Module 4. Special Populations. Geneva Briggs

Transcription

1 Module 4 Special Populations Geneva Briggs Pre-Assessment Exercise 1

2 Question #1 Which medication is NOT used in preventing exercise induced bronchospasm? a. Cromolyn b. Albuterol c. Theophylline d. Montelukast Question #2 Exercise induced bronchospasm is caused by a loss of heat, water, or both from the lung during exercise. a. True b. False 2

3 Question #3 Which of the following is an accurate statement about asthma in children? a. Males have a greater prevalence than females b. Long acting beta agonists are ineffective c. Low dose inhaled corticosteroids are preferred first step in persistent asthma d. In the U.S, Puerto Ricans have the highest prevalence Question #4 When counseling an adolescent with asthma, assessing whether the patient smokes is important. a. True b. False 3

4 Question #5 Which of the following is an accurate statement about asthma and pregnancy? a. Patients with adequately controlled asthma has birth outcomes similar to non-asthmatic populations. b. The rate of low birth weight is high even in well controlled asthmatic mothers. c. The risk of adverse effects with inhaled beta agonists is higher during pregnancy. d. Symptoms of asthma typically improve dramatically during pregnancy allowing medication reductions. Choose your option below. Next Topic: Exercise Induced Bronchospasm 4

5 Exercise Induced Bronchospasm Exercise Induced Bronchospasm (EIB) Airway narrowing 5-10 minutes after the cessation of vigorous exercise Bronchoconstriction only, no inflammatory response Cause: loss of heat and water from the lungs during exercise and leukotriene release Not prolonged or dangerous 5

6 Difficulty with EIB is the resulting limitation on activity Diagnosis of EIB History 15% decrease in peak flow between measurements taken before and after vigorous activity 6

7 Symptoms of EIB During exercise Rapid breathing Irregular breathing Decreased endurance Following exercise Cough Wheezing Shortness of breath Chest tightness Influencing Factors Type of exercise Intensity Duration Environment Warm vs. cold air Humid vs. dry air 7

8 Goals of Therapy Allow patients to live a normal active life style Prevention of exercise induced symptoms Prevention Increase physical conditioning Warm up for at least 10 minutes before actual exercise begins Cover mouth and nose with scarf or mask during cold weather Exercise in warm, humidified environment, if possible Avoid aeroallergens and pollutants Cool down or gradually lower the intensity of the exercise before stopping Wait at least 2 hours after a meal before exercising 8

9 Interactive Check Point Which of the following is first line therapy for EIB? a. Inhaled ipratropium b. Inhaled cromolyn c. Inhaled corticosteroids (ICS) d. Inhaled short acting β2 agonists (SABA) Interactive Check Point Answer d. Inhaled SABA These agents are first line because of their quick onset of action in reversing bronchospasm 9

10 Drug Treatment First line treatment Inhaled SABA Second line treatment Cromolyn / Nedocromil Leukotriene modifiers LABA Use of SABA in EIB 2 puffs, minutes before exercise Duration of protection = hours May also use after exercise for slow to resolve symptoms 10

11 Use of LABA in EIB Salmeterol: 2 puffs 30 minutes before exercise Formoterol : 1 inhalation 15 minutes before exercise Duration of protection = hours Consider using: If exercise planned for > 3 hours In children or adolescents to avoid inhaler use in front of peers Use of Cromolyn in EIB 2 puffs, minutes before exercise Duration of protection = hours Somewhat less effective May have role as add on therapy to SABA 11

12 Use of Leukotriene Modifiers in EIB Advantages Oral administration Long duration of action (24 hrs) Medication Use in Competition U.S. Olympic Committee Allowed without prior approval: cromolyn, nedocromil, ipratropium, theophylline, leukotriene modifiers Require prior approval: inhaled β2 agonists (short and long-acting), ICS NCAA Permits most medications except oral β2 agonists 12

13 Choose your option below. Next Topic: Asthma in Children and Adolescents Asthma in Children and Adolescents 13

14 Prevalence Asthma affects 6.2 million children < % of children with asthma develop symptoms before age 5 Prevalence rates are highest among Puerto Ricans (131/1000), Native Americans (99/1000) and African Americans (95/1000) and greater in boys than girls Prevalence From 1980 to 1996: Prevalence increased 160% in children < 4 years old Increased 72% in children 5 to 16 years old Rates have remained stable from

15 Each Year Asthma in Children Accounts for: 2.7 million doctor visits 720,000 ER visits 200,000 hospitalizations Over 8.7 million prescriptions for children under 17 years old 14.7 million school days are missed annually due to asthma In 2002, 187 children died from asthma Costs Lost productivity among parents of children with asthma = $1 billion each year Annual cost of treating children with asthma = $1.9 billion 15

