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Asthma Management

A Stepwise Approach

Jane Cooper, RN, FNP- BC, CORLN

University of Missouri Health Care

Depart. of Otolaryngology –Head and Neck Surgery

Columbia, Missouri

• Disclosure - None

Objectives

• Review definition and diagnosis of asthma

• Discuss the 4 components of asthma management– Regular monitoring – airflow measurements

– Control of environmental triggers and comorbid conditions

– Medication – Take correctly

– Patient education – partnership

Examine the 2007 NAEEP Guidelines for Stepwise Approach

Review asthma medications

Discuss asthma management in the ENT patient.

Prevalence of Asthma

• “According to CDC and Prevention, an estimated 7.1 million children ( 9.5%)have asthma, making it the most common pediatric chronic illness in America.” 1.

– Leading cause of school absenteeism. Average 30 kids in classroom, 3 will have asthma.

• Number of adults in the U.S. with asthma is 18.9 million or 8.2%. 2.

• WHO estimates 235 million people worldwide suffer from asthma.

1. CDC and Prevention. Healthy Youth: Asthma. http://www.cdc.gov/HealthYouth/asthma. Accessed July 29,2013

2. Http://www.cdc.gov/nchs/fastats/asthma.htm Accessed July 29, 2013.

Increasing Globally

• “Sharp increase in the global prevalence, morbidity, mortality, and economic burden associated with asthma over the last 50 years, mostly in children, as the most common chronic disease.”

• The increase parallels the increase of atopic diseases worldwide. “Probably due to urbanization of communities.”

• Braman,SS. Asthma Guidelines in Day-To-day Practice. Pulmao RJ 2012;21(2):70-75.

Costs

• Treating asthma patients under the age of 18 costs an estimated 3.2 billion per year.

– Asthma causes 12.8 million lost school days in kids

yearly.

• Children from low income families have a higher prevalence of asthma and are 3 times more likely to have acute exacerbations leading to ED visits.

• Adults lose 14.5 million work days yearly due to asthma.

• Centers of Disease Control and Prevention. FastStats: Asthma.

• www.cdc.gov/nchs/faststats/asthma.htm. Accessed August 10, 2013.

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Asthma Guidelines

• The asthma guidelines were first published in 1991 by the National Heart, Lung, and Blood Institute (NHLBI) and National Asthma Education and Prevention Program (NAEPP).– Updated in 1997 , 2002 and 2007.

– The Guidelines provide “medically evidenced best practice methodology for treating asthma.”

Despite guidelines, asthma has continued to be challenging to manage.

There are discrepancies between what providers prescribe and teach and the care patients receive.

Asthma is often under diagnosed and inappropriately treated.

Rance,Karen Understanding and Implementing the New NHLBI Asthma Guidelines. J for Nurse Practitioners. 2008; April 254-261.

2007 Guideline Changes

New Emphasis On…• Monitoring asthma control as goal for therapy. Distinguish

between asthma Severity and monitoring asthma Control.

• Provider should gauge impairment and risk as two components in determining the Level of Asthma Control.

• Multifaceted approaches to Pt education and to control environmental factors and co-morbid conditions that affect asthma. (allergy, reflux etc)

• Changes in managing asthma long term. (Step up and down)– Step down medications after 3 months of stability

• Changes to treatment for managing asthma exacerbations.

Rance, Karen

GINA – Global Initiative for Asthma

• Global strategy to provide a “roadmap for improved allergy care.”

1. Use objective measures, such as spirometry to

diagnose and monitor response to treatment.

2. Provide advice for effective environmental control.

3.Use the step-up approach for pharmacological therapy.

4.Develop a partnership of care with patient or caregiver.

