Asthma SAM Preparation August 2013 Tim Munzing, MD & Carrie Nelson-Vasquez, MD Kaiser Permanente So Cal Symposium

Transcription

1 Asthma SAM Preparation August 2013 Tim Munzing, MD & Carrie Nelson-Vasquez, MD Kaiser Permanente So Cal Symposium Overview Review the MC-Family Medicine process SAM process Explore asthma triggers and pathogenesis Identify asthma classification based on severity Discuss specific tips regarding medications used for asthma Learn the evidence-based stepwise management of asthma Size of the Problem 15 Million Americans with Asthma 5000 Deaths per year 500,000 Hospitalizations per year 2,000,000 ER visits per year Cost of Care: $6 Billion Components of Asthma Reversible Airway Obstruction Airway Hyper reactivity Airway Inflammation and bronchoconstriction Mediators Histamines Leukotrienes Granulocyte-macrophage colony-stimulating factor (GM-CSF) Interleukin-4 and interleukin-5 Tissue necrosis factor-a Chronic Uncontrolled Asthma irreversible airway modeling Goblet cell hyperplasia Subepithelial collagen deposition Smooth muscle hypertrophy Microvascular proliferation Establish Asthma Diagnosis History Physical Exam Spirometry Asthma SAM Update Handout.doc Page 1

2 Quality asthma care: Recommendations by the National Asthma Education and Prevention Program NAEPP Symptoms Cough Wheezing Dyspnea Physical Exam Prolonged expiratory phase Diffuse wheezing Tachypnea Intercostal retractions Spirometry >12% improvement in FEV 1 after treatment with short-acting bronchodilator or short course of oral corticosteroids Differential Diagnosis Upper airway obstruction due to foreign body or tumor Bronchitis/bronchiolitis/pneumonia COPD Vocal Cord dysfunction CHF GERD DDX Cough in children GERD, Congenital heart disease, cystic fibrosis, inhaled foreign body, bronchiolitis, and TE fistula Control Asthma Triggers Tobacco Smoke!!! Dust Mites Encase pillow, wash sheets in hot water, vacuum carpet 1-2 times weekly w/ HEPA filter Cockroaches higher inner city Cats Dogs Laughing or crying Mold Sulfites Workplace sensitivities chemicals, perfumes Asthma SAM Update Handout.doc Page 2

3 Treat or Prevent Comorbid Conditions Allergic Rhinitis Sinusitis GERD Drug sensitivities Beta Blockers Aspirin NSAIDs Flu and Pneumonia Vaccines to decrease infection Allergic Bronchopulmonary aspergillosis Asthma not due to Asp infection Aspergillosis transient, recurrent infiltrates on CXR Prox. Bronchiectasis evident on high-res chest CT Dx criteria include the presence of serum precipitins to A. fumigats Should be considered in pts with severe asthma refractory to tx Aspirin induced asthma Assoc with perennial vasomotor rhinitis, rhinosinusitis and nasal polyps, salisalate is a safe alternative, and leukotriene modifiers are especially effective Tools for Assessing Asthma Control - includes Asthma Therapy Assessment Questionnaire Asthma Control Test Asthma Control Questionnaire Classify Severity of Asthma Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent When sx discordant classify at the highest level Mild Intermittent Asthma Symptoms and SABA use no more than twice weekly Brief exacerbations Nocturnal asthma no more than twice monthly Asymptomatic with normal lung function between episodes FEV1 and Peak Flow no less than 80% of predicted Peak Flow variability less than 20% 0 or 1 use of oral steroids per year Includes asthma due to triggers (exercise, cats, URI, etc.) Asthma SAM Update Handout.doc Page 3

