Managing Asthma During Pregnancy and Lactation

Mary McMahon, RNC, MS

Guidelines for Asthma during Pregnancy

National Asthma Education and Prevention Program (NAEPP)• Working Group Report on Managing Asthma during

Pregnancy: Recommendations for Pharmacologic Treatment – Update 2004

American College of Obstetrician and Gynecologist (ACOG) • Asthma in Pregnancy Bulletin 90, 2008, Reaffirmed

2012

Let’s Discuss…

• Asthma Control • Management of Asthma during

Pregnancy and Lactation• Educational Resources for Patients and

Professionals

Respiratory Physiology in Pregnancy

Changes in respiratory status occur more rapidly in pregnant patients than in

nonpregnant patients

Respiratory RateVital Capacity

UnchangedUnchanged

Tidal Volume Increased

Minute Ventilations Increased

Minute Oxygen Uptake Increased

Functional Residual Capacity Decreased

Residual Volume of Air Decreased

Airway Conductance Increased

Total Pulmonary Resistance Reduced

Effects of Pregnancy on Asthma

When women with asthma become pregnant:

• One-third of the patients improve,• One-third worsen,• Last third remain unchanged

Effects of Asthma on Pregnancy

• One of the most common chronic medical problem that occurs during pregnancy– Approximately 8% of pregnancy women

• Let’s take a deep look at this……..

Asthma is Characterized by

• Inflammation of the airways, with an abnormal accumulation of eosinophils, lymphocytes, mast cells, macrophages, dendritic cells, and myofibroblasts.

• Leads to a reduction in airway diameter caused by smooth muscle contraction, vascular congestion, bronchial wall edema and thick secretions.

Airway Inflammation& Symptoms

Risk Factors

Inflammation

AirwayHyperresonsiveness

AirwayObstruction

ClinicalSymptoms

Adapted from NAEPP Expert Panel Report 2 & 3

PrecipitatingFactors

Clinical Symptoms

• Cough• Wheeze• Shortness of breath• Chest tightness

Asthma

• Impairment– Frequency and intensity of symptoms– Functional limitations

• Risk– Likelihood of asthma exacerbations– Progressive decline in lung functions – Risk of adverse effects from treatment

Adapted from NAEPP, Expert Report 3

What Are Goals of Treatment?

• Your patient should be able to– Participate in activities, including physical

activity without asthma symptoms– Sleep through the night without asthma

symptoms– Have normal or near normal lung function– Minimal use of short-acting inhaled beta2-

agonist– Have few, if any side effects from

medication taken

Goals of Therapy:Asthma Control

• Reduce impairment– Prevent chronic and troublesome symptoms (e.g.

coughing or breathlessness in the daytime, in the night or after exertion)

– Require infrequent use (<2 days a week) of SABA for quick relief of symptoms

– Maintain (near) normal pulmonary function– Maintain normal activity levels (including exercise

and other physical activity and attendance at work or school)

– Meet patients’ and families’ expectations of and satisfaction with asthma careNAEPP Expert Panel Report 3

Goals of Therapy:Asthma Control

• Reduce risk– Prevent recurrent exacerbations of asthma and

minimize the need for ED visits or hospitalizations

– Prevent progressive loss of lung function; blood oxygenation that ensures oxygen supply to fetus

– Provide optimal pharmacotherapy with minimal or no adverse effects

NAEPP Expert Panel Report 3

Treatment Goal - Pregnant Asthma Patient

To provide optimal therapy to maintain control of asthma for maternal health and quality of live as well as for normal fetal maturation.

When Asthma is not Controlled

Maternal health risks include:• High Blood Pressure• Preeclampsia, which can affect

– Placenta– Kidneys– Liver– Brain

When Asthma is not Controlled

Risks to the Fetus include:• Perinatal Mortality• Intrauterine Growth Restriction• Preterm Birth• Low Birth Weight

Differential Diagnosis

Patients presenting with new respiratory symptoms during pregnancy; Is it......?• Dyspnea• GERD• Chronic cough from postnasal drip• Bronchitis

Goals

• What are the patient’s and family’s personal goals?

