Asthma Case Studies & Asthma Case Studies & GIST ToolsGIST Tools

Karen Meyerson, MSN, RN, FNPKaren Meyerson, MSN, RN, FNP--C, AEC, AE--CCFebruary 6, 2013February 6, 2013

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TylerTyler Tyler is a twoTyler is a two--yearyear--old boy with a old boy with a

history of wheezing, frequent cough, history of wheezing, frequent cough, and three emergency room visits for and three emergency room visits for asthma last winter.asthma last winter.

At the first two emergency room visits, At the first two emergency room visits, Tyler was treated with antibiotics.Tyler was treated with antibiotics.

At the last visit, he also was treated At the last visit, he also was treated with with albuterolalbuterol syrup.syrup.

He was hospitalized in March with He was hospitalized in March with bronchiolitisbronchiolitis which was culturewhich was culture--positive for infection with RSV positive for infection with RSV (respiratory (respiratory syncytialsyncytial virus). virus).

TylerTyler At discharge, Tyler's mother was provided with a At discharge, Tyler's mother was provided with a

nebulizer and instructed to give him inhaled nebulizer and instructed to give him inhaled albuterolalbuterol as needed, which he has needed daily in as needed, which he has needed daily in winter months.winter months.

There were no further serious episodes after that There were no further serious episodes after that hospitalization. hospitalization.

This winter, Tyler has begun coughing again.This winter, Tyler has begun coughing again.

TylerTyler’’s mother has a history of asthma.s mother has a history of asthma.

He and his mother are now at their doctor's office He and his mother are now at their doctor's office to see whether the same type of symptoms and to see whether the same type of symptoms and episodes can be avoided this winter. episodes can be avoided this winter.

TylerTyler In children of this age, it may be difficult to In children of this age, it may be difficult to

diagnose viraldiagnose viral--induced wheezing.induced wheezing.

UnderUnder--diagnosis of asthma is a common problem diagnosis of asthma is a common problem in children who wheeze only when they have a in children who wheeze only when they have a respiratory infection. respiratory infection.

Often these children are misdiagnosed as having Often these children are misdiagnosed as having pneumonia, bronchitis, or pneumonia, bronchitis, or bronchiolitisbronchiolitis and receive and receive antibiotics, but this is not the appropriate antibiotics, but this is not the appropriate treatment.treatment.

TylerTyler The procedure for establishing a diagnosis of asthma includes The procedure for establishing a diagnosis of asthma includes

obtaining a thorough history to document episodic symptoms of obtaining a thorough history to document episodic symptoms of airflow obstruction. This is accomplished by assessing:airflow obstruction. This is accomplished by assessing:

–– Type(sType(s) of symptoms (cough, wheezing or a mixture of both); ) of symptoms (cough, wheezing or a mixture of both);

–– Time of day that symptoms occur; Time of day that symptoms occur;

–– Situations (exercise, stress) or other exposures (tobacco Situations (exercise, stress) or other exposures (tobacco smoke, elevated pollen levels) that precipitate or exacerbate smoke, elevated pollen levels) that precipitate or exacerbate symptoms; symptoms;

Other risk factors that may help establish a diagnosis of asthmaOther risk factors that may help establish a diagnosis of asthmainclude a family history of allergy, asthma, include a family history of allergy, asthma, atopyatopy, sinusitis, , sinusitis, rhinitis or other respiratory problems.rhinitis or other respiratory problems.

Think: Think: Asthma Predictive Index (API)Asthma Predictive Index (API)

Asthma Predictive Index (API)Asthma Predictive Index (API)

High risk children (under age 3) who: High risk children (under age 3) who: –– have had have had >> 4 wheezing episodes in the past year 4 wheezing episodes in the past year

that lasted more than one day that lasted more than one day andand affected sleep affected sleep are significantly are significantly moremore likely to have persistent likely to have persistent asthma after the age of 5 if they have either (1) of asthma after the age of 5 if they have either (1) of the following: the following:

CastroCastro--Rodriguez J et al. Rodriguez J et al. AJRCCM AJRCCM 2000; 162:14032000; 162:1403--1406.1406.

One major criteriaOne major criteria•• Parent with asthma (Tyler)Parent with asthma (Tyler)

•• Physician diagnosis of Physician diagnosis of atopic dermatitisatopic dermatitis

•• Evidence of sensitization to Evidence of sensitization to aeroallergensaeroallergens

Two minor criteriaTwo minor criteria•• Evidence of sensitization to Evidence of sensitization to

foodsfoods

•• >>4 percent blood 4 percent blood eosinophiliaeosinophilia

•• Wheezing apart from coldsWheezing apart from colds

OROR

TylerTyler Most asthma clinicians believe that a stepMost asthma clinicians believe that a step--wise wise

approach to treatment is the most effective. approach to treatment is the most effective.