16 Factors Associated with ONSET of Asthma Symptoms in Children Allergy Family history of asthma and/or allergy Perinatal exposure to tobacco smoke Viral respiratory infections Smaller airways at birth and in early life Male gender Low birth weight Factors Associated with Continuing Asthma Allergy Family history of asthma and/or allergy Perinatal exposure to passive smoke and aeroallergens 16

17 Symptoms in Young Children Cough may be only symptom Wheezing Tachypnea with accessory muscle use Decreased activity level and alertness Symptom precipitant - recurrent sinusitis, rhinitis, or an upper respiratory tract infection Considerations Children < 5 years old are unable to use peak flow meters, so assessment of severity is based on symptoms 17

18 Classifying Severity and Assessing Control Assessed in children the same way as in adults impairment and risk domains Severity is either intermittent or mild, moderate, or severe persistent Control is either well controlled, not well controlled, and very poorly controlled Pharmacologic management of children and adolescents follows same basic principles as those for adults with special consideration for growth, school and social development 18

19 Drug Treatment in Children Intermittent asthma SABA prn (Step 1) Low dose inhaled corticosteroids (ICS) are preferred first agent in persistent asthma (Step 2) Alternatives Cromolyn, nedocromil, leukotriene modifiers, or theophylline in 5-11 years old Cromolyn or montelukast in 0-4 years old Stepwise Approach for Managing Asthma in Children 0-4 Intermittent Asthma Persistent Asthma: Daily Medication ICS, inhaled corticosteroid; LABA, inhaled long acting beta agonist;ltra, leukotriene receptor antagonist; SABA, inhaled short acting beta agonist;steroids, corticosteroids Step 1 Preferred: SABA prn Step 2 Preferred: Low-dose ICS Alternative: Montelukast, Cromolyn Step 3 Preferred: Medium-dose ICS Step 4 Preferred: Medium-dose ICS AND Either: Montelukast or LABA Step 5 Preferred: High-dose ICS AND Either: Montelukast or LABA Step 6 Preferred: High-dose ICS AND Either: Montelukast or LABA AND oral steroids 19

20 Stepwise Approach for Managing Asthma in Children 5-11 Intermittent Asthma Persistent Asthma: Daily Medication ICS, inhaled corticosteroid; LABA, inhaled long acting beta agonist;ltra, leukotriene receptor antagonist; SABA, inhaled short acting beta agonist; steroids, corticosteroids Step 1 Preferred: SABA prn Step 2 Preferred: Low-dose ICS Alternative: LTRA Cromolyn Nedocromil or Theophylline Step 3 Preferred: Medium-dose ICS OR Low-dose ICS + either LABA, LTRA or Theophylline Step 4 Preferred: Medium-dose ICS + LABA Alternative: Medium-dose ICS + either LABA or Theophylline Step 5 Preferred: High-dose ICS + LABA Alternative: High-dose ICS + either LTRA or Theophylline Step 6 Preferred: High-dose ICS + LABA + Oral steroid Alternative: High-dose ICS + either LTRA or Theophylline + oral steroid Drug Treatment in Children Oral medications Nebulizers Metered dose inhalers with holding chambers Dry powder inhalers 20

21 Adherence Problems in Children Unpalatable Difficulty swallowing Medication regimen conflicts with parents schedule or school Child is not actively involved in medication regimen School Days Asthma Action Plan Medication letter to school nurse Provide extra labeled medication containers Ensure the patient has medications for home and school 21

22 When possible, schedule daily medications so they do not need to be taken at school How Asthma Friendly is Your School or Child-Care Setting? chk.htm Seven item checklist designed to help parents evaluate the setting Addresses: Environmental issues Medication management Availability of health professionals Helpful list of resources for parents and child-care staff 22

23 Counseling Children Educate both parent and child Talk directly to the child Encourage questions and feedback from the child Adolescents More likely to be in denial Peer pressure Nonadherence used as control over parents Do not see long term benefits 23

24 Counseling Adolescents Listen to the patient Find out their expectations and goals Find out what the adolescent is willing to do and then work out a management plan together Ask about smoking, exposure to tobacco smoke and possible drug use Treatment Strategies Develop a medication plan that does not require teen to use medications around peers Encourage the parent to allow teen to have more control over treatment 24

25 Choose your option below. Next Topic: Managing Asthma During Pregnancy Managing Asthma During Pregnancy 25

26 Asthma During Pregnancy Asthma is one of the most common potentially serious problem to complicate pregnancy 4% of pregnancies are complicated with asthma 33% of asthmatics symptoms worsen during pregnancy Severe asthmatics are at the highest risk Asthma During Pregnancy Small changes in lung function can dramatically affect fetal oxygenation Uncontrolled asthma Fetal death Low birth weight Preterm birth Preeclampsia Adequately controlled asthma has outcomes similar to non-asthmatic populations 26