Asthma Severity

• Severe persistent asthma 4

• Moderate persistent asthma 3

• Mild persistent asthma 2

• Intermittent asthma 1

Classification of Asthma Severity and Control in Pregnant Patients

Components of Severity Intermittent MildPersistent

Moderate Persistent

SeverePersistent

Impairment Symptoms <2 days/wk or less

>2 days/wk, not daily

Daily Throughout the day

Nighttime awakenings

<2 Xs/mth or less

>2 Xs per month

More than once a week

Four times per week or more

SABA prn <2 days/wk >2 days/wk, not daily, not >1 X/day

Daily Several xs/day

Interference with normal activity

None Minor limitation

Some limitation Extremely limited

Lung function Normal FEV1 between exacerbationsFEV1>80%FEV1/FVC normal

FEV1>80%FEV1/FVC normal

FEV1>60%, but <80%FEV1/FVC reduced 5%

FEV1 <60%FEV1/FVC reduced >5%

Risk Exacerbations requiring oral steroids

0-1/yr >2/yr

Recommended Step forInitiating Treatment

Step 1 Step 2 Step 3 Step 4 or 5

Asthma Severity

Dictates only initial therapy in the untreated patients.• Intermittent asthma is appropriately treated with only short-

acting beta-agonists for rescue and prevention of symptoms, such as those that occur with exercise.

• Persistent asthma should be treated with inhaled corticosteroids (ICS). If symptoms or rescue inhaler use are daily, nighttime awakenings at least weekly, there is moderated interference with normal activities, or there is reduced pulmonary function when not having symptoms, then initial treatment should be medium doses of ICS or a combination of low-dose ICS and a long-acting inhaled beta-agonist.

Once the patient with asthma is receiving controller medication, further adjustments to asthma therapy are based on the level of asthma control.

Spirometry

• Get Valid Spirometry Results EVERY Time

• DHHS (NIOSH) Publication No. 2011-135

Stepwise Approach to Asthma

Quick Relief Medication for all patients

Patient Education, Environmental Control, Comorbidities

Step1

Step2

Step3

Step4

Step5

Step6

StepUp

AssessControl

StepDown

Int.Asthma Persistent Asthma

Long Term Control Medication

Level of Asthma Control

• Well-Controlled• Not Well-Controlled• Very poorly controlled

– Many patients experience poor control of asthma

Adapted from NAEPP, Expert Report 3

Asthma Control Test

• Simple self assessment questionnaire (takes few minutes)

• Patient fills out while waiting• 70-75% accuracy in determining level of

asthma control• Validated & Guidelines recommended• Educates the goals of ‘Well Controlled’

Asthma Control Test

• 5 items completed by the patient reflecting on the past 4 weeks– Daytime and nighttime symptoms– Activity limitations– Rescue inhaler use

• Add up: 0 - 25– > 20: well controlled– 16 – 19: not well controlled– < 15: very poorly controlled

• A 23 year old patient, G1P0 at 11 wks with history of asthma was seen by her provider with recurrent cough and wheeze. She admits to waking twice per month with a cough and requiring albuterol twice per week. The provider knows that according to the EPR-3 guidelines, this woman’s level of asthma control would be classified as:A. Very well controlledB. Well controlled C. Not well controlledD. Very poorly controlled

Controlling Asthma Triggers

• Smoking• Avoiding Allergens

– Pollen– Dust mites– Pet dander

Team Approach to Managing Asthma During Pregnancy

• Expectant Mother and her family• Obstetrical Provider• Primary Care Provider• Asthma Specialist

– Refer to a specialist if asthma is poorly controlled.

Asthma Action Plan

• Everyone with asthma should have an asthma action plan.– Developed with patient and provider– Shows daily treatment

• What kind of medicines to take• When to take medicines

– How to control asthma long term– How to handle worsening asthma – When to call the doctor or go to the ED

U.S. FDA Pregnancy Categories

Pregnancy Category DefinitionA Well-controlled studies have failed to

demonstrate a risk to the fetus.

B Animal reproduction studies demonstrate an adverse effect on the fetus, There are no well-controlled studies in pregnant women. The potential benefits of this drug may outweigh the potential risks.

C There is positive evidence of human fetal risk based on adverse reaction data from research or clinical experience. The potential benefits of this drug may outweigh the potential risks.

D Studies in humans and animals have demonstrated fetal abnormalities. There is positive evidence of human fetal risk. The risks of this drug outweigh any benefit to its use.

How Medications Work?