The NHLBI guidelines recommend that patients <5 The NHLBI guidelines recommend that patients <5 y/oy/o with persistent asthma be treated with an inhaled with persistent asthma be treated with an inhaled antianti--inflammatory medication routinely/daily and also inflammatory medication routinely/daily and also receive a shortreceive a short--acting Betaacting Beta--agonist (SABA) on an as agonist (SABA) on an as needed basis. needed basis.

Inhaled corticosteroids (ICS) are the first line of Inhaled corticosteroids (ICS) are the first line of treatment for persistent asthma for ALL ages. treatment for persistent asthma for ALL ages.

Every child with asthma should have a prescription Every child with asthma should have a prescription for a shortfor a short--acting betaacting beta-- agonist for use as needed. agonist for use as needed.

TylerTyler

Tyler's family and other care providers should be Tyler's family and other care providers should be told that if Tyler requires told that if Tyler requires albuterolalbuterol routinely (>2 routinely (>2 x/week), this is an indication that his asthma is not x/week), this is an indication that his asthma is not in good control and his therapy may need to be in good control and his therapy may need to be changed.changed.

Everyone who cares for Tyler needs to receive Everyone who cares for Tyler needs to receive instructions, including demonstration and return instructions, including demonstration and return demonstration, addressing how, when and which demonstration, addressing how, when and which medicines are to be provided to him. medicines are to be provided to him.

Develop an asthma action plan for Tyler.Develop an asthma action plan for Tyler.

NAEPP Guidelines: every patient with persistent NAEPP Guidelines: every patient with persistent asthma should have a written home asthma should have a written home management planmanagement plan EPR-3, p115-123

Questions Questions -- TylerTylerWhat are the longWhat are the long--term effects of daily term effects of daily

medication on growth and puberty?medication on growth and puberty?

The longThe long--term effects of daily medication on term effects of daily medication on growth and puberty are still being studied, growth and puberty are still being studied, but we know that underbut we know that under--treatment or poorly treatment or poorly controlled asthma itself may suppress controlled asthma itself may suppress growth.growth.

Treatment with corticosteroids both oral and Treatment with corticosteroids both oral and inhaled have been shown to impact growth. inhaled have been shown to impact growth.

Questions Questions -- TylerTyler The goals of asthma therapy are to have patients The goals of asthma therapy are to have patients

on the lowest possible dose of the least number of on the lowest possible dose of the least number of medications.medications.

Controlling asthma is the primary goal.Controlling asthma is the primary goal.

Most asthma experts believe if treatment is Most asthma experts believe if treatment is initiated early and at the appropriate doses, growth initiated early and at the appropriate doses, growth and puberty will not be permanently or significantly and puberty will not be permanently or significantly impacted.impacted.

The potential small risk of adverse effects on linear The potential small risk of adverse effects on linear growth from the use of ICS are wellgrowth from the use of ICS are well--balanced by balanced by their efficacy. their efficacy.

Questions Questions -- TylerTylerWill he "outgrow" his asthma? What does that really Will he "outgrow" his asthma? What does that really

mean? mean?

Asthma by definition is a chronic inflammatory Asthma by definition is a chronic inflammatory disease. People with asthma have "twitchy," disease. People with asthma have "twitchy," hypersensitive airways.hypersensitive airways.

Because Tyler's primary trigger appears to be viral Because Tyler's primary trigger appears to be viral infection he could potentially "outgrow" his infection he could potentially "outgrow" his asthma. This is less likely with a + family history.asthma. This is less likely with a + family history.

This would mean that as TylerThis would mean that as Tyler’’s sensitivity to viral s sensitivity to viral infection decreases as he gets older, he might not infection decreases as he gets older, he might not exhibit any asthma symptoms. exhibit any asthma symptoms.

TylerTyler If Tyler does not acquire other risk factors, such as If Tyler does not acquire other risk factors, such as

allergies which cause his airways to react, he may allergies which cause his airways to react, he may be symptombe symptom--free for years and appear to have free for years and appear to have outgrown his asthma.outgrown his asthma.

