how to approach a patient with asthma at family practice setting

7/28/2019 how to approach a patient with asthma at family practice setting

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BRONCHIALASTHMA

Dr Hanan abbasAssistant professor of familyMedicine


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At the conclusion of the presentation,participants should be able to:

ID signs and symptoms consistent with asthma Differentiate the severity of asthma

Summarize an appropriate treatment regimen forasthma of various severity


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Epidemiology:

According to epidemiological studies asthmaaffects 1-18% of population of different

countries High cost of medical services

5 million work days are lost / yr worldwide

Fatalities still occurring: 0.1-1% of all deaths


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Barriers to control:

About 50% of asthmatics are not controlled Common causes are:

Poor patient education

Poor patient compliance Poor prescription (6-44%) Side effects of drugs Expensive medications Poor communication Steroid resistance


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Asthma is Increasing ?!Why the increase?

Increased recognition, diagnosis-shifting

Environmental allergens - indoor, outdoor Energy-efficient buildings, carpet

Exposure to mothers tobacco smoke

Psychosocial and socioeconomic factors

More time indoors

Overcrowding

Access to care


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The Underlying Mechanism

INFLAMMATION

Risk Factors (for development of asthma)

AirwayHyper-responsiveness

AirflowLimitation

Symptoms- (shortnessof breath, cough,

wheeze)

Risk Factors

(for exacerbations)


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Definition

Chronic inflammatory disorder of the airways , In susceptibleindividuals, this inflammation causes recurrent episodes ofwheezing, breathlessness, chest tightness, and coughing,

particularly at night or in the early morning. These episodes are associated with widespread but variable

airflow obstruction that is reversible either spontaneously, orwith treatment.


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Triggers:

Tobacco smoke. Infections such as colds, flu, or pneumonia .

Allergens such as food, pollen, mold, dust mites, and pet dander

Exercise .

Air pollution and toxins . Weather, especially extreme changes in temperature

Drugs (such as aspirin, NSAID, and beta-blockers)

Food additives

Emotional stress and anxiety . Singing, laughing, or crying .

Smoking, perfumes, or sprays .

Acid reflux .

8


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Some allergens which may cause

asthma

House-dust mites which live incarpets, mattresses andupholstered furniture

Spittle, excrements,hair and fur

of domestic

animals

Plant pollen

Pharmacological agents

(enzymes, antibiotics,vaccines, serums)

Food components(stabilizers, genetically

modified products)

Dust of

bookdepo-sitories


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Signs &

Symptoms: Shortness of breath . Tightness of chest.

Excessive coughing or a cough thatkeeps you awake at

night. Feeling very tiredorweak when exercising.

Wheezing or coughing after exercise .

Decreases or changes in lung function as measuredon a

peak flow meter . Signs of a cold, or allergies (sneezing, runny nose,

cough, nasal congestion, sore throat, and headache) .

Trouble sleeping .

4/9/2013 10


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Diagnosing Asthma

Troublesome cough, particularly at night

Awakened by coughing

Coughing or wheezing after physical activity

Breathing problems during particular seasons

Coughing, wheezing, or chest tightness after

allergen exposure

Colds that last more than 10 days

Relief when medication is used


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Diagnostic Testing

Peak expiratory flow (PEF)

Inexpensive

Patients can use at home May be helpful for patients with severe disease to

monitor their change from baseline every day

Not recommended for all patients with mild or

moderate disease to use every day at home Effort and technique dependent


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Peak expiratory flow (PEF) Meters

Allows the

patient toassess thestatus of his orher asthma


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PEF can be measured with the help of individualdevices peak flow meters

P l i h d


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PeakflowChart

Source: What You and Your Family Can Do About Asthma by the Global Initiative For Asthma

Created and funded by NIH/NHLBI

People with moderate or severeasthma should take readings Every morning and evening After an exacerbation Before inhaling certain

medications


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Asthma severity classification

Clinical course,severity Daytime asthmasymptoms

Nighttimeawakenings FEV1, PEF

Intermittent < 1 /week2 and < /month >80% predicted.

Daily variability 2 /month

>80% predicted.

Daily variability

20-30%

Moderate

persistent

Daily > 1 /week> 60 but < 80%

predicted.Variability>30%.

Severe

persistentPersistent,which limitnormal activity

Daily 30%.


