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Teach Asthma Management Teach Asthma Management (TAM)(TAM)
Provided by:
Generously supported by the Robert Wood Johnson FoundationSome slides adapted from Physician Asthma Care Education, developed by
Noreen Clark, University of Michigan, School of Public Health
OBJECTIVES:
Increase your knowledge of pediatric asthma epidemiology
Improve your clinical and community care of children with asthma and their families
Asthma Patient Demographics
US Population = 277.8 Million (US Census, 3/01)Asthma Patients = 5.6% Prevalence (ALA, 2/01)
1. Morbidity & Mortality Weekly Report, 2001.2. Asthma Physician Market Dynamics Study, 2001.3. National Center for Health Statistics, 1986-1999.4. Scott Levin, PDDA, MAT 12/01.
Age1
Age 18 y
12.1 million
68%
Age 0-17 y
5.6 million 32%
Severe 18%
Moderatepersistent
34%
Mildpersistent
22%Mild
intermittent26%
17.7 million
patients with
asthma
2.7 m AA7.2%
4.2 million Hispanic11.7%
10.8 million Caucasian
5.4% prevalence
Patients With Asthma1
Severity2 Race3 Gender4
Male45%
Female55%
CDC Press Release
9 million children <18 have been diagnosed with asthma >4 million have had an asthma attack in the past 12
months 12% of children <18 have been diagnosed with asthma
Boys 14%, Girls 10%Poor families 16%, Not poor families 11%
www.cdc.gov/nchs released 3/2004
Burden of ASTHMA in Wisconsin
12% of adults and 8% of children have been told they have asthma (Overall = 9%)
5,000 asthma hospitalizations (2002)Costs of $36 million in 2002Average charge of $6,942/stay
22,418 asthma emergency department visitsCosts of $13.3 million in 2002
Wis. DHFS; PPH 45055 (03/04) http://dhfs.wisconsin.gov
Burden of ASTHMA in Wisconsin
80% report asthma symptoms in past 30 days Only 48% report having a routine health care visit for asthma in
past 12 months Only 40% report daily medication use In past 12 months:
14% adults had ED visit18% adults had limited daily activities due to asthma
Wis. DHFS; PPH 45055 (03/04) http://dhfs.wisconsin.gov
• Episodic and/or chronic symptoms of airway obstruction.
• Bronchial hyperresponsiveness to triggers.
• Evidence of at least partial reversibility of the airway obstruction.
• Alternative diagnoses are excluded.
A chronic inflammatory disease of the airways with the following clinical features:
Definition of Asthma
Epithelialdamage
Inflammatorycell infiltration
Vasculardilation
Mucous glandhypertrophy
Edema
Mucus
Thickening of basement membrane
Adapted from National Asthma Education and Prevention Program. Expert Panel Report. Guidelines for the Diagnosis and Management of Asthma. August 1991.
Changes in Airway Morphology in Asthma
Airway smoothmuscle
1970s–1980sBronchoconstriction
(Spirometry)
1980s–1990s
Inflammation(PC20, Inflam cells,
FeNO)
1990s–2000s
Remodeling
Relieve SymptomsPrevent Symptoms
Prevent AttacksPrevent Remodeling
Prevent SymptomsPrevent Attacks
Evolution of Asthma Paradigms
Bronchial Hyperreactivity
Fixed ObstructionSymptoms
A Lot Going On A Lot Going On Beneath The SurfaceBeneath The Surface
Airway inflammation
Airflow obstruction
Bronchial hyperresponsiveness
Symptoms
Expert Panel Report 2:Four Components ofAsthma Management
Measures of Assessment and Monitoring Control of Factors Contributing to
Asthma Severity
Pharmacologic Therapy
Education for a Partnership in Asthma Care
Component 1:
Initial Assessment and Diagnosis of Asthma
Determine that:Patient has history or presence of episodic symptoms of airflow
obstruction
Airflow obstruction is at least partially reversible
Alternative diagnoses are excluded
Methods for establishing diagnosis:
Detailed medical history
Physical exam
Spirometry to demonstrate reversibility
Component 1:
Initial Assessment andDiagnosis of Asthma (continued)
Does patient have history or presence ofepisodic symptoms of airflow obstruction? Wheeze, shortness of breath, chest tightness, or
cough
Asthma symptoms vary throughout the day
Absence of symptoms at the time of the examination does not exclude the diagnosisof asthma
Initial Assessment andDiagnosis of Asthma (continued)
Is airflow obstruction at least partiallyreversible? Use spirometry to establish airflow obstruction:
FEV1 < 80% predicted;
FEV1/FVC <65% or below the lower limit of normal
Use spirometry to establish reversibility:
FEV1 increases >12% and at least 200 mL after using a short-acting inhaled beta2-agonist
Component 2:
Control of Factors Contributing to Asthma Severity
Assess exposure and sensitivity to:
Inhalant allergens
Occupational exposures Ask specifically about work-related triggers
Irritants: Indoor air (including tobacco smoke)
Air pollution
Component 2:
Control of FactorsContributing to Asthma Severity (continued)
Assess contribution of other factors:
Rhinitis/sinusitis
Gastroesophageal reflux
Drugs (NSAIDs, beta-blockers)
Viral respiratory infections
Sulfite sensitivity
Pediatric Differential Diagnosis
Chronic sinusitis Vocal cord
dysfunction (VCD) Croup Tracheomalacia Pertussis TE fistula
Foreign bodyBronchiolitisCystic fibrosis / Ciliary dysfunctionGERDHyperventilation syndrome
Viruses and Asthma
Viral infections frequently cause wheezing
30-60% of children will wheeze in 1st 5 yearsFrequent cause of asthma exacerbation
Unable to directly link viral infections with development of asthma
Proven risk factors include:Family history of asthmaEnvironmental smoke exposureHistory of severe bronchiolitis in 1st 18 months
Benchmarks of Good Asthma Control
Infrequent coughing or wheezing No shortness of breath or difficulty breathing No waking up at night due to asthma Normal physical activities No childcare or school absences due to asthma No missed time from work for parent or caregiver
AAAAI Guide
Classification Of Asthma Severity: Clinical Features Before Treatment
Days with Symptoms
Nights with Symptoms
PEV or FEV1
STEP 4Severe
Persistent
Continual Frequent < 60
STEP 3Moderate Persistent
Daily > 5/month > 60% to <80%
STEP 2Mild
Persistent
3-6/week 3-4/month > 80%
STEP 1Mild
Intermittent
< 2/week < 2/month > 80%
Misclassification of Intermittent Asthma#
of
Pat
ien
ts
400
600
800
1,000
Mild intermittent asthmabased on symptoms
and FEV1 alone
Mildintermittent
60%
Mildpersistent
22%Moderatepersistent
15% Severepersistent
3%
200
400
600
200
Classification of the same group but now based on symptoms, FEV1,
and medication use
Adapted from Liard. Eur Respir J. 2000;16:615-620.
n=4,362
953 patients
40%
Robertson et al. Pediatr Pulmonol. 1992;13:95-100.
0
5
10
15
20
25
30
35
40
Severe Moderate MildPatient AssessmentFindings from a cohort study reviewing all pediatric asthma-related deaths
(n=51) in the Australian state of Victoria from 1986 to 1989.
Pediatric Asthma Deaths: Patients With Mild Asthma Are Also at Risk
Patient
Deaths
(%)
36%
31%33%
Functional status?
Daytime symptoms?
Missed work and/or school?
Nighttime awakenings?
Lung function?
AsthmaControl
Use of “quick relief” inhaler
and/or nebulizer?
Utilization of healthcare resources?
Patient self-report of control?
How Can Asthma Control Be Measured?
Inflammation?Direct or indirect?
Satisfaction with care?
Asthma Control and Steroid Doses After Early or Delayed Intervention
Patients with asthma started on budesonide were compared based on duration of asthma at budesonide initiation
Asthma for <2 yearsAsthma for 2 years
Outcomes assessed
Lung function: FEV1, PEFPersistent need for inhaled corticosteroidPersistent symptoms
Selroos et al. Respir Med. 2004;98:254-262.
Mean ICS Doses and Lung Function5 Years After Early or Delayed Intervention
Selroos et al. Respir Med. 2004;98:254-262.
412
93.995 825
84.5
87.2
Delayed TreatmentEarly Treatment
1000
900
800
700
600
500
400
300
200
100
0
Do
se
of
Inh
ale
d S
tero
id
% o
f P
red
icti
ve
FE
V1,
PE
F
100
95
90
85
80
75
Inhaled steroid
FEV1 % pred
PEF, % pred
Does chronic use of inhaled corticosteroids improve long-term outcomes for children with mild or moderate asthma, compared
to other asthma medications? “Strong evidence” established that inhaled corticosteroids
improve asthma control for children with mild-moderate asthma None of the alternatives “listed alphabetically” cromolyn,
leukotriene modifier, nedocromil, sustained release theophylline are as effective
“Low dose” inhaled corticosteroids are the “preferred” treatment for mild asthma
“Low dose” inhaled corticosteroids plus long acting inhaled beta2 agonists are the “preferred” treatment for moderate asthma
NIH Publication No. 02-5075, June 2002
Inhaled Glucocorticoids Versus Leukotriene Receptor Antagonists as Single Agent Asthma Treatment: Systematic
Review of Current EvidenceDucharme FM. BMJ 2003;326:621-625.