Tyler may never have another asthma episode for Tyler may never have another asthma episode for the rest of his life, but because his airways are still the rest of his life, but because his airways are still sensitive, his asthma may present itself again sensitive, his asthma may present itself again when Tyler becomes an adolescent or adult.when Tyler becomes an adolescent or adult.

The strongest The strongest predictorpredictor for wheezing that for wheezing that develops into asthma is ATOPY (genetic develops into asthma is ATOPY (genetic predisposition toward allergic response). Again, predisposition toward allergic response). Again, remember that his mother has asthma (+ API)remember that his mother has asthma (+ API)

Questions Questions -- TylerTyler

What could have been done differently to prevent the What could have been done differently to prevent the emergency room visits and hospitalization? emergency room visits and hospitalization?

Asthma is often misdiagnosed as pneumonia and Asthma is often misdiagnosed as pneumonia and clinicians are often reluctant to "label" a child with clinicians are often reluctant to "label" a child with asthma until they have experienced 2asthma until they have experienced 2--3 "wheezing 3 "wheezing type" episodes.type" episodes.

This is problematic when the correct therapy is not This is problematic when the correct therapy is not initiated. initiated.

TylerTyler

In this case, Tyler may have had a viral In this case, Tyler may have had a viral infection, that did not respond to antibiotics, infection, that did not respond to antibiotics, which precipitated his early ER visits.which precipitated his early ER visits.

If this was the case, then treating Tyler with If this was the case, then treating Tyler with inhaled inhaled albuterolalbuterol and an antiand an anti--inflammatory inflammatory such as oral steroid (such as oral steroid (PrelonePrelone, , OrapredOrapred, etc.), , etc.), for quick stabilization of his symptoms may for quick stabilization of his symptoms may have decreased or eliminated the need for have decreased or eliminated the need for ER care. ER care.

KeishaKeisha

Keisha is a 15Keisha is a 15--yearyear--old high school sophomore.old high school sophomore.

Keisha was well, with the "usual colds," until the age Keisha was well, with the "usual colds," until the age of six. She then began having a large number of of six. She then began having a large number of lower respiratory illnesses.lower respiratory illnesses.

Though she improved during the spring and summer, Though she improved during the spring and summer, she developed sneezing, coughing, along with chest she developed sneezing, coughing, along with chest tightness, shortness of breath with exercise, and tightness, shortness of breath with exercise, and wheezing 4 to 5 days a week in the early fall.wheezing 4 to 5 days a week in the early fall.

These symptoms persisted through the winter These symptoms persisted through the winter months. months.

KeishaKeisha Keisha uses an Keisha uses an albuterolalbuterol inhaler at least twice a day inhaler at least twice a day

when she "needs" it.when she "needs" it. She has an inhaler that she was supposed to use She has an inhaler that she was supposed to use

twice a day (prescribed by her previous doctor), but twice a day (prescribed by her previous doctor), but she "forgets" to use it.she "forgets" to use it.

Keisha tells you that her Keisha tells you that her albuterolalbuterol inhaler "works" and inhaler "works" and the other didn't when she used it.the other didn't when she used it.

She used to participate in sports at school, but quit She used to participate in sports at school, but quit because she "got too tired."because she "got too tired."

Keisha admits that she is awakened by coughing two Keisha admits that she is awakened by coughing two nights a week and more often if her family uses their nights a week and more often if her family uses their fireplace.fireplace.

KeishaKeisha In addition, she coughs when she visits her girlfriend's In addition, she coughs when she visits her girlfriend's

house where there is a cat.house where there is a cat. ACT score is 17. KeishaACT score is 17. Keisha’’s asthma is s asthma is ““Not Well Not Well

Controlled.Controlled.”” Both her daytime symptoms and nighttime symptoms, Both her daytime symptoms and nighttime symptoms,

as well as ACT score, fall into that category.as well as ACT score, fall into that category. She, like all patients with asthma, should be assigned She, like all patients with asthma, should be assigned

to the category that demonstrates the most severe to the category that demonstrates the most severe findings.findings.

Her asthma is triggered by seasonal allergen Her asthma is triggered by seasonal allergen exposure and possibly by other perennial allergens, exposure and possibly by other perennial allergens, which need to be more precisely identified.which need to be more precisely identified.

KeishaKeisha She is nonShe is non--adherent, possibly related to her age, adherent, possibly related to her age,

and she has a poor understanding of asthma and its and she has a poor understanding of asthma and its management.management.

NonNon--allergic triggers also appear to be present, such allergic triggers also appear to be present, such as smoke exposure.as smoke exposure.