Global Strategy for asthma management and prevention. (GINA) Updated 2012. www.ginasthma.org

Asthma is…

• Chronic inflammatory disorder of the airways

– Episodic and reversible airflow obstruction

– Airway Hyper -Responsiveness

– Subsequent narrowing of small airways

Common Symptoms

Wheezing, Cough, Shortness of breath and

chest discomfort

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http://www.nlm.nih.gov/medlineplus/magazine/issues/fall11/articles/fall11pg4.html

• Etiology of Asthma is not clear.

– Complex disease with many immunological

variables.

– Many different cell types ( dendritic, T cells, TH1

and TH2) and cytokines ( IL-4, IL-13 and IL-5) that

play critical roles in asthma pathogenesis.

Asthma Pathways Diagnosis

• Clinical Evaluation

– Detailed history

– Allergy exposure: Home, school, work

environment

– Smoke and chemical exposure

– Smoking ( active and passive)

– Viral infections

Diagnosis

• Clinical picture - cough, SOB, wheezing etc..

• Spirometry with flow volume loops or PFTs give information on breathing patterns.

• Evidence of obstructive breathing, improved with use of bronchodilator.

+ Bronchodilator response: FEV1 increased by 200 ml + 12%

OR FVC increased by both 200 ml + 12%.

• Exhaled nitric oxide (if high can indicate inflammation)

• Allergy Evaluation- Skin prick test or lab

• Chest X-ray

• Lab – CBC with diff (Eosinophils), IgE, sweat chloride/genetic tests for CF, Vitamin D

Asthma Triggers

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Asthma Triggers

• Food Allergy

Most Allergic Foods

• Milk

• Egg

• Peanut

• Tree Nuts

• Wheat

• Soy

• Shellfish

• Fish

asthmainstitute.pitt.edu

341 × 409 - The University of Pittsburgh Asthma Institute -

• Tobacco smoke

• Smoke from wood stoves

and fireplaces

• Perfume

• Cleaning Products

• Air pollution

• Nail and hair products

Asthma Management

• Regular monitoring of symptoms and lung function

• Control of the environmental triggers and comorbid

conditions that contribute to asthma severity

• Pharmacologic Therapy

• Patient Education - Partnership

Asthma Control Test R

• 5 questions designed to help a patient describe their symptoms and how they are feeling.

1. In the past 4 weeks, how much of the time did your asthma keep

you from getting as much done at home?

All of the time Most of the time Some of the time A little of the time None of the time

1 2 3 4 5

2. During the past 4 weeks, how often have you had shortness of breath?

All of the time Most of the time Some of the time A little of the time None of the time

1 2 3 4 5

Kosinsski, M, Bayliss, MS, Turner-Bowker, DM, Fortin,EW. Asthma Quality Control Test: A Users Guide, Lincoln (RI): QualityMetric, Incorporated, 2004. Copyright @2004 QualityMetric.

Asthma Control Test

• 3. In the past 4 weeks, how often did your asthma symptoms (wheezing, cough, SOB, chest tightness or pain) wake you up at night or earlier than usual in the morning?

– 4 or more 2-3 nights a week once a week Once or twice Not at all

nights a week

1 2 3 4 5

4. In the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (Albuterol, Maxair or Primatene Mist)?

3 or more 1-2 times/day 2-3 times/week 1 time week Not at all

1 2 3 4 5

5. How would you rate your asthma control during the past 4 weeks?

Not Poorly Somewhat Well Completely

controlled controlled controlled controlled controlled

1 2 3 4 5

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Asthma Control Test

• Results:

– 5 to 15 Poorly Controlled

– 15 to 20 Somewhat Controlled

– 20 to 25 Controlled

A tool to help educate patients and parents.

Help raise awareness of how they are doing.

Not a diagnostic tool. Ages 12 to adult.

Monitoring Asthma

• Spirometry – Measures forced vital capacity (FVC) and

forced expiratory volume in one second (FEV1)

Reduced Ratios of (FEV1/FVC ) can help determine restriction

or obstruction.