Objective: To compare the safety and efficacy of leukotriene modifiers (LTM) with inhaled corticosteroids (ICS) as monotherapy in patients with asthma
Primary Outcome: Rate of exacerbations that required treatment with systemic corticosteroids
Secondary Outcomes: Lung function (FEV1, AM PEF), nocturnal awakenings, use of rescue ß2- agonist, withdrawal rates, days with symptoms, & adverse events
Results - Primary Outcome
Patients receiving LTM were 60% more likely to experience an exacerbation than those treated with ICS (11 trials; RR 1.6, 95% CI 1.2-2.2)
No difference in risk for exacerbations was found in the one pediatric trial reviewed (RR 0.78, 0.32-1.85)
Ducharme FM. BMJ 2003;326:621-625.
What are the long-term adverse effects of chronic inhaled corticosteroid use in children:
growth, bone density, ocular, HPA?
“Strong evidence” shows that inhaled corticosteroids at recommended doses do not have clinically significant or irreversible effects on these outcomes
Low to medium doses of inhaled corticosteroids have the potential to decrease growth velocity 1cm in the first year but this is NOT sustained, progressive, and may be reversible
Observational studies up to 6 years reveal no adverse effect on bone density, cataracts, glaucoma, or clinically significant HPA axis changes
NIH Publication No. 02-5075, June 2002
Dose, drug, &Dose, drug, &route dependentroute dependent
Corticosteroids for Asthma: Benefits and Risks
ReducesReducesinflammationinflammation
Most effectiveMost effectivelong-term control long-term control
medication for medication for asthma*asthma*
DecreasesDecreasesmorbidity / mortalitymorbidity / mortality
Generally knownGenerally knownand can beand can bemonitoredmonitored
BenefitsBenefits
RisksRisks
In patients with moderate persistent asthma who are on ICS, does the addition of another long-term control agent improve
outcomes? “Strong evidence” consistently indicates that the addition of a
long acting inhaled ß2 agonist leads to improvement in lung function, symptoms & reduced additional ß2 agonist use
Adding an LTM or theophylline to an ICS or doubling the ICS dose improves outcomes “but the evidence is not as substantial”
For children less than 5 the preferred treatment is low dose ICS + a long acting inhaled ß2 agonist or medium dose ICS
NIH Publication No. 02-5075, June 2002
What have we learned from all of the studies?
Lung function Symptoms Albuterol use Exacerbations Reduces need to increase ICS dose
low-dose ICS + LABA vs. “other therapy” results in:
Replicated numerous times by other investigatorsGreening et al. Lancet. 1994;344:219-224.Woolcock et al. Am J Respir Crit Care Med. 1996;153:1481-1488Nelson et al J Allergy Clin Immunology 2000;106:1088-1095
Infants and Young Children— When to Start Controllers
>3 episodes of wheezing in the last year and Parental history of asthma or physician diagnosis of eczema
Or 2 of the following Physician diagnosis of allergic rhinitis, wheezing apart from
colds, peripheral eosinophilia Courses of oral steroids more often than every 6 wk Symptoms >2x/wk, nocturnal symptoms >2x/mo
Principles of Maintenance Therapy
Start high. Step down once control is achieved. Maintain at lowest dose of medication that
controls asthma. Step up and down as indicated.
Step-down Therapy
Step down once control is achieved. After 2–3 mo. 25% reduction over 2–3 mo.
Follow-up monitoring Every 1–6 mo. Assess symptoms. Review medication use. Objective monitoring (PEFR or spirometery). Review medication.
Step-up Therapy
Indications: symptoms, need for quick-relief medication, exercise intolerance, decreased lung function.
May need short course of oral steroids. Continue to monitor.
Follow and reassess every 1–6 mo.
Step down when appropriate.
Acute Exacerbations
Principle: Gain control as quickly as possible.
Treat all asthma exacerbations promptly and aggressively.