Based upon the NHLBI guidelines, consider referral Based upon the NHLBI guidelines, consider referral for consultation to an allergy/asthma specialist, for consultation to an allergy/asthma specialist, which can help improve care through appropriate which can help improve care through appropriate testing to identify allergens and other environmental testing to identify allergens and other environmental factors that worsen Keisha's asthma.factors that worsen Keisha's asthma.

The specialist can also help in the overall education The specialist can also help in the overall education of the patient.of the patient.

Questions Questions -- KeishaKeisha

Persistent Asthma in a NonPersistent Asthma in a Non--Adherent Teenager: Adherent Teenager: What Works?What Works?

Keisha requires longKeisha requires long--term control medication.term control medication. The most effective longThe most effective long--term control term control

medications for asthma are those that reduce medications for asthma are those that reduce airway inflammation.airway inflammation. Inhaled steroids are the most potent antiInhaled steroids are the most potent anti--

inflammatory medications currently available.inflammatory medications currently available.

KeishaKeisha Before starting any treatment, identify KeishaBefore starting any treatment, identify Keisha’’s s

concerns and fears about asthma.concerns and fears about asthma.

Mutually establish asthma goals Mutually establish asthma goals –– what is it that what is it that Keisha wants to do, but canKeisha wants to do, but can’’t because of her t because of her asthma?asthma?

Develop an asthma action plan with Keisha so she Develop an asthma action plan with Keisha so she understands what to do if problems arise.understands what to do if problems arise.

At each visit, teach appropriate use of her inhalers At each visit, teach appropriate use of her inhalers and have her demonstrate inhaler skills.and have her demonstrate inhaler skills.

The more the knowledgeable Keisha becomes The more the knowledgeable Keisha becomes about her disease, the more she will gain effective about her disease, the more she will gain effective control.control.

Questions Questions -- KeishaKeishaWhy does exercise cause asthma?Why does exercise cause asthma?

Exercise doesn't "cause" asthma, but 80Exercise doesn't "cause" asthma, but 80--90% of 90% of individuals with asthma will have individuals with asthma will have bronchospasmbronchospasm(airway narrowing) that is triggered by exercise.(airway narrowing) that is triggered by exercise.

It is believed that hyperventilation associated with It is believed that hyperventilation associated with exercise cools and dries the upper and lower airway exercise cools and dries the upper and lower airway resulting in the release of histamine and other resulting in the release of histamine and other substances that produce the substances that produce the bronchospasmbronchospasm..

Hyperventilation of cold dry air produces a similar Hyperventilation of cold dry air produces a similar response.response.

Thus, individuals with asthma generally are more likely Thus, individuals with asthma generally are more likely to have symptoms if they exercise in a cold dry to have symptoms if they exercise in a cold dry climate.climate.

KeishaKeisha Also, as patients with asthma improve their physical Also, as patients with asthma improve their physical

conditioning, they can tolerate greater levels of exercise conditioning, they can tolerate greater levels of exercise and hyperventilation with less risk of and hyperventilation with less risk of bronchospasmbronchospasm..

Patients should not limit their exercise due to asthma.Patients should not limit their exercise due to asthma.

Instead, they should preInstead, they should pre--treat with a shorttreat with a short--acting acting bronchodilator, such as bronchodilator, such as albuterolalbuterol, prior to an exercise that , prior to an exercise that otherwise would produce otherwise would produce bronchospasmbronchospasm..

This should block exerciseThis should block exercise--induced induced bronchospasmbronchospasm in the in the majority of patients.majority of patients.

Loss of exercise tolerance is also a sign of uncontrolled Loss of exercise tolerance is also a sign of uncontrolled asthma and may require a daily longasthma and may require a daily long--term control term control medicine.medicine.

Questions Questions -- KeishaKeishaAm I going to grow hair or get pimples or get fat from Am I going to grow hair or get pimples or get fat from

my asthma medicine? my asthma medicine?

These are side effects of systemic or oral These are side effects of systemic or oral corticosteroids, like prednisone.corticosteroids, like prednisone.

These adverse effects can also occur with inhaled These adverse effects can also occur with inhaled corticosteroids, if taken in excessively high doses, corticosteroids, if taken in excessively high doses, but they are unlikely in the low to medium doses but they are unlikely in the low to medium doses required for moderate asthma.required for moderate asthma.

Anabolic steroids (male sex hormones, like Anabolic steroids (male sex hormones, like testosterone) used for muscle building are the type testosterone) used for muscle building are the type of steroids most associated with these side effects. of steroids most associated with these side effects.

