Asthma. Micah Long, MD
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1 Asthma Micah Long, MD
2 Goals Define the two components of asthma. Describe the method of action and uses for: Steroids (inhaled and IV) Quick Beta Agonists (Nebs and MDIs) The "Others" Magnesium, Epi IM, Terbutaline, Heliox. Know the management of asthma, from mild to severe, and acute / sub-acute / routine. Know "what to do next" in a decompensating asthmatic. Describe what "good" asthma control is and categorize severity of asthma.
3 Components of Asthma 1. Bronchoreactivity Muscles constrict and cause the wheeze! 2. Inflammation Swelling around the airways. Chronic, with long-term complications. Inflammation begets inflammation, and it begets bronchoconstriction! Over time, thickens the muscles and the tissue. Figure out your triggers Allergies, Illnesses, Exercise, Cold Air, Dust Mites, Animal allergies, etc. "Atopy" Eczema, Allergies, Asthma
4 Expiratory Obstruction Hard to blow out air! Decreased FEV 1 Prolonged expiratory phase Harder WOB expiring. Air Trapping Flat Diaphragms Small Heart This is why intubation is a horrible idea. Mechanical Vent is always passive expiration When you sedate / paralyze a patient, they cannot use their muscles to help them breath out.
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7 PFTs FEV1 / FVC Methacholine Challenge Peak Flow Testing
8 Physical Examination --- important. Auscultation: Not just wheezing! Wheezing is "polyphonic" Early: End Expiratory Wheezing Early-middle: Expiratory Wheezing, maybe inspiratory Middle: Lots of wheezing, decreasing air movement Late: No wheezing, poor air movement Expiratory : Inspiratory Phase Overall Aeration or amount of air movement. Work of Breathing Vitals are vital - calculate the RR yourself. Trigger - Pneumonia?
9 Medication Options Anti-Inflammatories Steroids Inhaled Systemic (po / IV) Immune Modulators Singuliar Anti-Histamines (e.g. loratidine, benadryl) Last Ditch Efforts Inhaled Anesthetics BiPaP ECMO [avoid intubation] Bronchial "Relaxers" Rapid Acting (Neb or MDI) Albuterol Ipratropium (Atrovent) Slow Acting Inhalers: Salmeterol (Advair) Rapid Acting IV Drugs Magnesium Epinephrine Oxygen, and Heliox Others: Aminophylline, Terbutaline, Ketamine
10 Really Bad? NPO, Get IV Access, increase Albuterol amount Magnesium, Epinephrine IM, Heliox + Oxygen Higher dose IV steroids Terbutaline, Aminophylline, Ketamine, Anesthetics, BiPAP ECMO + Intubate Treating Acute Exacerbations 1. Albuterol + Atrovent (3x back-to-back in the ED) Then switch to continuous or scheduled Albuterol 2. Start steroids (3-5 day course) Prednisone / Prednisolone, versus Methylprednisolone IV 3. Oxygen if needed (low threshold) 4. Start up ICS Won't help now, but will help transitioning to home
11 Non-Acute Asthma - The Office Visit Establish triggers, and gauge control and compliance. Establish what "Category", or "Classification" of severity the patient is at This determines treatment options and directs escalation of care. Your goal of treatment is to place their asthma into the "Mild Intermittent" category.
12 Classification Mild Intermittent 2 or fewer days / week 2 or fewer nights / month Mild Persistent 3-5 days / week 3-4 nights / month (weekly) Moderate Persistent Daily 5-6 nights / month Severe Persistent Multiple times daily Most nights Step-Wise Treatment Albuterol only Always treat triggers (e.g. Claritin) Low-dose ICS or Singulair Albuterol PRN Mod-dose ICS +/- Singulair Albuterol PRN Some consider Advair (I don't) High-dose ICS Albuterol + Atrovent (if it helps) Singulair if it helps Advair or other long acting beta agonist. Remember, Step-Wise increases in treatment follow this same pattern.
13 The Rule of 2's = Good Control Good control < 2 days per week < 2 nights per month Move up a severity "category" and escalate treatment if... On meds & compliant for current category e.g. Mild Intermittent, on inhaled corticosteroids And you... Have more than 2 days / week of symptoms Have more than 2 nights / month of symptoms Consider moving down a severity "category" if... Categorizes into "mild intermittent" for a long time No symptoms whatsoever for a long time.
14 Good Resources Asthma Update, Epidemiology and Pathophysiology. (2004). Wood, PR., & Hill, VL. Pediatrics in Review, 25 (9): Practical Management of Asthma. (2009). Wood, PR., & Hill, VL. Pediatrics in Review, 30 (10): Picture reference dir/7/files/2011/05/diseases/asthma-1.jpg
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7 Asthma Asthma is a common disease in children and its incidence has been increasing in recent years. Between 10-15% of children have been diagnosed with asthma. It is therefore a condition that pharmacists
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