The 2007 NAEPP (National Asthma Education and Prevention

Program) guidelines recommend using spirometry in practices

that routinely care for asthma patients.

Monitoring Asthma

• Peak expiratory flow rate (PEFR) Ages 5 to adult

– Benefits: Inexpensive ($20), convenient – can be done at

home, useful for detecting changes in asthma control

– Limitations: Measurements are dependent on the

patient’s technique. A reduced peak flow reading does

not always indicate airway obstruction.

The patient establishes a baseline measurement when

feeling well – “personal best”.

Readings below the range may indicate narrowing of the

airway and prompt implementing the “Asthma Action Plan”

Reduce Impairment

• Freedom from symptoms

• Minimal need (< 2x per week) of short acting beta

agonists (SABAs ) to relieve symptoms.

• Optimal lung function

• Maintaining normal ADL. School, work, athletics and

exercise

• Patients and families are satisfied with asthma care

• UptoDate – An Overview of Asthma Management, Author Fanta, Christopher MD Accessed 12/31/12

Asthma Severity

• First step is to classify severity of the asthma

• How is asthma classified?

• Look at 3 factors

– Reported symptoms over the previous 2-4 weeks

– Current level of lung function

– Number of exacerbations requiring the use of oral steroids per year.

– NAEPP: Expert Panel Report III: Guidelines for the diagnosis and management of asthma. (NIH publication no 08-4051). Bethesda, MD: National Heart, Lung, and Blood Institute, 2007.

– www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on July 29, 2013).

Four Categories of Asthma Severity

• Intermittent

• Mild Persistent

• Moderate Persistent

• Severe Persistent

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Intermittent Asthma

• Daytime asthma sxs occur 2 or less days per week

• 2 or less night time awakenings per month

• Use of short-acting beta agonists (SABA) < 2x per

week

• Normal activity between exacerbations

• FEV1 readings are normal (80% or higher of

predicted nomal) between exacerbations.

• Rx - SABA Step 1 for starting treatment

Mild Persistent

• Sxs > 2x per week, but less than daily

• Use of SABA > 2x week, but not daily

• Nocturnal awakenings 3-4 x per month

• Mild interference with activities

• Spirometry within normal range

• Use of oral steroids 2 or more times a year

• Rx – Low dose ICS or montelukast (Singulair), Cromolyn

• Step 2 for starting treatment

Moderate Persistent

• Daily asthma sxs

• Nocturnal awakenings > once a week

• Daily need of SABA

• Decrease in normal activity

• FEV1 - between 60-80% of predicted

• FEV1/FVC – below normal

• Use of oral steroids > 2x year

• Step 3 for starting treatment

Severe Persistent

• Have one or more

– Asthma sxs throughout the day

– Nightly awakenings

– Need for SABA several times daily

– Normal activity is extremely limited

– FEV1 < 60% of predicted

– Step 3 (age 0-4) Step 3 or 4 (5-11) Step 4 or 5 (> 12)

Assessing Control

Well Controlled Not Well Controlled Very Poorly Controlled

Maintain current stepStep up 1 step and

reevaluate in 2-6 weeks

Consider short course of

oral corticosteroids

Consider step down if well

controlled for at least 3

months

For side effects, consider

alternative treatment

Step up 1-2 steps and

reevaluate in 2 weeks

For side effects consider

alternative treatment

options

Classifying Asthma Severity – Ages 12 - Adult

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Assessing Asthma Control - Ages 12 - Adult Managing Asthma ages 12 to Adult

Managing asthma ages 12 to adult

http://pulmonarycriticalcare.med.wayne.edu/asthma-program.php

Short Acting Beta-2 Agonists -SABA

• Potent bronchodilator – Dilates the bronchial smooth muscle.

• Medication of choice for intermittent asthma, exercise induced bronchoconstriction and a

rescue medication.

• Dose: Prevention and treatment: 2 inh every 4-6 hrs, can decrease to 1 inh.