Questions Questions -- KeishaKeisha

Is asthma or the medicine going to affect my Is asthma or the medicine going to affect my menses?menses?

The corticosteroids used for treatment of asthma The corticosteroids used for treatment of asthma are not the same type of steroids that are in sex are not the same type of steroids that are in sex hormones, birth control pills, or steroids that hormones, birth control pills, or steroids that athletes use to increase muscle strength.athletes use to increase muscle strength.

Thus, they will not affect menses. Thus, they will not affect menses.

Questions Questions -- KeishaKeishaWill I have to take this medication for the rest of my life? Will I have to take this medication for the rest of my life?

Will I get addicted?Will I get addicted?

Asthma is a disease that comes and goes, but it Asthma is a disease that comes and goes, but it cannot be cured.cannot be cured.

By treating asthma aggressively with antiBy treating asthma aggressively with anti--inflammatory inflammatory therapy, it may be prevented from getting worse.therapy, it may be prevented from getting worse.

Current recommendations are that therapy should be Current recommendations are that therapy should be reduced once symptoms come under control, so we reduced once symptoms come under control, so we will continually attempt to lower your dose and will continually attempt to lower your dose and possibly even stop your medications once control is possibly even stop your medications once control is achieved.achieved.

KeishaKeisha

Many patients' asthma improves as they get older, Many patients' asthma improves as they get older, so in general, your symptoms should improve over so in general, your symptoms should improve over time.time.

Asthma medications are not addicting and taking Asthma medications are not addicting and taking them does not make your asthma worse or more them does not make your asthma worse or more dependent on taking medication.dependent on taking medication.

Once the medications reduce the inflammation in Once the medications reduce the inflammation in your airways, you will likely need less medication. your airways, you will likely need less medication.

Questions Questions -- KeishaKeishaI've heard that steroids are bad for me.I've heard that steroids are bad for me.

Any drugs are bad for you if taken in excessive doses, Any drugs are bad for you if taken in excessive doses, however, the steroids you may be referring to are however, the steroids you may be referring to are systemic corticosteroids or steroids used for muscle systemic corticosteroids or steroids used for muscle building.building.

The inhaled corticosteroids avoid systemic effects by The inhaled corticosteroids avoid systemic effects by directing the antidirecting the anti--inflammatory effect to the lungs.inflammatory effect to the lungs.

Once absorbed from the lungs, they are quickly broken Once absorbed from the lungs, they are quickly broken down and inactivated. If taken in very large doses, they down and inactivated. If taken in very large doses, they can produce bad effects.can produce bad effects.

Using a spacer device will decrease the amount of drug Using a spacer device will decrease the amount of drug that is swallowed with each dose and also reduce that is swallowed with each dose and also reduce systemic activity. systemic activity.

Steroid Dose ComparisonSteroid Dose Comparison Inhaled SteroidInhaled Steroid vs.vs. Systemic SteroidSystemic Steroid

(oral or IV)(oral or IV)

MicrogramsMicrograms vs.vs. milligramsmilligrams

1000 micrograms1000 micrograms = = 1 milligram1 milligram

A usual prednisone A usual prednisone ““burstburst”” is 40mg a day for 5 days for a total of is 40mg a day for 5 days for a total of 200mg or 200,000mcg.200mg or 200,000mcg. By way of comparison, each dose of By way of comparison, each dose of AdvairAdvair100/50 contains 100mcg of 100/50 contains 100mcg of fluticasonefluticasone, the steroid., the steroid. If you took If you took AdvairAdvair100/50 twice a day (200 mcg), the usual dose, it would take you 100/50 twice a day (200 mcg), the usual dose, it would take you 1000 1000 days (2.7 years) of regular use to equal the amount of steroids days (2.7 years) of regular use to equal the amount of steroids in one in one

burst of prednisone on a mcgburst of prednisone on a mcg--perper--mcg basis.mcg basis.

SharonSharon Sharon is a 51Sharon is a 51--yearyear--old female with 4old female with 4--5 year 5 year

history of cough which is worse in the fall, at history of cough which is worse in the fall, at night, and in the early morning, with exercise, night, and in the early morning, with exercise, exposure to cold air, and with upper respiratory exposure to cold air, and with upper respiratory viral illness.viral illness.

The cough has occurred daily for the past three The cough has occurred daily for the past three years.years.