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years of age*12Classification of asthma severity

Components of severity Intermittent Persistent -mild Persistent-moderate Persistent -severeImpairment

Symptoms 2 days per week >2 days per week,but not daily

Daily Throughout the day

Nighttime awakenings 2 times per month 3 to 4 times permonth

> Once per week, but notnightly

Often 7 times per week

Short-acting beta agonistuse for symptom control(not for prevention ofexercise-inducedbronchospasm)

2 days per week >2 days per week,but not more than once perday

Daily Several times per day

Interference with normalactivity

None Minor limitation Some limitation Extremely limited

Lung function Normal FEV1 betweenexacerbations; FEV1 >80percent of predicted;FEV1/FVC normal

FEV1 80 percent ofpredicted; FEV1/FVCnormal

FEV1 > 60 percent but < 80percent of predicted;FEV1/FVC reduced 5percent

FEV1 < 60 percent ofpredicted; FEV1/FVCreduced >5 percent

Risk

Exacerbations requiringoral systemiccorticosteroids

0 to 1 per year 2 per year 2 per year 2 per year

Consider severity and interval since last exacerbation; frequency and severity may fluctuate over time forpatients in any severity category; relative annual risk of exacerbations may be related to FEV1


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In recommendations of Global Initiative for Asthma(GINA) asthma is classified on the base ofcontrolassessment andis divided into well-controlled,partially controlled and uncontrolled.

Asthma control is considered as:

daytime symptoms 2 /week;

ability to engage in normal daily activity;

the absence of night-time awakenings as a result ofasthma symptoms;

need in bronchodilators administration 2 /week;

the absence of asthma exacerbations;

normal or near normal lung function parameters.


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Asthma complicationsThe complications ofasthma exacerbations are:

pneumothorax

lung atelectasis

pneumonia

acute or subacute corpulmonale

asthmatic status.

Persistent asthma causes:

fibrosing bronchitis

small bronchideformation andobliteration

emphysema pneumosclerosis,

chronic respiratoryfailure

chronic cor pulmonale.

Asthmain childhoodleads to growth inhibition

and thoracic deformation.


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Goals of Asthma Treatment

Control chronic and nocturnal symptoms

Maintain normal activity, including exercise

Prevent acute episodes of asthma Minimize ER visits and hospitalizations

Minimize need for reliever medications

Maintain near-normal pulmonary function Avoid adverse effects of asthma medications


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years of age)*12Classification of asthma control (

Components of control Well controlled Not well controlled Very poorly controlledImpairmentSymptoms 2 days per week > 2 days per week Throughout the day

Nighttime awakenings 2 times per month 1 to 3 times per week 4 times per weekInterference with normalactivity

None Some limitation Extremely limited

Short-acting beta agonist usefor symptom control (not forprevention of exercise-induced bronchospasm)

2 days per week > 2 days per week Several times per day

FEV1 or peak flow > 80 percent of predicted/personal best 60 to 80 percent ofpredicted/personal best < 60 percent ofpredicted/personal bestRiskExacerbations requiring oralsystemic corticosteroids

0 to 1 time per year 2 times per year 2 times per yearConsider severity and interval since last exacerbation

Progressive loss of lungfunction

Evaluation requires long-term follow-up care

Treatment-related adverse

effects

Medication adverse effects can vary in intensity from none to very troublesome and

worrisome; the level of intensity does not correlate to specific levels of control, but shouldbe considered in the overall assessment of risk

Recommended action forfor1Figuretreatment (see

treatment steps)

Maintain current step; regularfollow-up every one to sixmonths to maintain control;consider step down if wellcontrolled for at least three

months

Step up one step andreevaluate in two to sixweeks; for adverse effects,consider alternativetreatment options

Consider short course of oralsystemic corticosteroids; stepup one to two steps, andreevaluate in two weeks; foradverse effects, consider

alternative treatment options


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Asthma Control

Levels of Asthma ControlUncontrolledPartly Controlled

(any measure present

in any week)

Controlled(All of thefollowing)

Characteristics

Three or more of

partly controlledasthma present

in any week

> Twice /wNone (twice or

less/week)

Day time symptoms

AnyNoneLimitations of

activity

AnyNoneNocturnalsymptoms/

awakening> Twice / weekNone (twice or

less/week)Need for relievers

< 80% of predictedNormalLung function(PEF or

FEV1)

One in any weekOne or per yearNoneExacerbation


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years of age)*12Classification of asthma control (

Components of control Well controlled Not well controlled Very poorly controlledImpairmentSymptoms 2 days per week > 2 days per week Throughout the day

Nighttime awakenings 2 times per month 1 to 3 times per week 4 times per weekInterference with normalactivity

None Some limitation Extremely limited

Short-acting beta agonist usefor symptom control (not forprevention of exercise-induced bronchospasm)