Inhaled ß2-agonist inhalants for quick relief
Access to quick relief medication Written action plan
Indications
Medications
When to contact physician or emergency medical services Short course of oral corticosteroids
Acute ExacerbationsOffice Management
Assess severity. Symptoms, signs, lung function, pulse oximetry (if
available)
Oxygen recommended Short acting ß2-agonist inhalant every 20–30 min Ipratropium—metered-dose inhaler, inhalation solution Corticosteroid—orally, intravenous if vomiting Intravenous favored if dehydrated Follow-up—hours (phone) to 1–7 d
Step 1Mild Intermittent
No Daily Medication
Step 2 Mild Persistent
Preferred: Low-dose ICS
Step 3Moderate Persistent
Step 4Severe Persistent
Alternative: Cromolynor LTRA
Preferred:Low-dose ICS +
LABA or Medium-dose ICS
(+ LABA if needed)
Alternative: Low- to Med-dose ICS
+ LTRA or Theophylline
High-dose ICS + LABA
(+ systemiccorticosteroids
if needed)
Stepwise Approach to Therapy for Children 5 Years
ICS = inhaled corticosteroid; LABA = long-acting 2-agonist; LTRA = leukotriene receptor antagonist
NIH/NHLBI Guideline Update. June 2002. NIH Publication No. 02-5075.
ICS = inhaled corticosteroid; LABA = long-acting 2-agonist; LTM = leukotriene modifier; SR = sustained release.
Stepwise Approach to Therapy for Adults and Children >5 Years
Alternative:Cromolyn, LTM, Nedocromil, or
SR Theophylline
Step 1Mild Intermittent
No Daily Medication
Step 2 Mild Persistent
Preferred:Low-dose ICS
Step 3Moderate Persistent
Step 4Severe Persistent
High-dose ICS + LABA
(+ systemiccorticosteroids
if needed)
Preferred:
Alternative: ICS With No LABAor Low- to Med-dose
ICS + LTM or Theophylline
Low- to Med-dose ICS + LABA
( to med-dose ICS+ LABA if needed)
NIH/NHLBI Guideline Update. June 2002. NIH Publication No. 02-5075.
Tools to Improve Asthma Documentation & Quality Care
Living with Asthma Questionnaire Asthma Control Test Progress Note Template Asthma Action Plan
More QI information see:
www.eqipp.org
www.improvingchroniccare.org
Medication Adverse Effects
Short & Long-Acting Bronchodilators
Increased heart rate, tremors, headache (last short time)
Cromolyn / Tilade Rare, may have throat irritation
Leukotriene Modifiers GI upset
Inhaled Corticosteroids Thrush, dysphonia, high doses may have systemic effects
Systemic Corticosteroids Many - Increased appetite, stomachache, mood changes, fluid retention, diabetes, osteoporosis
Education for Partnership in Care
Develop a written asthma management planAgree on therapy goals Outline daily treatment and monitoring measuresPrepare an action plan to handle worsening symptoms
Provide routine education on patient self-managementHow and why to take medicationsCorrect technique for devicesPeak flow or symptom monitoringFactors that worsen asthma and actions to take
Objective:
Teach caregivers to administer daily anti-inflammatory control medications as needed and quick relief medicines for patients with persistent asthma
Asthma Can be Managed
With proper therapy, the child can be symptom free
Goal is to use the least amount of medication as possible, increasing on an as-needed basis
Long-term goal of reducing or even stopping regular medications
Emphasis on as little as possible address parents’ fears of over-medication and dependence
What makes Asthma Management so hard for Parents and Children?
Here today, gone tomorrow: periods of symptoms interspersed with symptom-free periods
Daily medicines even when feeling well Unpredictability: don’t know exactly what triggers the episode Complicated medication plan varies with symptom intensity
and disease severity Need to monitor asthma symptoms Fears about medication side-effects Medication only part of the plan, trigger reduction also
needed.