Since childhood, Sharon has experienced Since childhood, Sharon has experienced sneezing, sneezing, rhinorrhearhinorrhea, and nasal congestion in , and nasal congestion in the springtime.the springtime.

Her rhinitis became perennial in nature three Her rhinitis became perennial in nature three years ago when she was given a cat which years ago when she was given a cat which sleeps on her bed.sleeps on her bed.

SharonSharon She denies wheezing, but has had persistent She denies wheezing, but has had persistent

chest tightness on a daily basis for two years.chest tightness on a daily basis for two years.

She has never smoked, but her husband smokes She has never smoked, but her husband smokes cigarettes.cigarettes.

The history of nighttime cough, early morning The history of nighttime cough, early morning cough, cough with exercise and exposure to cold cough, cough with exercise and exposure to cold air, and prolonged cough with viral illness all point air, and prolonged cough with viral illness all point to a diagnosis of asthma.to a diagnosis of asthma.

On physical exam, the "allergic shiners" and the On physical exam, the "allergic shiners" and the typical pale edematous nasal tissue with clear typical pale edematous nasal tissue with clear discharge confirm the diagnosis of allergic discharge confirm the diagnosis of allergic rhinitis. rhinitis.

SharonSharon SharonSharon’’s asthma should be treated with inhaled s asthma should be treated with inhaled

corticosteroids (or ICS/LABA combination) for her corticosteroids (or ICS/LABA combination) for her lower airway symptoms, and she should be given a lower airway symptoms, and she should be given a shortshort--acting inhaled betaacting inhaled beta--agonist (SABA) to use agonist (SABA) to use PRN and 15PRN and 15--30 minutes prior to exercise.30 minutes prior to exercise.

Her nasal allergy symptoms should be treated with Her nasal allergy symptoms should be treated with a inhaled nasal corticosteroid (INCS) and a nona inhaled nasal corticosteroid (INCS) and a non--sedating antihistamine, which would eliminate sedating antihistamine, which would eliminate many of her symptoms, including sneezing, and many of her symptoms, including sneezing, and itchy and runny nose (itchy and runny nose (Think: United Airway Think: United Airway DiseaseDisease).).

SharonSharon Sharon should be tested (skin or in vitro) to Sharon should be tested (skin or in vitro) to

determine whether she is allergic to her cat.determine whether she is allergic to her cat.

If she is, then the most important part of her If she is, then the most important part of her intervention would be to convince her to at least intervention would be to convince her to at least keep the cat out of her bedroom, perform strict keep the cat out of her bedroom, perform strict dust mite control and consider the use of a HEPA dust mite control and consider the use of a HEPA filter in her bedroom.filter in her bedroom.

The dust control should include encasing the The dust control should include encasing the mattress and pillows in dustmattress and pillows in dust--proof covers.proof covers.

SharonSharon

Cigarette smoking cessation by her husband Cigarette smoking cessation by her husband should be instituted immediately. If not possible, should be instituted immediately. If not possible, he should smoke ONLY outdoors and NEVER in he should smoke ONLY outdoors and NEVER in the car.the car.

A short course of oral corticosteroids (OCS) A short course of oral corticosteroids (OCS) initially would also help control her symptoms until initially would also help control her symptoms until the inhaled corticosteroid and environmental the inhaled corticosteroid and environmental controls lead to the decrease or elimination of controls lead to the decrease or elimination of symptoms. symptoms.

Questions Questions -- SharonSharonWhat is the longWhat is the long--term outlook?term outlook?

Most likely she will continue to have allergy and Most likely she will continue to have allergy and asthma symptoms unless environmental controls asthma symptoms unless environmental controls and medications are instituted.and medications are instituted.

The concept of airway remodeling needs to be The concept of airway remodeling needs to be discussed with her.discussed with her.

She would actually be a candidate for She would actually be a candidate for immunotherapy, which may enhance the longimmunotherapy, which may enhance the long--term term outlook. outlook.

Questions Questions -- SharonSharonAre the inhaled corticosteroids safe to take for a long Are the inhaled corticosteroids safe to take for a long

time?time?

At this age, the data are not very clear. However, the At this age, the data are not very clear. However, the concern for the preconcern for the pre-- and postand post--menopausal female is menopausal female is the effect of inhaled corticosteroids on the the effect of inhaled corticosteroids on the development of osteoporosis.development of osteoporosis.

The recommendation would be to use the lowest The recommendation would be to use the lowest possible dose that adequately controls her disease.possible dose that adequately controls her disease.