2 days per week > 2 days per week Several times per day

FEV1 or peak flow > 80 percent of predicted/personal best 60 to 80 percent ofpredicted/personal best < 60 percent ofpredicted/personal bestRiskExacerbations requiring oralsystemic corticosteroids

0 to 1 time per year 2 times per year 2 times per yearConsider severity and interval since last exacerbation

Progressive loss of lungfunction

Evaluation requires long-term follow-up care

Treatment-related adverse

effects

Medication adverse effects can vary in intensity from none to very troublesome and

worrisome; the level of intensity does not correlate to specific levels of control, but shouldbe considered in the overall assessment of risk

Recommended action forfor1Figuretreatment (see

treatment steps)

Maintain current step; regularfollow-up every one to sixmonths to maintain control;consider step down if wellcontrolled for at least three

months

Step up one step andreevaluate in two to sixweeks; for adverse effects,consider alternativetreatment options

Consider short course of oralsystemic corticosteroids; stepup one to two steps, andreevaluate in two weeks; foradverse effects, consider

alternative treatment options


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Management Avoiding the contact with allergen.

Elimination of trigger factors (rational jobplacement, changing the residence, psychological andphysical adaptation, careful drug using) is the second

condition for successful asthma treatment. Optimally selected medical care is the base of

asthma management.


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Treatment:

Bases of treatments: one way is to relaxes themuscles during expiration.

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Drug therapy

Antiinflammatory drugs(basic)

Bronchodilators

2 drug categories are used:

Are divided into:

hormone-containing(corticosteroids)

nonhormone-containing(cromones, leukotriene

receptor antagonists)

3 groups:

anticholinergic drugs

b2-agonists

methylxanthines


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Corticosteroids

The working

mechanism lays in:

cell membrane

stabilization

inhibition ofinflammatory

mediators

restoring the sensivity

ofb2-receptors.

Inhaled corticosteroids

(beclamethazone, inhacort,budesonide, flixotid,fluticazone, asmacort,asthmanex) are the mosteffective and safe and

considered to be the firstline drugs for asthmatreatment. Systemic areused during short courses,

mainly in case of severepersistent asthma orasthmatic status.


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Cromones

(cromolyn sodium

intal,and nedocromiltiled)

stabilize cell membranes,

used mainly in pediatricpractice (in childhood)

in case ofintermittent ormild persistent asthma.

Leukotrienereceptor

antagonists(montelukast, zafirlukast)

have the moderateintiinflammatory activity

used in case ofaspirin-

induced asthma and

asthma of physical

exertion.


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Inhaled b2-agonistsare the basic drug group amongbronchodilators.

Short-acting (duration of action 5-6 h) b2-agonists - salbutamolused for quick relief ofasthma symptoms.

Long-acting (> 12 h) b2-agonists - salmoterol,formoterol- for prevention of asthma symptomsoccurring.


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Anticholinergic drugs (ipratropium bromide,

atrovent, troventol) are used predominantly innighttime asthma and in elderly patientsbecause of the least cardiotoxic effect.

Methylxanthines in comparison with otherbronchodilators have the less bronchodilatingpotential. There are long-acting (>12 h) - (theopec,

theolong, theodur, euphilong) as well as short-acting (aminophylline, theophylline) drugs in thisgroup.


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Combined inhaled drugs (corticosteroids with b2-agonists) seretid, simbicort with use ofdelivery

devices (nebulizers, turbuhalers, spacers) enhance theeffectiveness of asthma therapy.


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Prognosis In case of early detection and adequate

treatment the prognosis for the disease

is favourable. It becomes serious in severe persistent

and poorly controlled (insensitive for

corticosteroids) asthma.


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Reducing Exposure to House Dust Mites

Use bedding encasements

Wash bed linens weekly

Limit stuffed animals tothose that can be washed

Reduce humidity level(between 30% and 50%relative humidity

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


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Reducing Exposure to Tobacco Smoke

Evidence suggests an associationbetween environmental tobaccosmoke exposure and exacerbationsof asthma among school-aged,older children, and adults.

Evidence shows an association

between environmental tobaccosmoke exposure and asthmadevelopment among pre-schoolaged children.


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Tool Kit for Achieving

Management Goals Relievers

Preventers

Peak Flow meter

Patient education


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What Are Relievers?

- Rescue medications- Quick relief of symptoms

- Used during acute attacks

- Action lasts 4-6 hrs

- Not for regular use


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RELIEVERS

Short acting b2 agonistsSalbutamol

Levosalbutamol

Anti-cholinergicsIpratropium bromide

Xanthines

Theophylline Adrenaline injections


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Relievers(Bronchodilators)

Relaxes muscles in the airways to help relieve asthma

symptoms

Should be taken as needed for symptomsNeed to wait 1-2 minutes between puffs for best

deposition of medication in the lungs

Overuse is a big warning sign indicating the childs

asthma may not be well controlled


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What are Preventers?