• Prevention of EIB: > 4 yr Give 2 inh 15 minutes before exercise.

• Quick relief of symptoms – Onset 10-15 min

• Adverse Reactions: Nervousness, tremor, HA, cough, tachycardia, GI upset, dizziness,

hyperactivity, throat irritation, insomnia.

• Albuterol – ProAir HFA Proventil HFA, Ventolin HFA

• MDI are 90 mcg. Solution for inh 0.5% 0.083%

VoSpire ER (tablets) 4 mg 8 mg tabs

Dose: Adults: 4 – 8 mg every 12 hours. Max. 32 mg/day

Child: age 6 on up. 4mg every 12 hours, max 24 mg/day

Asthma Exacerbation

• For asthma exacerbations requiring an ER visit

albuterol remains the drug of choice

– If the person has good technique of the MDI,

2 – 6 puffs using a spacer or Aerochamber mask.

Repeat after 20 minutes up to 3 doses then every

one to four hours as needed.

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Giving Asthma Medications to a Child: Some Great Videos | Craig ...

drcraigcanapari.com

allergyasthmatech.com

300 × 290 - Facts About Asthma Prevention - Allergy Asthma Tech

SABA continued• Levalbuterol – Xopenex Solution (nebulizer)

Ages 6-11 yrs. 0.31mg by neb Tid

> 12 yrs. 0.63mg Tid can increase to 1.25 mg

Levalbuterol- Xopenex HFA 45 mcg MDI

Not recommended for children < 4 yrs.

> 4 yrs 2 inh every 4-6 hrs, or 1 inh every 4 hrs

Adverse reactions: Single -isomer of albuterol, similar side effects.

There is no significant difference between albuterol or levalbuterol in efficacy, safety or prevalence of adverse side effects.

Use should be reserved for those with known adverse effects from albuterol.

Uptodate.com/content/beta-agonists-in asthma-acute administration and prophylactic use. Accessed 7/18/13

SABA continued

• Pirbuterol - Maxair Autohaler

– 200mcg per inhalation –breath actuated MDI

– Age 12 to Adult

– Dose is 1-2 inh every 4-6 hours

Max of 12 inh per day

Not studied for use in severe asthma exacerbation

LABA

• Long-acting beta agonists have a long lipophilic side

chain that increases the duration of binding the

drugs to the adrenergic receptor.

• Causes a longer duration of action

• Salmeterol and formoterol

• Used with ICS for those with moderate or severe

asthma not controlled with ICS alone.

• Have an additive effect with ICS when combined

• Not used in monotherapy.

Leukotriene Receptor Antagonist

LTRA

• Leukotrienes (LTC4, LTD4 and LTRA) are strong

bronchoconstrictors and pro-inflammatory agents.

• Found in nasal secretions, sputum and bronchoalveolar lavage

fluid in asthma patients

• Can be used in addition to ICS for daily

treatment of persistent asthma in kids > 1 yr.

Or in mild persistent asthma – as “step down”

therapy from ICS.

Montelukast - Singulair

• Approved for ages > 1 yr for asthma and 6 months or greater for rhinitis.

– Dosages: 4 mg granules or chewable tab ages 1-5

– 5 mg chewable tab ages 6-14

10 mg 15 and older

Adverse Effects:

URI, fever, cough, headache,

pharyngitis, abdominal pain,

diarrhea

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What does the evidence show?

• Compared to placebo:

• A randomized DB study for children ages 2-5 years with intermittent asthma triggered by viral infections.

• 270 children in each group and given placebo or montelukast for one year.

Results: Those on montelukast had 32% less asthma exacerbations (from 2.3 to1.6) and decreased used of ICS.

Compared to ICS:

Many studies for adults and children have shown ICS to be more effective than LTRAs in treating asthma for most patients.