• Bronchodilator • Anti-Inflammatory

Stepwise Approach to Manage Asthma

Stepwise Approach to Asthma

• Asthma Medications–Quick relief

• Taken when asthma symptoms present

–Long term control • Taken daily, even when asthma

well controlled

Stepwise Approach to Asthma

• Medications–Preferred treatment–Alternative treatment–Consider variability in response

based on the individual

Stepwise Approach - 12 yrs-Adult (revised)

Quick Relief Medication for all patients (SABA)Patient Education, Environmental Control, Comorbidities

Step 1

SABAprn

Step 2

Preferred• ICS

(low dose)

Step 3Preferred

ICS(low dose)

Or ICS(med dose)

&• LABA

Step 4

Preferred• ICS

(med dose)&

• LABA

Step 5Preferred• ICS

(high dose)&

• LABA+

• Omalizumab• (if allergens)

Step 6Preferred• ICS

(high dose)+

• LABA+

OralCorticosteroid

And Consider

Omalizumab(if allergens)

StepUp

AssessControl

StepDown

Int.Asthma Persistent Asthma

Long Term Control Medication

Adapted from NAEPP, Expert Report 3

Quick Relief Medication

• All levels of asthma severity require short-acting beta2-agonist (SABA)

• Anyone with asthma can have a severe exacerbation

Short-Acting Beta2-Agonists

• Used as a pretreatment before exercise• Used to treat asthma symptoms• Increased use >2 days per week

indicates inadequate asthma control• Regular use not recommended

Long Term Control Medication

• Preferred treatment• Inhaled Steroids

–Most effective long term control medication for mild, moderate and severe persistent asthma

Inhaled Steroids

• Improve asthma control• Improve quality of life• Improve spirometry• Decrease airway hyper responsiveness• Prevent exacerbations• Reduce severity of symptoms• Reduce systemic steroids, ED visits,

hospitalizations and death

Inhaled Steroids• Mometasone

– Twisthaler®

• Ciclesonide– MDI

• Fluticasone– MDI

• Budesonide– Flexhaler ®, Respules®

• Beclomethasone– MDI (HFA propellant)

Adapted from NAEPP Expert Panel Report 3 & ACOG Bulletin No. 90

Comparative Daily DosageInhaled Corticosteroids

Medicine Low Daily Dose Med Daily Dose High Daily Dose

Beclomethasone HFA 40 80 mcg per puff

2-6 puffs1-3 puffs

More than 6-12 puffsMore than 3-6 puffs

More than 12 puffsMore than 6 puffs

Budesonide DPI200 mcg/inhalation

1-3 puffs More than 3-6 puffs More than 6 puffs

Flunisolide 250 mcg per inhalation

2-4 puffs 4-8 puffs More than 8 puffs

Fluticasone HFA 44 mcg 110 mcg per puff, 220 mcg per puff

2-6 puffs2 puffs 2-4 puffs

1-2 puffsMore than 4 puffsMore than 2 puffs

Fluticasone DPI 50 mcg100 mcg per inhalation250 mcg per inhalation

2-6 puffs1-3 puffs

1 puff3-5 puffs2 puffs

More than 5 puffsMore than 2 puffs

Triamcinolone75 mcg/inhMometasone DPI200 mcg/inh

4-10 puffs

1 puff

10-20 puffs

2 puffs

More than 20 puffs

More than 2 puffs

Inhaled Steroids

• Increased effect in lungs with decreased systemic side effects

• Side effects– Thrush (oral candidiasis)– Sore throat– Hoarseness– Dry mouth

Combination Therapy

• Preferred treatment– Varies with age

• The combination of long-acting inhaled beta2-agonists (LABA) added to low-to-medium doses of inhaled steroids leads to improvements in:– Lung function– Symptoms– Reduced use of short-acting beta2-agonists

• Increase in inhaled steroid given equal weight

Anti-IGE Treatment

• Omalizumab• Approved for:

– Poorly controlled moderate to severe persistent asthma

– Year round allergies– Individuals taking routine inhaled steroids

• Not recommended to initiate during pregnancy

Oral Corticosteroids

• Action - Reduces and prevents inflammation

• Pills– Prednisone– Methylprednisolone

• Short course to speed recovery with moderate to severe exacerbation

Medication Technique Is Important

• Check inhalation technique at every visit

Medication Technique Is Important

• Patients should know– How to use the device– How to tell when the device is empty– How to clean the device

• www.NJHealth.org

Maintaining Asthma Control

• Once asthma control achieved– Gradual reduction of pharmacotherapy

(Step Down)– Monitor asthma control with the goal of

providing optimal pharmacotherapy with minimal or no adverse effects

Managing Exacerbations – Home Treatment

• Assess Severity• Initial Treatment• Response

– Good– Incomplete– Poor

• Follow-up

Management of Exacerbations – Emergency Dept. and Hospital Care

• Initial Assessment• Initial Treatment depending on severity

– Mild to mod exacerbation– Severe– Impending or actual respiratory arrest

• Repeat Assessment– Level of Response

Transition of Care

• Admit to Hospital Intensive Care• Admit to Inpatient Unit• Discharge Home

Key Patient Education Messages

Teach and reinforce at initial visit and follow up• Basic facts about asthma• Well controlled asthma and patient's

current level of control– Asthma Control Test– Ask “How often are you using your SABA in

a week?”