The doses that are used, especially when one uses an The doses that are used, especially when one uses an MDI inhaled steroid with a spacer, would probably not MDI inhaled steroid with a spacer, would probably not lead to any increased incidence of eye problems or lead to any increased incidence of eye problems or bone problems.bone problems.

Questions Questions -- SharonSharon

Why is asthma worse at night?Why is asthma worse at night?

We really don't know. There are a lot of theories We really don't know. There are a lot of theories involving indoor allergens and silent involving indoor allergens and silent gastroesophagealgastroesophageal reflux, but most likely it is a reflux, but most likely it is a biorhythm, possibly related to the body's secretion biorhythm, possibly related to the body's secretion of corticosteroids.of corticosteroids.

Possibly also related to asthma medications Possibly also related to asthma medications wearing off, body positioning, airway cooling, etc.wearing off, body positioning, airway cooling, etc.

Questions Questions -- SharonSharon

How can the cat make me worse, even though I do How can the cat make me worse, even though I do not have symptoms around the cat?not have symptoms around the cat?

If you prove to be sensitive to the cat, the cat If you prove to be sensitive to the cat, the cat allergen functions as a primer to enhance allergen functions as a primer to enhance symptoms to other allergens, added to the pool of symptoms to other allergens, added to the pool of triggers, and although silent, make one more triggers, and although silent, make one more sensitive to other triggers such as dust mite and sensitive to other triggers such as dust mite and pollen allergy. pollen allergy.

LuisLuis Luis is a 42Luis is a 42--yearyear--old manager who presents to old manager who presents to

your office with a history of coughing episodes your office with a history of coughing episodes during the winter months.during the winter months.

As a toddler, Luis experienced episodes of As a toddler, Luis experienced episodes of wheezing and coughing.wheezing and coughing.

He was treated frequently in the emergency He was treated frequently in the emergency room and was hospitalized at least one or two room and was hospitalized at least one or two times each winter for the first 10 years of his life.times each winter for the first 10 years of his life.

Thereafter, he improved and throughout his Thereafter, he improved and throughout his adolescence and young adult life, Luis had few adolescence and young adult life, Luis had few or no symptoms other than an intermittent cough or no symptoms other than an intermittent cough in the winter. in the winter.

LuisLuis Last year, Luis began coughing with exercise and Last year, Luis began coughing with exercise and

was prescribed a shortwas prescribed a short--acting bronchodilator by his acting bronchodilator by his primary care physician.primary care physician.

For the last few months, Luis states that he is For the last few months, Luis states that he is waking three times or more each week with waking three times or more each week with coughing.coughing.

His job performance is also suffering because he His job performance is also suffering because he cannot concentrate due to frequent coughing cannot concentrate due to frequent coughing episodes at work.episodes at work.

He is using two puffs of his He is using two puffs of his albuterolalbuterol inhaler at inhaler at least four times a day. least four times a day.

LuisLuis Luis' childhood history is indicative of childhood Luis' childhood history is indicative of childhood

asthma that was not appropriately diagnosed or asthma that was not appropriately diagnosed or treated.treated.

If Luis presented today with the symptoms that he If Luis presented today with the symptoms that he exhibited as a youngster he would most likely have exhibited as a youngster he would most likely have been diagnosed with asthma.been diagnosed with asthma.

In spite of that, it became somewhat quiescent during In spite of that, it became somewhat quiescent during adolescence and early adulthood with the exception of adolescence and early adulthood with the exception of an intermittent cough.an intermittent cough.

Asthma symptoms may decrease or become nonAsthma symptoms may decrease or become non--existent during adolescence and early adulthood even existent during adolescence and early adulthood even though the airways are still hypersensitive.though the airways are still hypersensitive.

LuisLuis A physical exam is the next step in establishing A physical exam is the next step in establishing

the diagnosis and developing Luis' treatment plan. the diagnosis and developing Luis' treatment plan.

Spirometry is an important diagnostic tool that can Spirometry is an important diagnostic tool that can assist the clinician in making the diagnosis of assist the clinician in making the diagnosis of asthma after the history and physical is completed. asthma after the history and physical is completed.

If Luis has not had a baseline CXR performed, If Luis has not had a baseline CXR performed, some clinicians might request one to assist in some clinicians might request one to assist in ruling out other diagnoses.ruling out other diagnoses.

Others would make the diagnosis from the Others would make the diagnosis from the information at hand and initiate treatment. If Luis information at hand and initiate treatment. If Luis responds to this treatment, they would not do a responds to this treatment, they would not do a CXR. CXR.

