RITA ALLNUR 652 PRIMARY CARE

ICD 9 CODES:493 .00 EXTRINSIC ASTHMA, UNSPECIFIED493 .90 ASTHMA, UNSPECIFIED, WITHOUT

MENTION OF STATUS ASTHMATICUS493 .92 ASTHMA, UNSPECIFIED, WITH

ACUTE EXACERBATION

Asthma

Asthma- Definition

Asthma is a chronic, reversible, inflammatory airway disease

Characteristics include bronchoconstriction that is reversible, airway edema and hyperresponsiveness

Recurrent bouts of breathlessness and wheezing, chest tightening, and cough (can be worse at night)

Can be highly unpredictable, from mild attack to complete airway obstruction leading to death.

Asthma- Classification

4 major classifications : Based on daily activity, symptom occurrences, use of rescue inhaler, and FEV levels

Intermittent- no daily medication needed, rescue inhaler only

There is no interference with daily activity

Symptoms may occur 2 or less days a week, with awakening from sleep 2 or less nights a month

Rescue inhaler used 2 or less days a week

Normal forced FEV between bouts, and greater than 80% during episodes

Asthma- Classification

Mild persistent- One daily control med needed- low dose inhaled corticosteroid, cromolyn, leukotriene modifier

There is minor interference with daily activity

Symptoms may occur 2 or more days a week, but not daily, with awakening from sleep 3-4 nights a month

Rescue inhaler used 2 or more days a week

Greater than 80% FEV between and during episodes

Asthma- Classification

Moderate persistent- inhaled beta2 agonist PRN, daily control medication- combination inhaled medium dose corticosteroid with long acting bronchodilator; cromolyn; leukotriene modifier.

There is some interference with daily activity

Symptoms may occur daily, with awakening from sleep at least 1 night a week, but not every night

Rescue inhaler used daily

60-80% FEV between and during episodes

Asthma- Classification

Severe persistent- inhaled beta2 agonist PRN, multiple daily control medication- combination inhaled high dose corticosteroid with long acting bronchodilator; cromolyn; leukotriene modifier, may need long term corticosteroids.

There is major interference with daily activity

Symptoms occur throughout the day, with awakening from sleep every night

Rescue inhaler used several times a day

Less than 60% FEV between and during episodes

Asthma- Pathophysiology

Inflammatory cell infiltration

Sub basement fibrosis

Mucous hypersecretion

Epithelial injury

Smooth muscle hypertrophy

Angiogenesis

Airflow obstruction and bronchial responsiveness

Asthma Pathophysiology

Asthma- Etiology

Caused by extrinsic (environmental) and intrinsic (stress) triggers causing spontaneous remittance or exacerbation.

Genetic predisposition- IgE mediated response to aeroallergens (atopy)- strongest identifiable risk factor for asthma.

3 principle triggers: Allergens and environmental factors-

Molds, animal dander, pollen, dust, smoke, beta-blockers, or aspirin containing products, temperature changes Infections- URI’s, RSV Psychological factors- stress

Also can be caused by certain drugs : Betablockers, aspirins, new evidence suggests a Tylenol connection (Soferman, et al, 2013)

obesity, reflux

Inflammation allows for hyper-reactivity of the bronchi, limiting airflow, causing the symptoms of wheezing, chest tightness, cough and difficulty breathing

Incidence

Affects 5-10% of population7 million children, one of the most common childhood

chronic diseases, highest in 5-17 years old30 million Americans, 300 million globally and growingMore common in boy youthsMore common in adult women, African AmericanAfrican Americans have a higher rate of mortality,

possibly due to access of care, low income, compliance with treatment plans (Halterman, et al, 2011)

Increase in prevalence, hospitalization, and death in the past 20 years

5500 deaths annually due to asthma in the US

Clinical findings

Accurate history very importantMay be normalGeneral appearance:

Signs of respiratory distress or use of accessory muscles Rhinitis Nasal polyps Swollen turbinates Wheezing Prolonged expiratory phase Cough Shortness of breath

Differential Diagnosis- Children

Upper Airway Allergic rhinitis Sinusitis

Airway Obstruction Foreign body aspiration Vocal cord dysfunction Vascular ring/ laryngeal web Laryngotracheomalacia Airway obstruction from lymph nodes or tumor

Small airway obstruction Viral bronchiolitis (up until age of 2- most common RSV)

Recurrent cough GERD Aspiration

Differential Diagnosis- Adults

COPDCHFPETumorPulmonary infiltration with eosinophiliaMedications such as ACE inhibitorsVocal cord dysfunction

Social/ Environmental Considerations

Adolescents have a poor rate of complianceThose with mild symptoms are least like to get

ongoing preventative care, have an action plan, or know what to do or when to initiate therapy when symptoms occur

Chronic illness self image issuesThose that are uninsured or have lack of access to

quality of healthcare will have poorer outcomesCost of medication:

Albuterol $50 Pulmicort $175 Flovent $170 Singlair $185

Laboratory Tests

Labs: not necessary, but may show eosinophilia, or elevated IgE, ABG’s to determine hypoxemia.

Spirometry: Normal testing doesn’t rule out asthma. Measures forced vital capacity and forced expiratory volume in 1 sec. A reduced ratio of fev1/fvc with reversibility of 12% after bronchodilator use establishes diagnosis.

Bronchoprovocation with use of methacholine, histamine, cold air, or exercise is the only definitive diagnostic test.

Peak expiratory flow rates cannot determine diagnosis

Management/ Treatment Guidelines- Non pharmacologic

Identification of triggersControlling exposuresIdentify those at risk for reaction to aspirins

or NSAIDS, beta- blockers, avoid exposureFood allergies and sulfites in food can

precipitate symptomsDaily monitoring of peak expiratory flow

record it on a record with any symptomsWritten instructions including crisis plan

Management/ Treatment guidelines- Pharmacologic

First line: Short acting beta agonist

Quick relief of symptoms, and prevent exercise induced asthma Albuterol, xopenex, alupent, maxair Use with aerochamber or spacer for increased efficacy with decreased

side effects as compared to neb treatments.

Anticholinergic agents Ipratropium bromide (atrovent), used in combination with SABA for acute

treatment

Systemic corticosteroids Can be used in all patients with acute asthma exac. In mod to severe asthma as adjunct Prednisolone 1-2 mg/kg/d for 7 days in adults and 3 days for children.

Management/ Treatment guidelines- Pharmacologic

Second line (for long term control): Inhaled corticosteroids- preferred long term therapy for persistent

asthma and during pregnancy (flovent, pulmicort) Long acting beta agonists- not to be used alone, or severe outcomes

including death may occur. Salbutamol or Formoterol Combination products- preferred in moderate persistent asthma, if

inhaled corticosteroids alone are not helpful (advair) Leukotriene receptor agonists- not preferred for mild persistent.

Singulair Lipoxygenase pathway inhibitor- Alternative, not preferred for

adjunctive treatment in adults. Theophylline- not preferred as adjunt to inhaled corticosteroids Cromolyn sodium and nedocromil are alternatives, but not preferred Immunodilators- Adjunctive therapy, Omalizumab- for allergies and

severe persistent

Complications

AtelectasisPneumoniaPneumomediastinumPneumothoraxMedication specific side effects/adverse

reactionsRespiratory failureDeath

Follow up

Step down therapy gradually, visits in 1-6 months depending on symptoms and response to treatment

Review short term and long term goals

Review daily self management plan

Medication adjustment based on symptoms

Counseling/ Education

Smoking cessationPrevention of second hand smoke exposureRemoval or modification of allergens/ irritant

triggers in living spaceAllergen immunotherapyTreat allergic rhinitisUse of inhalers with aerochambers When to use rescue inhaler (role of

medications)Flu vaccine annually

Asthma action plan

Asthma action plan

Self monitoring of symptoms

Self monitoring of peak flow measurements

When to call provider

When to go to emergency room

Asthma Treatment Plan

Consultation/ Referral

Referral to allergist or pulmonologist if:

Unclear if true asthma

Additional patient education needed

If other diagnoses exist: Rhinitis, GERD, Sinusitis, OSA

If bronchoprovocation or skin testing is needed

For consideration of immunotherapy or anti- IgE therapy

Poorly controlled asthmatics with moderate to severe persistent asthma or multiple ECC visits

Multiple choice questions

1. What drug class is the most effective rescue therapy for acute asthma symptoms?a. Short acting beta agonistb. Anticholinergic agentc. Systemic corticosteroidsd. Inhaled corticosteroids

2. Which is not a commonly associated condition of asthma?

e. Obesityf. Allergic Rhinitisg. Eczemah. Diabetes

Multiple choice questions

3. Which is not an environmental risk factor for asthma?a. Genetic predispositionb. Viral infectionsc. Tobacco smoke d. Animal dander

4. The physical exam on a patient with asthma:e. May be normal f. May show accessory muscle useg. Eczema may be presenth. All of the above

Multiple choice questions

5. Which test would be appropriate for diagnosis of asthma?a. Spirometryb. CBCc. Bronchoprovocationd. Peak expiratory flow rates

6. Which person would be least likely to be diagnosed with asthma?

e. African American Male age 6f. Caucasian male aged 70g. African American female aged 48h. 2 year old caucasian boy with recent RSV

Multiple choice questions

7. A 7 year old asthmatic male is questioned about his asthma control. His mom reports he only requires his inhaler once weekly, and is rarely awakened by symptoms at night. Which class of asthma would he fall into based on info provided?a. Mild persistentb. Intermittentc. Moderate persistentd. Severe persistent

8. What result may be found on a blood test for an asthmatic patient?e. low WBC countf. Elevated potassiumg. Elevated IgEh. Low sed rate

Multiple choice questions

9. Which would not be found in a patient with Severe persistent asthma?a. Symptoms throughout the dayb. Use of albuterol inhaler several times of dayc. Mild limitations to daily activity

10. Which statement regarding asthma is true?a. Chronic, reversible airway diseaseb. Chronic, irreversible airway diseasec. Acute, intermittent, airway disease

References

Burns, C. (2013). Pediatric Primary Care (5th ed.) Philadelphia: Elsevier Saunders. Dunphy, L. (2011). Primary Care (3rd ed.). Philadelphia: FA Davis and Co. Domino, F. (2013). The 5 Minute Clinical Consult 2014 (22nd ed.). Philadelphia:

Lippincott Williams & Wilkins. Halterman, J. S., Riekert, K., Bayer, A., Fagnano, M., Tremblay, P., Blaakman, S., &

Borrelli, B. (2011). A pilot study to enhance preventive asthma care among urban adolescents with asthma. Journal of Asthma, 48(5), 523-530.

Juel, C. T. B., & Ulrik, C. S. (2013). Obesity and Asthma: Impact on Severity, Asthma Control, and Response to Therapy. Respiratory care, 58(5), 867-873.

Melén, E., & Pershagen, G. (2012). Pathophysiology of asthma: lessons from genetic research with particular focus on severe asthma. Journal of internal medicine, 272(2), 108-120.

Rosenthal, E. (2013, October 13). Paying til it hurts. New York Times. Retrieved from http://www.nytimes.com/2013/10/13/us/the-soaring-cost-of-a-simple-breath.html.

Tapp, H., Hebert, L., & Dulin, M. (2011). Comparative effectiveness of asthma interventions within a practice based research network. BMC health services research, 11(1), 188.

UTD (2013). Asthma treatment guidelines. Retrieved fromhttp://www.uptodate.com/