during pollen season, shower and change clothes

Person with allergies should not mow the lawn

Allergens - Pets

If a pet is making your asthma worse, the best option by far is to find it a new home

If it is not possible to find it a new home: Keep pet out of bedroom always Wash pet twice a week Encase pillows and mattress in

allergy-proof covers Remove carpeting if possible Use a large HEPA* filter air cleaner in bedroom Vacuum furniture regularly with vacuum equipped with a

HEPA* filter, or central vacuum system with exhaust outside the house

*HEPA = High Efficiency Particulate Air

Worse Case Scenario

Reliever Medications

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids

Anticholinergics

Theophylline

Short-acting oral β2-agonists

Controller Medications

Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists in

combination with inhaled glucocorticosteroids

Systemic glucocorticosteroids Theophylline Cromones Anti-IgE

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by AgeEstimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)

> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)

> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide 200-600 100-200

600-1000 >200-400 >1000 >400

Budesonide-Neb Inhalation Suspension

250-500

500-1000 >1000

Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320

Flunisolide 500-1000 500-750

>1000-2000 >750-1250 >2000 >1250

Fluticasone 100-250 100-200

>250-500 >200-500 >500 >500

Mometasone furoate 200-400 100-200

> 400-800 >200-400 >800-1200 >400

Triamcinolone acetonide 400-1000 400-800

>1000-2000 >800-1200 >2000 >1200

Regularly Reassess

Control Spirometry or PEF Inhaler Technique Adherence Triggers and new exposures Medications Environment – home and work Comorbidities Sputum eosinophils

60% of Canadians with asthma do not have it under control

Why do so many peoplelet asthma affect them so much?

Do not know what good asthma control is

Do not realize that you can get good control of asthma

May not think that their asthma is bad enough to need treatment (even mild asthma often needs daily medicines)

Worried about taking medicines every day, about side effects, and costs

It may be hard to avoid triggers (eg. pets, smoke, dust mites in the bed, carpets, moulds, pollen)

Possible reasons …


Factors Involved in Non-AdherenceAsthma Management and Prevention Program

Factors Involved in Non-Adherence

Medication Usage Difficulties associated

with inhalers Complicated regimens Fears about, or actual

side effects Cost Distance to pharmacies

Medication Usage Difficulties associated

with inhalers Complicated regimens Fears about, or actual

side effects Cost Distance to pharmacies

Non-Medication Factors Misunderstanding/lack of

information

Fears about side-effects

Inappropriate expectations

Underestimation of severity

Attitudes toward ill health

Cultural factors

Poor communication

Non-Medication Factors Misunderstanding/lack of

information

Fears about side-effects

Inappropriate expectations

Underestimation of severity

Attitudes toward ill health

Cultural factors

Poor communication

ASTHMA CONTROL

Characteristic Frequency or Value

Daytime Symptoms < 4 days/week

Night time symptoms < 1 night/week

Physical Activity Normal

Exacerbations Mild, infrequent

Absence from work/school None

Need for fast acting beta2 agonist < 4 doses/week

FEV1 or PEF ≥ 90% personal best

PEF diurnal variation < 10-15%

Sputum eosinophils <2-3%

Asthma Diary - Sample

Asthma Action Plan - Sample

Warning Signs What to Do

Green Light I feel Good! I am not coughing! I sleep well! I have lots of energy!

Green Zone Take my regular controller Carry my blue reliever Exercise /play everyday

Yellow Light I am coughing/wheezing I use my reliever 3 or more times I don’t feel good!

Yellow Zone Follow my action plan Use my controller Get lots of rest Go get help!

Red Light I am breathing fast I have trouble walking/ talking I am coughing lots

Red Zone Asthma is dangerous!!!Take my reliever!Go Get Help from an adult or call 911!

