Asthma Guideline and Therapy: Simplified

Transcription

1 Asthma Guideline and Therapy: Simplified DONNA J. LEE, MD PEDIATRIC PULMONOLOGY THE JOSEPH M. SANZARI CHILDREN S HOSPITAL HACKENSACK UNIVERSITY MEDICAL CENTER

2 National Asthma Education Prevention Program- Expert Panel Report 3 NHLBI asthma guideline

3 NAEPP Guidelines EPR 1 published in 1991 EPR 2 published in 1997 Selected update to EPR 2 in 2002 EPR 3 in 2007 EPR 3 selected update now in the works anticipated for publication in 2017 Intermittent therapy with inhaled corticosteroid (ICS) Addition of long acting muscarinic antagonist (LAMA) to ICS Thermoplasty Fraction exhaled nitric oxide (FeNO) in assessing medication response Remediation of indoor allergen Role of immunotherapy in asthma control

4 Sections of NAEPP-EPR 3 1. Introduction 2.Definition/pathophysiology/pathogenesis/ natural history of asthma 3. Four Components of asthma management 4. Managing asthma long term 5. Management of asthma exacerbation

5 Sections of NAEPP-EPR 3 1. Introduction Level of evidence 2.Definition/pathophysiology/pathogenesis/ natural history of asthma Purpose of medication is to improve control Use of medication DOES NOT alter disease 5. Management of asthma exacerbation Initiation of controller in ETD/inpatient Start controller along with rescue medication

6 Definition of Asthma Chronic airway inflammation T-helper type 2 inflammation with TH2 lymphocytes, eosinophil, basophil mucous production, mucosal edema association with serum IgE sensitization for various allergen Bronchial hyperresponsiveness Reversible airway obstruction overwhelming airflow obstruction in response to exposure various environmental changes

7 Section 3 & 4: components of asthma management & control Diagnose asthma Assess Severity Start Medication Establish treatment partnership with patient Control environmental factors Reassess Control Review treatment plan

8 How do you diagnose asthma?

9 Diagnosis of Asthma The diagnosis of asthma is made on CLINICAL grounds. The outward manifestation of the illness: RECURRENT coughing, wheezing, and dyspnea With airway hyperresponsiveness (Sx in presence of various stimuli: odor, viral infection, allergen exposure, exercise, temperature change, weather change.) Following points LENDs support to the diagnosis -Laboratory studies (signs of allergies: IgE, eosinophilia, skin test) -Personal and/or family atopy -Radiology -Lung function (Spirometry) also follow disease control.

10 Diagnosis: Phenotypes of Wheezing Reactive airway disease (RAD) Pre-asthma/RAD Intrinsic Extrinsic collection of wheezing diseases respond to bronchodilator therapy BUT clear diagnosis of asthma has not yet been made. Asthma predictive index: Predict the likelihood of persistent asthma for children < 3 yoa with > 3 episodes of wheezing within the previous year Lack asthma predicative index ASTHMA -atopic dermatitis -parental asthma -2 out of 3 : wheezing apart from viral illness, peripheral eosinophilia, allergic rhinitis, At 6 yoa: (+) in 76% of asthma (-) in 97% of not asthma Castro-Rodriguez, JA 2000, AJTCCM

11 ASTHMA DIAGNOSED Now assess Severity

12 Severity Assessment: Risk and Impairment analysis Risk: the likelihood of either asthma exacerbations, progressive decline in lung function (or, for children, reduced lung growth), or risk of adverse effects from medication Impairment: frequency and intensity of symptoms and functional limitations the patient is experiencing or has recently experienced - at time of diagnosis and before therapy week recall of symptoms - (+/-) Spirometric data in age appropriate

13 Risk and impairment analysis: Intermittent Persistent Mild Day Sx < 2 days/week > 2 days / week but not daily Persistent Moderate Daily Persistent Severe Throughout the day Nighttime Awakening < 2x / month 3-4 x / month > 1 x / week but not daily Every night SABA use <2 days/ week > 2 days / week but only once daily Interference w. Activity Lung Function (5-11) Lung Function FEV1/FVC % % % % Exacerbations daily Several time per day None Minor limitation Some limitation Extremely limited Normal FEV1 well FEV1> 80% FEV1/FVC > 85% Normal FEV1 well FEV1> 80% FEV1/FVC = N FEV1> 80% FEV1/FVC > 80% FEV1> 80% FEV1/FVC = normal FEV1=60-80% FEV1/FVC = 75-85% FEV1=60-80% FEV1/FVC = dec by 5% FEV1, 80% FEV1/FVC < 75% FEV1, 60% FEV1/FVC > 5% drop 0-1x / year > 2x per year > 2x per year > 2x per year Medication Step 1 Step 2 Step 3-4 Step 5-6

14 Most important: Intermittent vs. Persistent

15 ASTHMA DIAGNOSED Severity determined NOW START MEDICATION

16 Section 4: medications Medication choice: Inhaled corticosteroid (ICS) remains the first line and first choice for maintenance therapy Leukotriene receptor antagonist (LTRA) and long acting beta agonist (LABA) are used as adjunct to ICS for severe persistent patients and/or those who failed to response to increasing ICS LTRA can be used as alternative to low dose ICS in mild persistent asthmatic patients