- Prevent future attacks

- Long term control of asthma

- Prevent airway remodeling

PREVENTERS


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PREVENTERS

Corticosteroids Anti-leukotrienes

Prednisolone, Betamethasone Montelukast, ZafirlukastBeclomethasone, Budesonide

Fluticasone Xanthines

Theophylline SR

Long acting b2 agonists Mast cell stabilisers

Bambuterol, Salmeterol Sodium cromoglycate

Formoterol

COMBINATIONS

Salmeterol/Fluticasone

Formoterol/Budesonide

Salbutamol/Beclomethasone


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Inhaled Corticosteroids

Potential adverse effects

Cough, dysphonia, thrush

Therapeutic issues

Different inhaled corticosteroids are not

interchangeable

Azmacort and Aerobid reportedly have particularly

bad taste, Pulmicort , Turbuhaler has no taste


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Steroid Phobia: Unfounded!

Inhaled steroids in doses most often prescribedare very safe

Inhaled meds delivered directly to lungs where

they are needed

Little systemic absorption if proper techniqueused


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ICS + LABA

Which LABA ?

Formoterol: Immediate relief (as fast assalbutamol)-----12 hours effect

Can be combined with budesonide

All Asthma Drugs Should Ideally Be Taken

Through The Inhaled Route.Dose: 1- 4 puffs ( OD/BD )


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Combination Medication

Advair(Flovent + Serevent)Combo corticosteroidand long acting beta-agonist

3 strengths: 100/50, 250/50, 500/50

Strengths based on Flovent doses, Serevent doseremains the same in all three strengths.

Usual dosing, 1inhalation every 12 hours

Has remaining-dose counter


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Why inhalation therapy?

Oral

Slow onset of action

Large dosage used

Greater side effects

Not useful in acute

symptoms

Inhaled routeRapid onset of action

Less amount of drugused

Better tolerated

Treatment of choice

in acute symptoms

MDI


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MDI

Metered dose inhalers (MDI)

The health-care provider should evaluate inhaler technique at each visit.


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How MDI Technology Works


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spacers

Spacers can help patients whohave difficulty with inhaleruse and can reduce

potential for adverse effects

from medication.

No co-ordination required

Reduced oro-pharyngeal

deposition Increased drug deposition in

the lungs

N St id l A ti i fl t


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Non-Steroidal Anti-inflammatory

Intal(Cromolyn) (also available as Intal HFA)

Tilade (Nedocromil) For symptom prevention or as preventive treatment

prior to allergen exposure or exercisePotential adverse effects

None (Tilade tastes bad)

Therapeutic issues

Must be taken up to 4 times a day, maximum benefitafter 4-6 weeks

k t i difi


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Leukotriene Modifiers

Singulair(Montelukast) Accolate(Zafirlukast)

Zyflo

Oral: Prevention of symptoms in mild persistent asthma,

and/or to enable a reduction in dosage of inhaled steroids inmoderate to severe persistent asthma


None significant elevation of liver enzymes

Therapeutic issues

Drug interactions, monitor hepatic enzymes (esp. Zyflo)


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Methylzanthines

TheophylineFor prevention of symptoms (bronchodilation, and

possible epithelial effects)

Potential adverse effects Insomnia, upset stomach, hyperactivity, bed wetting

Therapeutic issues

Must monitor serum concentrations, not helpful in acuteexacerbations, absorption and metabolism affected bymany factors


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Systemic Corticosteroids

PrednisonePrevents progression of moderate to severe exacerbations,

reduces inflammation


Short-term- increased appetite, fluid retention, moodchanges, facial flushing, stomachache. Long term-growth suppression, hypertension, glucose intolerance,muscle weakness, cataracts


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CASE SCENARIO

Khalid 14 years old come to the clinic c/o shortnessof breath for one day duration.

He is a known asthmatic patient for more than 8years, he visited A/E frequently.

His school performance is below average, withfrequent absence from school due to his illness.

how you will proceed during thisconsultation ?


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Asthma has been defined as

A. reversible airway obstruction.

B. chronic airway inflammation.C. nonreversible airway obstruction.

D. a and b.

E. b and c.


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Risk factors for the development of asthmainclude all of the following except

A. Personal or family history of atopy.

B. Prenatal smoking by the mother.

C. Being the youngest sibling in a family.

D. Chronic allergic rhinitis.

E. Exposure to increased concentrations ofknown allergens.


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how to approach a patient with asthma at family practice setting

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