Two comparison studies of fluticasone and montelukast in children aged 6-14, reported fewer asthma attacks, increased pulmonary measures, and less nighttime symptoms with those using fluticasone only.

www.uptodate.com/contents/chronic-asthma-in children - accessed July, 2013.

LTRA

• Intermittent Use

– More information needed to confirm if taking montelukast at the

onset of increased asthma or URI symptoms can be encouraged for

children with intermittent asthma.

– Summary:

Consider using montelukast in addition to a ICS for persistent

asthma. Or when “stepping down” from ICS in mild persistent asthma.

Inhaled Corticosteroids - ICS

• For long term asthma control

• If night awakenings are > 1x week

• Use of oral steroids > 2x a year

• Limitations of normal activity

• Addition of ICS prevents loss of lung function

– Increase quality of life

– Decreases risk of severe exacerbations

ICS

• Adverse Reactions- Most Common

– Headache

– Rhinitis

– URI

– Pharyngitis

– Oral symptoms with MDI

– Increased asthma symptoms

In young children –average 1.1cm reduction in rate of growth in first year

of Rx. A temporary, not a progressive slowing.

PEAK STUDY (Prevention of Early Asthma in Kids) monitored 285 kids over

2-3 years.

ICS

• Pulmicort – budesonide

– Flexhaler (dry pwd) inhaler

– Respules ( susp)

QVAR – beclomethasone MDI

ICS

• Alvesco – ciclesonide (MDA) age 12 >

• Asmanex – mometasone (dry pwd) age 4 >

• Flovent – fluticasone ( MDI, dry pwd diskus)

age 4>

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Combined ICS + LABA

• Fluticasone/salmeterol Advair age 4 >

DPI 100 mcg/ 50 mcg

250 mcg/ 50 mcg

500 mcg/ 50 mcg

45 mcg-21mcg

MDI 115 mcg-21mcg

230 mcg-21mcg

• Mometasone /formoterol Dulera Adults

MDI 100 mcg/5 mcg

200 mcg/5mcg

• Budesonide/formoterol Symbicort Adults

• MDI 80 mcg/4.5 mcg

160 mcg/4.5 mcg

ICS + LABA

• Use when asthma symptoms not adequately

controlled on a medium or higher dose

of asthma-controller medications.

Likely Moderate persistent asthma

Step 3 on the Asthma Rx Guidelines

Anti-IgE Therapy

• Omalizumab – Xolair

– Approved for ages 12 and up in the U.S.

• In other countries used down to age of 6.

– Used to treat moderate to severe asthma that is not well controlled with standard medications.

• IgE level of 30 to 700 IU/ml, + allergen skin test or IgE to a perennial allergen.

• Dose is given SQ every 2-4 weeks.

• Response rate is 30 – 50%

• Minimum of a 12 week Rx is needed to reach efficacy.

Before Adding More Meds: ICE

Inhaler technique – Check patient's technique. Compliance – Ask when and how much medication the patient is

taking. Environment – Ask patient if something in his or her environment has

changed. Is there environmental tobacco smoke in the home? Find out about

cotinine levels, which can help track exposure to tobacco smoke and its toxic constituents using a saliva, blood or urine test.

You may also want to consider an alternative diagnosis. Assess patient for presence of other upper respiratory disease.

Adapted from the Practical Guide for the Diagnosis and Management of Asthma, NIH Publication, August 2007, National Institutes of Health, National

Heart, Lung and Blood Institute

Cost Comparison of Asthma

Medications• Article: Cost Effective Asthma Treatments for Uninsured or

Underinsured Pediatric Patients by

Karlen E. Luthy, DNP, FNP, Emilianne Dougall, MS, FNP and Renea L Beckstrand, PhD, CCRNJournal of Nurse Practitioners, Vol 8, Issue 8, Sept 2012.

Identified studies related to the treatment of pediatric patients with asthma.

Used an online pharmacy, drugstore.com to collect cost-related information.