Step 1 – As-needed reliever medication

Patients with occasional daytime symptoms of short duration

A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A)

When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)

Treating to Achieve Asthma Control

Step 2 – Reliever medication plus a single controller

A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A)

Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids


Step 3 – Reliever medication plus one or two controllers

For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2-agonist either in a combination inhaler device or as separate components (Evidence A)

Inhaled long-acting β2-agonist must not be used as monotherapy

For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)


Additional Step 3 Options for Adolescents and Adults

Increase to medium-dose inhaled glucocorticosteroid (Evidence A)

Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)

Low-dose sustained-release theophylline (Evidence B)


Step 4 – Reliever medication plus two or more controllers

Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence A)

Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)

Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence B)



Step 5 – Reliever medication plus additional controller options

Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A)

Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)

Treating to Maintain Asthma Control

Stepping up treatment in response to loss of control

Rapid-onset, short-acting or long-acting inhaled β2-agonist bronchodilators provide temporary relief.

Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy


Stepping up treatment in response to loss of control Use of a combination rapid and long-acting

inhaled β2-agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations (Evidence A)

Doubling the dose of inhaled glucocortico-steroids is not effective, and is not recommended (Evidence A)


Stepping down treatment when asthma is controlled

When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (Evidence B)

When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (Evidence A)


Stepping down treatment when asthma is controlled

When controlled on combination inhaled glucocorticosteroids and long-acting inhaled β2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β2-agonist (Evidence B)

If control is maintained, reduce to low-dose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D)

Assess Patient Risk

Features that are associated with increased risk of adverse events in the future include:

Poor clinical control

Frequent exacerbations in past year

Ever admission to critical care for asthma

Low FEV1, exposure to cigarette smoke, high dose medications

Assessment of Future Risk Risk of exacerbations, instability, rapid decline

in lung function, side effects

Features that are associated with increased risk of adverse events in the future include:

Poor clinical control Frequent exacerbations in past year Ever admission to critical care for asthma Low FEV1, exposure to cigarette smoke,

high dose medications

Any exacerbation should prompt review

of maintenance treatment

Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness

Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)

Severe exacerbations are potentially life-threatening and treatment requires close supervision

Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness

Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)

Severe exacerbations are potentially life-threatening and treatment requires close supervision


Component 4: Manage Asthma Exacerbations



Primary therapies for exacerbations: Repetitive administration of rapid-acting

inhaled β2-agonist Early introduction of systemic

glucocorticosteroids

Oxygen supplementation

Closely monitor response to treatment with serialmeasures of lung function

Primary therapies for exacerbations: Repetitive administration of rapid-acting

inhaled β2-agonist Early introduction of systemic

glucocorticosteroids

Oxygen supplementation

Closely monitor response to treatment with serialmeasures of lung function





CTS Asthma Guidelines 2012

Role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy

The initiation of adjunct therapy to ICS for uncontrolled asthma

The role of single inhaler ICS/long acting beta2agonist as a reliever

Escalation of controller for acute loss of asthma control as a part of self management

Sputum Eosinophil Counts

Sputum Eosinophils are not normally present in healthy, nonatopic

Increased in asthmatics exposed to aeroallergens Decline within 3-7 days of ICS Normal sputum eosinophilic counts <2-3% of a

differential sputum count Maybe useful in guiding treatment Recommendation – monitoring sputum

eosinophils in adults in addition to Standard methods of control

FeNO levels

Biological mediator produced in the airways Produced through a reaction catalyzed by

inducible NO synthetase Upregulated in the presence of airway

inflammation Correlates with eosinophilic airway inflammation Confounding effect of atopic status, smoking

and concomitant ICS treatment Recommendation cannot be endorsed –

insufficient evidence

Adjunct Therapies with LABAs and LTRAs

Initiation of adjunct therapy with uncontrolled asthma despite adherence to low dose ICS in adults and medium dose ICS in children

In adults with asthma not achieving control with low dose ICS, addition of a LABA; alternative increase ICS to medium or start LTRA

In children not achieving control on medium ICS add in LABA or LTRA; also should be referred to a specialist

Efficacy of single ICS/LABA Recommendations

Do not recommend use as a reliever in lieu of FABA in adults with no maintenance therapy

Use of a SABA as a reliever in individuals with mild asthma on ICS monotherapy

In exacerbation prone individuals >12 yrs with moderate asthma on a fixed ICS/LABA; use of budesonide/formoterol as a reliever

Mild Persistent Asthma

Recommend daily ICS in lieu of starting intermittent ICS at the onset of an acute loss of asthma control

Safest and minimal effective ICS dose be prescribed to minimize side effects in all age groups

What is the efficacy of escalating ICS dose in acute loss of asthma control?