Key Patient Education Messages cont

• Role of medications• Patient skills

– Take medication correctly– Environmental control measures– Self monitoring

• Asthma Symptoms• Use of peak flow• Use of written asthma action plan

Patient Education Links

• Asthma, Allergies and Pregnancy Tip to RememberAmerican Academy of Allergy, Asthma & Immunology

(AAAI) (2013) Home>Conditions & Treatments>Library>Asthma Library>http://www.aaai.org/conditions-

and-treatments/library/asthma-library/asthma,allergies-and-pregnancy/TTR • Pregnancy is Complicated by Allergies and Asthma

American College of Allergy, Asthma & Immunology (ACAAI), 2010. Retrieved 08/13/2013 http://www.acaai.org/allergist/liv_man/pregnancy. • Asthma during Pregnancy March of Dimes, 2011. Retrieved

08/13/2013http://www.marchofdimes.com/pregnancy/asthma-during-

pregnancy.

Current Studies Related to Asthma

• Interaction between obesity and asthma• Dietary fat intake, may be an important

modifier of airway inflammation• Acetaminophen and folate may modify

asthma risk, although more data are needed• The effects of vitamin D on asthma are (in

theory) significant, more date to come• EXPECT Pregnancy Registry - XOLAIRR use

prior to conception or during pregnancy

Conclusions

• The ultimate goal of asthma therapy in pregnancy is maintaining adequate oxygenation of the fetus be preventing hypoxic episodes in the mother.

• It is safer for pregnant women with asthma to be treated with asthma medications than it is for them to have asthma symptoms and exacerbations.

References

• American College of Obstetricians and Gynecologists (ACOG). (2008). Asthma in pregnancy. ACOG Practice Bulletin No. 90. Obstet Gynecol 2008 111:457-64

• American College of Obstetricians and Gynecologists (ACOG). (2008). ACOG releases new recommendations on the management of asthma during pregnancy. Retrieved from http://www.acog.org/about_acog/news_room/news_ releases/2008/acog_releases. Retrieved 06/18/2013.

• Chambers, C., Asthma medications (2013) Clinician Reviews http://www.clinicianreviews.com/index.php?id=31613&type=98&tx_ttnews[tt_news]=216. Retrieved 09/20/2013.

• Enriquez, R., Griffin, M., Carroll, K., Wu, P., Cooper, W., Gebretsadik, T., … Hartert, T. (2007). Effect of maternal asthma and asthma control on pregnancy and perinatal outcomes. Journal of Allergy, Asthma & Immunology, 120(3), 625-630.

• Murphy, A., Proeschal, A., Brightling, C., Wardlaw, A., Parvord, I., Bradding, P., et al. (2012). The relationship between clinical outcomes and medication adherence in difficult-to-control asthma. Thorax, 67, 751-753.

References cont

• National Institutes of Health; National Heart, Lung, and Blood Institute [NHLBI]. (2002). Asthma are: quick reference diagnosing and managing asthma –Revised 2012. Retrieved from http://nhlbi.nih.gov/guidelines/asthma/

• National Institutes of Health; National Heart, Lung, and Blood Institute [NHLBI]. (2005). NAEPP working group report on managing asthma during pregnancy: Recommendations form pharmacologic treatment-Update 2004. Retrieved from http://nhlbi.nih.gov/health/prof/lung/asthma/ast.preg

• National Institutes of Health; National Heart, Lung, and Blood Institute [NHLBI]. (2007). Expert Panel Report 3 (EPR-#): Guidelines for the diagnosis and management of asthma. Retrieved from http://nhlbi.nih.gov/guidelines/asthma/

• Rance, K. & O’Laughlen, M. (2013) Managing asthma during pregnancy. Journal of the American Association of Nurse Practitioners, 25(2013), 513-521.

• Schatz, M. & Dombrowskin, M., (2009). Asthma in pregnancy. NEJM 2009;360:1862-1869.

• Weinberger, S. & Schatz, M., (2012) In B.S. Bockner, X.J. Lockwood & H. Hollingswork (Eds), Management of asthma during pregnancy. UpToDate. Retrieved from http://www.uptodateonline.com

Questions?Comments?