4 Mild Persistent Asthma Symptoms greater than twice weekly but less than once daily Exacerbations may affect activity Nocturnal symptoms more than twice monthly but no more than 4 FEV1 and Peak Flow no less than 80% of predicted Peak Flow variability from 20 to 30 % Two or less courses of oral steroid per year Moderate Persistent Asthma Daily symptoms Daily use of Rescue meds SABA s Exacerbations affect activity Nocturnal symptoms more than once weekly Exacerbations occur at least twice a week and may last for days FEV1 or Peak Flow between 60 and 80% of predicted Peak Flow variability greater than 30% Two or less courses of oral steroid per year Severe Persistent Asthma Continuous symptoms Use of rescue meds several times daily Limited physical activity Frequent exacerbations Frequent nocturnal symptoms FEV1 or Peak Flow less than 60% of predicted Peak Flow variability greater than 30% Two or more courses of oral steroid per year Exercise-Induced Asthma Bronchospasm occurs during or minutes after exercise Less risk of exercise in heated indoor pool compared to cooler exercise areas Decrease bronchospasm warm up 10 minutes, if in cold weather cover mouth and nose (scarf or mask), slowly taper down intensity of exercise before stopping Atrovent is not helpful in EIA Risk Factor for Death ER visit < 1 mo for asthma Recent withdrawal from systemic steroids Low socioeconomic status Illicit drug use Asthma SAM Update Handout.doc Page 4

5 Develop a Written Asthma Management Plan Be sure to include: Written instructions on recognizing signs and symptoms of worsening asthma Plans on medication type, dose and frequency Instructions on recognizing when to seek medical care Plans that can be based on symptoms or peak flow readings Provide Routine Education on Patient Self-Management Basic facts about Asthma Concept of Rescue and Controller meds Environmental controls Inhaler technique Peak Flow self-monitoring Concept of self-management Schedule Routine Follow-Up Care Review medication use Review Peak Flow records Demonstrate inhaler, spacer and Peak Flow meter technique Review self-management plan Medication Treatment Specific Tips Inhaled Corticosteroids (ICS) 1 st line treatment for persistent asthma Improved with spacer/holding chamber use to decrease adverse side effects Lower severity of sx, increase in pulmonary function, lower airway hypersensitivity, less exacerbation Low risk including in children Drug of 1 st choice in pregnancy Systemic Corticosteroids Potentiates bronchodilator effects of BAG s Should continue treat with systemic steroids until PEF 80% or more or sx resolution IV route is not proven better compared to oral Short Acting Beta-agonist (SABA) rescue inhaler Tolerance can develop after one week of tx Tolerance may cause an increase in severe attacks Regular use less prevention from bronchoconstriction Asthma SAM Update Handout.doc Page 5

6 Side effects tremors, tachycardia, temporary reduction of arterial O2 tension Long Acting Beta-agonist (LABA) Should only be used along with ICS Leukotriene Modifiers Not for quick relief Effective for exercise induced asthma 2 nd line treatment for mild persistent asthma, less helpful than ICS Unproven Asthma treatments Antibiotics Aggressive hydration Mucolytic treatment Chest PT Prescribe Medications According to Severity Treatment of Mild Intermittent Asthma Short-acting Rescue bronchodilator No Daily controller medication is needed Treatment of Mild Persistent Asthma Rescue Bronchodilator Daily Controller Medication Inhaled Corticosteroid (ICS) Leukotriene modifier Cromolyn Sustained release theophylline Evidence Based Practice Recommendation Inhaled Corticosteroids are more effective than anti-leukotriene agents and should remain first line in monotherapy for persistent asthma. Evidence Based Practice Recommendation For patients requiring inhaled corticosteroids, starting with a moderate dose is equivalent to starting with a high dose and down-titrating. Treatment of Moderate Persistent Asthma Rescue Bronchodilator Controller Meds: ICS (low to medium dose) and Long acting Bronchodilator Asthma SAM Update Handout.doc Page 6

7 Alternative Treatment for Moderate Persistent Asthma Increase ICS within medium-dose range Or Low to medium dose ICS and either leukotriene modifier or theophylline Treatment of Severe Persistent Asthma Rescue Bronchodilator Controller meds: ICS (high dose) and Long acting Bronchodilator and Oral corticosteroids (if needed) If allergy Omalizumab (Xolair) reduces free circulating IgE Asthma Exacerbation respiratory alkalosis initially Monitor use of Beta2-Agonist Drugs One canister should last one month Review dosage instructions and inhaler technique at follow up visits Modify daily controller therapy in response to change in beta2-agonist usage Practice Based Disease Management Patient education Physician education Flow sheets Action plan templates Urgent care/er guidelines Outcomes measurements Asthma SAM Update Handout.doc Page 7