Children and adults on maintenance ICS monotherapy do not routinely double their dose of ICS as part of the written action plan at the onset of an episode of acute loss of asthma control

Trial increasing ICS maintenance dose by 4-5 fold for 7-14 days (history of severe exacerbations in past requiring systemic steroids

Oral Corticosteroids

Prednisone dose and duration in adults should be individualized based on previous response

Dose of 30-50 mg/day for at least 5 days


Special ConsiderationsAsthma Management and Prevention Program

Special Considerations

Special considerations are required tomanage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma

Special considerations are required tomanage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma

Samters Triad (AERD)

Aspirin Exacerbated Respiratory Disease Asthma, Nasal Polyposis, ASA sensitivity 5%-20% asthmatics; symptoms occur 30 mins

to 3 hours after ingestion Perturbations of the arachidonic acid

metabolism and a resulting imbalance between proinflammatory and antiinflammatory mediators, leading to chronic airway inflammation

Leukotriene modifying agents

Occupational Asthma

Think occupation in a newly diagnosed adult asthmatic or difficult to control asthma

If diagnosed early and removed from exposure asthma resolves

If remains in exposure loss of lung function

Previous severe exacerbation (eg, intubation or ICU admission)Two or more hospitalizations for asthma in the past yearThree or more emergency department visits for asthma in the past yearHospitalization or emergency department visit for asthma in the past monthUse of more than two canisters of short-acting beta agonist per monthDifficulty perceiving asthma symptoms or severity of exacerbationsLow socioeconomic status, inner city residence, illicit drug use, major psychosocial problemsComorbidities, such as cardiovascular, chronic lung, or psychiatric disease

Risk Factors For Fatal Asthma Attack

Severity Assessment

Clinical Findings Pulsus Paradoxus Accessory muscle usage Diaphoresis Breathlessness when supine

Peak Flow < 200

Gas Exchange Hypoxemia Hypercapnea

Treatment

Inhaled Beta agonists Inhaled anticholinergics Glucocorticosteroids Magnesium Sulfate Nonconventional therapies

Helium Oxygen Leukotriene receptor antagonists

Ineffective therapies Methylxantines –theophylline Inhaled glucocorticosteroids Empiric antibiotics

Asthma and Pregnancy

Worse 35%, improve 28%, unchanged 33% FVC, FEV1, PEF do not change RV, FRC decrease; TLC decrease 3rd trimester MV, TV increase circulating progesterone PaO2 100-106 mmHg; PaCO2 28-30mmHg –

compensated respiratory alkalosis Exacerbations 20-36% middle trimester Small but statistically significant perinatal

mortality, preterm delivery, LBW Need to control asthma

Summary - whirlwind

Asthma control is achievable Patient education and self management is the

key Aim for the lowest medications, keep it simple Monitor, monitor and monitor Resources – CTS guidelines, GINA guidelines

Breath of Life

Levels of Asthma Control(Assess patient impairment)

Characteristic Controlled(All of the following)

Partly controlled(Any present in any week)

Uncontrolled

Daytime symptomsTwice or less

per weekMore than

twice per week

3 or more features of partly controlled asthma present in any week

Limitations of activities

None Any

Nocturnal symptoms / awakening

None Any

Need for rescue / “reliever” treatment

Twice or less per week

More than twice per week

Lung function (PEF or FEV1)

Normal< 80% predicted or

personal best (if known) on any day

Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)

controlled

partly controlled

uncontrolled

exacerbation

LEVEL OF CONTROL

maintain and find lowest controlling step

consider stepping up to gain control

step up until controlled

treat as exacerbation

TREATMENT OF ACTION

TREATMENT STEPSREDUCE INCREASE

STEP

1STEP

2STEP

3STEP

4STEP

5

RE

DU

CE

INC

RE

AS

E

Shaded green - preferred controller options

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

CAPA 2012 Deborah Hellyer MD. Review Asthma – what is it Control is possible What is new? CTS...

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Transcript of CAPA 2012 Deborah Hellyer MD. Review Asthma – what is it Control is possible What is new? CTS...