LuisLuis A physical exam can help with diagnosis. However, a A physical exam can help with diagnosis. However, a

normal physical exam does not exclude the diagnosis normal physical exam does not exclude the diagnosis of asthma.of asthma.

Pulmonary function tests are recommended by the Pulmonary function tests are recommended by the Guidelines to assess and manage treatment.Guidelines to assess and manage treatment.

Pulmonary function tests (prePulmonary function tests (pre-- and postand post--bronchodilator) should be performed in office (or bronchodilator) should be performed in office (or obtained as soon as possible at an asthma obtained as soon as possible at an asthma specialist's office or hospital PFT lab).specialist's office or hospital PFT lab).

A 12% improvement in PFT values postA 12% improvement in PFT values post--bronchodilator indicates reversibility and is suggestive bronchodilator indicates reversibility and is suggestive for asthma.for asthma.

Spirometry: FlowSpirometry: Flow--Volume LoopVolume LoopObstructionObstruction

Questions Questions -- LuisLuisWhy did my asthma come back? Did it ever go away?Why did my asthma come back? Did it ever go away?

It is common for asthma to improve or clinically disappear durinIt is common for asthma to improve or clinically disappear during g adolescence and worsen or reoccur in adulthood. adolescence and worsen or reoccur in adulthood.

Although it is a chronic disease, asthma symptoms are Although it is a chronic disease, asthma symptoms are precipitated by exposure to factors in our environment. If theseprecipitated by exposure to factors in our environment. If thesefactors/exposures change or the sensitivity to them changes, factors/exposures change or the sensitivity to them changes, then the ensuing symptoms may also change. then the ensuing symptoms may also change.

When this occurs, patients and family members may perceive that When this occurs, patients and family members may perceive that the asthma was "cured" or "outgrown" and believe that it will the asthma was "cured" or "outgrown" and believe that it will never return. never return.

If symptoms do return, prompt initiation of appropriate therapy If symptoms do return, prompt initiation of appropriate therapy can can lessen the impact that asthma has on the patient and the lessen the impact that asthma has on the patient and the family's lifestyle and allow them to have an excellent quality ofamily's lifestyle and allow them to have an excellent quality of f life. life.

Recommended Action for Treatment Recommended Action for Treatment Based on Assessment of ControlBased on Assessment of Control

WellWellControlledControlled

Not WellNot WellControlledControlled

Very Poorly Very Poorly ControlledControlled

Maintain current Maintain current stepstep

Step up 1 step Step up 1 step and reevaluate in and reevaluate in 22--6 weeks6 weeks

Consider short Consider short course of oral course of oral corticosteroidscorticosteroids

Consider step Consider step down if well down if well controlled for at controlled for at least 3 monthsleast 3 months

For side effects, For side effects, consider consider alternative alternative treatment optionstreatment options

Step up 1Step up 1--2 steps and 2 steps and reevaluate in 2 weeksreevaluate in 2 weeks

For side effects, For side effects, consider alternative consider alternative treatment optionstreatment options

Before stepping up therapy, Before stepping up therapy, check adherence and environmental controlcheck adherence and environmental control

•• Use Use inhaled corticosteroidsinhaled corticosteroids to control asthma. to control asthma. •• Use Use written asthma action planswritten asthma action plans to guide patient to guide patient

selfself--management. management. •• Assess asthma severityAssess asthma severity at the initial visit to at the initial visit to

determine initial treatment. determine initial treatment. •• Assess andAssess and monitor asthma controlmonitor asthma control and adjust and adjust

treatment if needed. treatment if needed. •• Schedule Schedule follow up visitsfollow up visits at periodic intervals. at periodic intervals. •• Control environmental exposuresControl environmental exposures that worsen the that worsen the

patientpatient’’s asthma.s asthma.

GIST Incorporates All GIST Incorporates All 66Guideline Implementation Panel ReportGuideline Implementation Panel Report

Key MessagesKey Messages

For more information...For more information...

Contact Karen Meyerson, MSN, RN, FNPContact Karen Meyerson, MSN, RN, FNP--C, AEC, AE--C at:C at:

•• Phone: Phone: (616) 685(616) 685--14321432•• ee--mail:mail: meyersok@trinitymeyersok@trinity--health.orghealth.org•• websites:websites: www.asthmanetworkwm.orgwww.asthmanetworkwm.org

www.GetAsthmaHelp.orgwww.GetAsthmaHelp.org