Step 1 Recommendation: Albuterol most cost effective for HFA and soln

Step 2 Recommendation: Low –dose beclomethasone (Qvar)

Step 3 Recommendation: Medium-dose beclomethasone + SABA

Patient Education

• Foster a partnership with patient and family.

– Discuss goals of asthma care

– Self management education

– Review actions of medications and potential side

effects

– Written Asthma action plan – for daily use and for

exacerbation. Know when to use oral steroids,

when to call Provider and when to seek

emergency care.

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Asthma ReadyTM Communities

• A Missouri program developed by Ben Francisco, PhD, PNP, AC-E aimed at improving asthma care by educating teachers, school nurses and other pediatric health care professionals.

• He’s spent over 14 years of studying and proving the effectiveness of different types of education on the treatment of kids with asthma.

– Uses live instruction and web-based lessons to train Missouri’s professionals. So far, over 900 persons have been educated.

His Four main messages about Asthma Education

– Daily medication can stop asthma.

– They work only if taken correctly.

– Airflow measures are critical to know if a child’s asthma is under control

– Environmental factors, such as high allergen areas, are a critical factor that will influence how well a child’s asthma is controlled.

Asthma Patient – Case Study

ENT Considerations

Ask about asthma symptoms and level of control

Ask about triggers and exposure at home, work and

school

Test and treat for allergies. Consider reflux

Do Spirometry if you treat for allergy.

Print out the Asthma guidelines – keep handy

Know when to refer to Pulmonary or asthma

specialist

References

• Center of Disease Control and Prevention. FastStats: Asthma.

www.cdc.gov/nchs/faststats/asthma.htm. Accessed 7/28/13

• CDC and Prevention, Healthy Youth: Asthma . http://www.cdc.gov/healthy youth/asthma.

Accessed July 29, 2013.

• American Academy of Allergy, Asthma and Immunology. Asthma

http://www.aaaai.org/conditions-and-treatments/asthma.aspx. accessed July 29, 2013.

• National Heart, Lung and Blood Institute. Expert Panel report (EBR3) Guidelines for the

diagnosis and management of asthma:Section 4, managing asthma longterm in children 0-4

yrs of age and age 5-11. http://www.nhlbi.nih.gov/guidelines/asthma/08_sec4_Accessed

7/18/2013.

• National Heart,Lung and Blood Institute. Expert panel report (EPR3): Guidelines for the

diagnosis and management of ashtma:sec.3, component 4:medications. http//www.

Nhlbi.nih.gov/guidelines/asthma/07_sec3_comp4.pdf. Accessed 7/18/2013.

• Global Strategy for asthma management and prevention (GINA) updated 2012.

www.ginasthma.org/uploads/users files. 7/18/2013.

• BramanSS Asthma Guidelines in Day-to-day Practice Pulmao RJ 2012;21(2):70-75.

References

• Rance K. Understanding and Implementing the New NHLBI Asthma Guidelines. J

Nurs Pract. 2008 : Apr 254-261.

• Luthy KE, Dougall, E, Beckstrand,R. Cost –Effective Asthma Treatments for

Uninsured or Underinsured Pediatric Patients. J Nurse Prac 2012:8(8 636-642.

• Up to Date www.uptodate.com/contents/chronic -asthma-in-children-younger-

than 12 years and An overview of asthma management .Accessed 12/31/12.

• Up to Date www.uptodate.com/contents/beta-agonists-in-asthma-acute

administration and prophylactic use. Accessed 7/18/13

• Up to Date www.uptodate.con/contents/treatment of moderate persistent asthma

in adolescents and adults and treatment of severe asthma in adolescents and

adults. Accessed 8/29/13.

• Asthma Education for missouri. http://www.muhealth.org Accessed 2/14/13.

• Rank,M et al. Factors associated with decisions to step down asthma medications.

J of Allergy and Clinical Immunology. May 2013 Vol.1, Issue 3 pages 312-314.

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