27 Goals of Treatment Control symptoms Prevent exacerbations Maintain normal lung function Maintain normal activity levels Avoid adverse drug reactions Deliver a healthy infant Drug Treatment Risks associated with uncontrolled asthma far outweigh possible side effects associated with drug therapy 27

28 Drug Treatment Individualize treatment plan Step approach based on severity Inhaled medications are preferred over oral Medications with a history of use during pregnancy are preferred NAEPP Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment Update 2004 Intermittent Step 1 Inhaled SABA prn Persistent Step 2 Low dose ICS Alternatives: cromolyn, leukotriene modifier, or sustained release theophylline 28

29 Recommendations Persistent Step 3 Preferred: Low dose ICS + LABA Medium dose ICS Persistent Step 4 Medium dose ICS + LABA Persistent Step 5 High dose ICS + LABA Persistent Step 6 High dose ICS + LABA + oral steroids Asthma Medications and Pregnancy SABA May be used Albuterol is preferred agent Salmeterol No human data on use during pregnancy Generally not recommended May be continued for patients well controlled on prior Ipratropium No human data on use during pregnancy May be used during acute attack if not responsive to first β2 agonist treatment 29

30 Asthma Medications and Pregnancy Cromolyn May be used Nedocromil No human data on use during pregnancy Generally not recommended May be continued for patients well controlled before pregnancy Asthma Medications and Pregnancy Inhaled corticosteroids Medication of choice in persistent asthma unless well controlled on cromolyn Budesonide first choice Continue a patient on corticosteroid patient well controlled on prior Theophylline May be used in patients not controlled with inhaled corticosteroids 5-12 mcg/ml 30

31 Asthma Medications and Pregnancy Montelukast or zafirlukast No human data on use during pregnancy Generally not recommended May be used in patients well controlled on prior Zileuton Animal studies have shown harmful effects Do not use during pregnancy Asthma Medications and Pregnancy Omalizumab Category B No adequate and well controlled studies in pregnant women 31

32 Choose your option below. Next Topic: Application Exercise Application Exercise Exercise Induced Bronchospasm 32

33 Case Presentation Steven is a 16 year old competitive swimmer with EIB Past medical history: Asthma Case Presentation Medications PRN albuterol Flunisolide (Aerobid ) 1 puff bid When he picks up his prescription today, you note he has been using 3-4 canisters of a SABA per month 33

34 What may his use of 3-4 albuterol canisters/month indicate? a. He has severe EIB b. He is exercising too much c. He needs to institute some nonpharmacologic measures d. His asthma is not well controlled Best Answer His asthma is not well controlled Excessive use of SABA indicates his asthma is not well controlled. Although he has EIB, he also appears to have persistent asthma because he is receiving an ICS. His dose may need to be increased but his adherence should be assessed first. The frequency of his use for EIB also needs to be assessed 34

35 Case Presentation Upon further review of Steven s medication profile, you note he is refilling his ICS about every 45 days when it should be every 30 days Which of the following would be the most important point to make with Steven today? a. Need for warming up before swimming to reduce episodes of EIB b. Need to take albuterol minutes before swimming c. Need to take his daily controller (ICS) to improve control of his asthma and reduce need for SABA 35

36 Best Answer c. Need to take his daily controller (ICS) to improve control of his asthma and reduce need for SABA Although all three points are important, he needs to begin to control his asthma. Improving his adherence with the ICS should help reduce his need for SABA. His inhaler technique should be reviewed Case Presentation Steven admits it is hard to remember to take his corticosteroid twice a day. He takes it first thing in the morning (7AM) and has no trouble remember this dose. He has trouble remembering the 7PM dose because he is usually at swim team practice 36

37 Which of the following would be the best schedule for his inhaled corticosteroid? a. Take all doses once daily b. Continue 7AM and 7PM schedule c. Suggest he take it at 7AM and then when he gets home from swim practice d. Suggest he take it at 7AM and then just prior to bedtime Best Answer d. Suggest he take it at 7AM and then just prior to bedtime This is the best option, if it is an acceptable schedule to him. Taking his dose right after swimming practice may be a problem because he may be having bronchospasm related to the exercise. It may be best to wait some time before taking the evening dose 37

38 Case Presentation He agrees that 7AM and at bedtime will work for him While talking with him, you notice he smells like cigarettes Summarize Action Plan for Steven Continue therapy with SABA PRN, before exercise, and ICS bid Demonstrate use of MDI to insure drug delivery Monitor use Monitor symptoms and activity Discuss smoking cessation and impact on his asthma 38

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