17 Match therapy to severity: Step up or step down Intermittent Asthma Persistent asthma: need daily medication Consult asthma specialist with step 3 or higher Step 6 Step 5 High ICS Step 3 Step 4 Medium ICS High ICS & & Montelukast 0 Step 1 PRN SABA Step 2 Low ICS OR Montelukast Cromolyn Medium ICS & Montelukast or LABA Montelukast or LABA or LABA + Oral steroid 4 Y O A Mild Moderate Severe NAEPP EPR3 Step 1 PRN SABA Step 2 Low ICS OR LRTA, Cromolyn, Theophylline Step 3 Medium ICS OR Low ICS + LABA, LRTA, Theophylline Step 4 Medium ICS + LABA OR Medium ICS+ LRTA, Theophylline Step 5 High ICS + LABA OR High ICS + LRTA, Theophylline & Consider Omalizumab Step 6 High ICS + LABA + oral steroid OR High ICS + oral steroid +LRTA & Consider Omalizumab 5 Y O A A D U L T

18 Which ICS?

19 Choosing an ICS: RRA F oral (%) F inhale (%) F nasal (%) Binding protein mometasone furoate (Asmanex) 2300 <1 11 < fluticasone proprionate (Flovent) 1800 <1 17 DPI 26 CFC 29 HFA < (%) F unbound beclomethasone dipropionate (Qvar-pre) HFA *17-beclomethasone monopropionate (Qvar) CFC 98.4 N/A beclomethasone (Vanceril/Beclovent) 76 N/A N/A N/A ciclesonide (Alvesco) 12 <1 N/A 99 <1 *des-ciclesonide 1200 <1 52 HFA 12 budesonide (Pulmicort) CFC triamcinolone (Asmacort) CFC flunisolide (Aerospan) CFC 68 HFA High Potency and less absorbability Potency efficacy (%)

20 Which ICS? Short answer: Personal Preference Which delivery option (match to patient) ****Teach patient HOW to USE device*****

21 Delivery systems: Nebulizer Patient cooperation is important Best result: tight fitting facemask for younger mouth piece for older children Not ideal but can use blow by methods Takes too long Can be scary Poor portability Needs electricity/battery Medications: SABA ICS (budesonide is the only available form) Antibiotic Mucolytics

22 Delivery system: Meter Dose Inhaler MDIs need coordination hard to use without valve holding chamber (Aerochamber, Optichamber ) Equivalent delivery to nebulizer if used properly Shortened treatment time More portable Requires full cooperation from the patient and caregiver Medications: SABA ICS LABA+ICS

23 Delivery system: Dry Powder Inhaler Better delivery and deposition to lower airway Quick administration Easy to use but requires understanding of technique Requires cooperation >30 L/min inspiratory flow Cannot blow into device Medication: ICS SABA (ProAir Respiclick is the only DPI SABA) LABA + ICS

24 ASTHMA DIAGNOSED Severity determined Medication given NOW ASSES RESPONSE

25 Assess Control: 0-4 years Well Controlled Not Well Controlled Poorly Controlled Day Sx < 2 days/week > 2 days / week Throughout the day Nighttime Awakening < 1x / month >1x / month > 1x per week SABA use <2 days/ week > 2 days / week Several time per day Interference w. Activity None Minor limitation Extremely limited Exacerbations 0-1x / year 2-3x per year > 3x per year adverse side effect

26 Assess Control: 5-11 years Day Sx Nighttime Awakening Well Controlled Not Well Controlled Poorly Controlled < 2 days/week < 1x per day > 2 days / week or multiple time on < 2 days /week Throughout the day < 1x / month >2x / month > 2x per week SABA use <2 days/ week > 2 days / week Several time per day Interference w. Activity None Minor limitation Extremely limited Lung Function FEV1 FEV1/FVC 80% or at personal best >80% FEV % / personal best 75-80% < 60% personal best <75% Exacerbations 0-1x / year > 2x per year > 2x per year Reduction in lung growth and adverse side effect

27 Assess Control: > 12 years Well Controlled Not Well Controlled Poorly Controlled Day Sx < 2 days/week > 2 days / week but not daily Nighttime Awakening Throughout the day < 2x / month 1-3x / week > 4x per week SABA use <2 days/ week > 2 days / week Several time per day Interference w. Activity None Minor limitation Extremely limited Lung Function > 80% or at personal best FEV1> 80% FEV1/FVC = normal < 60% personal best QOL questionnaires ACT > 20 ACT ACT < 15 Exacerbations 0-1x / year > 2x per year > 2x per year Progressive Loss in lung function/ adverse effect to therapy

28 Controlled: Wean or maintain Not Controlled: Escalate Therapy Look for complicating factor Reassess the diagnosis

29 When to Refer? Life threatening asthma When patient does not improve with adequate asthma therapy Atypical signs and symptoms / need to either re-evaluate the diagnosis Need to look at co-morbid conditions/complicating factors Asthma education Immunotherapy

30 Asthma mimickers DDx and/or complicators for ASTHMA Infants and Children Upper airway diseases Allergic rhinitis and sinusitis Obstructions involving large airways Foreign body in trachea or bronchus Vocal cord dysfunction Vascular rings or laryngeal webs Laryngotracheomalacia, tracheal stenosis, or bronchostenosis Enlarged lymph nodes or tumor Obstructions involving small airways Viral bronchiolitis or obliterative bronchiolitis Cystic fibrosis, ciliary dyskinesia Bronchopulmonary dysplasia Heart disease Other causes Protracted bacterial bronchitis Aspiration from swallowing mechanism dysfunction or gastroesophageal reflux Adults COPD (e.g., chronic bronchitis or emphysema) Congestive heart failure pulmonary embolism Mechanical obstruction of the airways (benign and malignant tumors) Pulmonary infiltration with eosinophilia Cough secondary to drugs (e.g., angiotensin-converting enzyme (ACE) inhibitors) Vocal cord dysfunction Obstruction leading to wheezing