Explaining How to Take Medicines
Clinician Message:
Demonstrate use of inhaler and spacer
Show how to use peak flow meter
Give step-by-step instructions
Parent Message:
Feel comfortable with “technology”
Know how and where to get equipment
What to do if you run out of medicine
Fears About Asthma Medicines
39% Believe medicines are addictive
36% Believe medicines are not safe to take over a long period
58% Believe regular use will reduce effectiveness
Quick Relief Medicines
Act fast, generally within 15-20 minutes Relaxes the smooth muscles around the bronchial tubes Parents need to know how often child is using Must have available at all times Is only medicine that helps child breathe quickly
ASTHMA MEDICATIONS Beta 2 agonists - bronchodilators
Albuterol (Proventil, Ventolin)Pirbuterol (Maxair)Levalbuterol (Xopenex)Terbutaline (Brethine)Metaproterenol (Alupent)
Explain About Quick-Relief Medications
Provider message:–Quick-relief medications relax the muscles after they have tightened during an attack –Parents are in charge of helping their children breathe through the quick-relief medications
–Quick- relief medications act fast, so that breathing is easy again within minutes
Parent Message:
–Know that medicines will open up lungs and child won’t suffocate–Know that reaction is not instant; may take a few minutes–Quick relief medicines are parents’ ticket to helping child breathe
Communication Tip for Quick-Relief Medications
Use a physical example: Unclamp fist to show how medicines work
Ask parent about fears they have regarding child’s asthma episode
Discuss concerns parents may have about medications Jitteriness; anxiety & other side effects parents may fear
(“dependence”) Be accurate about risks but reinforce message that medicines
work!
Explaining about Long-term Control Medications
Provider Message:
–Anti-inflammatory medicines don’t relieve symptoms–Do reduce inflammation and prevent frequent or severe episodes–Needed if symptoms more than 2X/week in day or 2X/month at night–Effective only if taken regularly
Parent Message:
–Anti-inflammatory meds are like a flu shot, to help keep away the “bad” asthma episodes –Anti-inflammatory medicines are like vitamins; they need to be taken all the time, even if not sick
Communication Tips about Long-term Control Medicines
Explain the different types of controllers (parents want to know the names), and why more than one may be used
Convey clearly information about any risks or side effects Discuss fears about medication “dependence”
Low Doses of Inhaled Corticosteroids do not cause side effects
Not the same as the body-building steroids Emphasize safety of the medications when used as
prescribed on the plan.
ASTHMA MEDICATIONS
Long-acting beta 2 agonists
Salmeterol (Serevent)Formoterol (Foradil)
Combine with ICS (ADVAIR available)
Corticosteroids Inhaled (ICS)
Beclomethasone (Vanceril, Beclovent, Q-VAR)Budesonide (Pulmicort)Flunisolide (Aerobid)Fluticasone (Flovent, ADVAIR)Triamcinolone acetonide (Azmacort)
Systemic
Prednisone/PrednisoloneMethylprednisolone (Solu-Medrol, Medrol)
ASTHMA MEDICATIONS
Mast cell stabilizersCromolyn sodium (Intal)Nedocromil (Tilade)
AnticholinergicIpratropium bromide (Atrovent)
MethylxanthinesTheophyllineAminophylline
ASTHMA MEDICATIONS
Leukotriene inhibitors
Oral, QD-BIDMontelukast (Singulair)Zafirlukast (Accolate)Zileuton (Zyflo)Some evidence of effectiveness in preventing premenstrual
asthma exacerbations1 1. J Allergy Clin Immunol 1999;104:585-8.
Teaching Checklist
Use of inhaler/spacer Use of nebulizer Use of Peak Flow Meter Give step by step directions Instruct how/where to get
spacers/nebs/PFM
Instruct what to do if run out of medicine or can’t get devices
Ask parent/child to demonstrate technique at each visit
Reassure parent about using alternative treatments with medications
Spacers/Holding Chambers
Recommended with all medium to high dose ICS Enhance delivery, especially with children Improves coordination and medication delivery
some provide auditory feedback Minimize adverse effects from ICS
decrease oral bioavailabilityreduce oral candidias (thrush)dysphonia, and bad taste
Dry Powder Inhalers (DPI)
Spacers can not be used with DPI Turbuhaler®, Diskus®, Aerolizer™ Must be able to do mouthpiece treatment Deep rapid inhalation
Peak Flow Monitoring
Provides objective information Documents personal best Detects worsening asthma before changes occur Useful only if breathing is monitored regularly Indicates need for quick-relief medications Assists in precipitant identification Aids in communication
Determine Personal Best Peak Flow
Take peak flow reading at least once per day for 2-3 weeks Measure peak flow at these times:
Between noon and 2pm each dayEach time quick-relief meds are taken for symptomsAny other time your doctor suggests
Use same peak flow meter over time Important Component of written action plan
Proper PF Technique
1- Set meter to Zero2- Stand up straight3- Take deep breath in4- Blow out hard & fast5- Repeat two more times6- Record your highest number
Teaching Peak Flow
Instruct in how to establish child’s personal best Demonstrate to child/parent how to set child’s zones (red,
yellow & green) Help parent establish a routine for peak flow measurements Remind parent to adjust medications according to peak flow
number Encourage parent to bring PF diary with to all appointments