Respiratory Update
Asthma: Causes, Monitoring and Treatment
Presented by Cynthia Fouts, June, 2012
Learning ObjectivesAfter viewing this presentation, the learner will be able to:understand the two major classifications of asthma
list ways to decrease the patient’s exposure to asthma triggers
coach the patient in performing peak flow measurements
write an asthma plan
classify asthma severity
choose correct management techniques based on severity.
Background:Asthma used to be viewed as a condition that a
person gets, is treated, and suffers no lasting damage.
Recent studies have shown that each asthma exacerbation leaves airway damage behind.
In addition to physical damage, asthma exacerbations result in loss of productivity (both for adults at work and children in school).
Asthma sufferers also report that asthma affects their activities and enjoyment of life
Asthma Types:There are two major types of asthma:
Intrinsic – also known as nonallergic or nonatopic
Extrinsic – also known as allergic or atopic
IntrinsicEtiology – elusiveUsually occurs after 40 years of ageNon-specific stimuli:
Infections Cold Air Exposure Exercise Esophageal Reflux Emotional Stress Pollutants Food Additives, Food Preservatives
Extrinsicclearly associated with exposure to a specific
antigenic agentType I anaphylactic hypersensitivity reactionIgE-mediated allergic reactionFamily relatedUsually appears in childrenHypersensitivity immune response causes the
disease by causing acute and chronic inflammation
Decreasing exposure to triggers:Tobacco smoke
Quit if smokerSmoke-free environments (car & house)
Dust mitesEncase mattress in special dust-mite free coverEncase pillow in special dust-mite free cover or wash
every week in hot water or cool water/bleachReduce indoor humidity to <60%Do not sleep on cloth covered cushions or furnitureRemove carpets from bedroom and from concreteStuffed toys
Keep out of the bed Wash weekly in hot water or cool water/bleach
Decreasing triggers, cont’d.Animal Dander
Keep animal with fur out of the homeKeep pet out of bedroom and keep door closedRemove carpet and cloth-covered furniture
CockroachKeep all food out of the bedroomKeep food and garbage in closed containersUse poison baits, traps and powders instead of
sprays
Decreasing triggers, cont’d.Vacuum cleaning
Try to get someone else to come in and do the vacuuming once or twice a week
If do it yourself, use a mask, central vac system or vacuum with a HEPA filter
Indoor moldFix leaky faucets and pipesClean moldy surfacesDehumidify basements
Decreasing triggers, cont’d.Pollen and Outdoor Mold
Keep windows closed during peak allergy seasonsStay inside during midday and afternoonTalk to doctor about anti-inflammatory meds before
allergy season startsSmoke, Strong Odors and Sprays
If possible do not use wood burning stove, kerosene heater, fireplace, or any unvented heater
Stay away from new paint, new carpet, hair spray, perfumes
Decreasing triggers, cont’d.Exercise or Sports
Check air quality index and avoid outside activity when air pollution or pollen levels high
Warm up before exercisingShould be able to be active without symptoms; if not
talk to dr. about taking meds before activity to prevent symptoms
Other triggersAvoid Sulfites in foods – beer or wine, shrimp, dried
fruit, processed potatoesCold air – cover mouth and nose with scarfOther meds – tell doctor about all meds you are taking
Daily monitoringAll asthma patients should use a peak flow
meter to monitor their daily symptoms.A peak flow meter is a small hand-held device
which measures the speed which a patient can exhale.
Measurement is in Liters/minute.Easy to use – even children who can follow
simple directions can use it.Many times a peak flow meter will show a
decrease in flow before the patient feels an increased shortness of breath.
Peak Flow Meters – different styles
How to Use a Peak Flow MeterHave patient in upright positionInstruct to place mouthpiece into their mouth but
do not obstruct the opening with their tongueFirmly seal lips around mouthpieceTake a big breath inBLAST out the breath – hard and fast!!!Note readingReset meter to zeroRepeat process twice more and record the best
reading
Asthma Zone Management SystemThis system is a process of daily monitoring using a peak flow meter, daily recording of results, and treatment based on those results.
Charting Peak Flow & ZonesYou will note on the preceeding example of a Peak Flow Chart that there were green, yellow, and red columns. These columns represent the 80-100%, 50-80%, and <50% zones of the patient’s personal best. The personal best is the best of two weeks of measurements made during a time when the patient’s asthma is well controlled.
Written Action PlanWritten asthma action plans include two important elements:
Daily management
Recognition and handling worsening symptoms
Daily ManagementMonitoring with a peak flow meter
Recording of peak flow measurement
What medications to take every day; when and how to take them
Recognition and Handling Worsening SymptomsWhat symptoms and PF measurements
indicate worsening asthma (yellow zone)What medications to take in response to these
signs and symptomsWhat symptoms and PEF measurements
indicate the need for urgent medical attention (red zone)
Emergency telephone numbers for the physician, ED, and person or service to transport the patient rapidly for medical care
Classification of Asthma Severity – Mild IntermittentSymptoms Nocturnal
SymptomsDaily Meds for Long Term Control
Medication for Quick Relief
Symptoms no more frequent than twice a week.Asymptomatic and with normal PF between exacerbations.Exacerbations brief (hours to days).Intensity of Exacerbations varies.
No more frequent than twice monthly
No daily medications
Short-acting inhaled β2-agonistUse more than twice weekly may indicate the need to initiate long-term therapy
Classification of Asthma Severity – Mild PersistentSymptoms Nocturnal
SymptomsDaily Meds for Long Term Control
Medication for Quick Relief
Symptoms more frequent than twice weekly but less than once per day.Exacerbation may affect activity.
More frequent than twice monthly
Once-daily medication:Antiinflammatory agent (low-dose corticosteroid, cromolyn)orSustained-release theophyllineNOTE: Leukotriene modifiers may be considered for pts at least 12 yr old.
Short-acting inhaled β2-agonistDaily use or increasing use may indicate the need to additional long-term therapy
Classification of Asthma Severity – Moderate PersistentSymptoms Nocturnal
SymptomsDaily Meds for Long Term Control
Medication for Quick Relief
Daily SymptomsDaily use of inhaled, short-acting β2-agonistExacerbations affect activity.Exacerbations at least twice weekly and may last for days.
More frequent than once weekly.
One or two daily med:Antiinflammatory agent (medium-dose inhaled glucocorticoid)and/orMedium-dose inhaled glucocorticoid plus long-acting bronchodilator
Short-acting inhaled β2-agonistDaily use or increased use indicates need for additional long-term therapy
Classification of Asthma Severity – Severe PersistentSymptoms Nocturnal
SymptomsDaily Meds for Long Term Control
Medication for Quick Relief
Continual symptoms.Limited physical activity.Frequent exacerbations.
Frequent Two daily medications:Antiinflammatory agent (high-dose inhaled glucocorticoid)andLong-acting bronchodilator (inhaled or oral β2-agonist or theophylline)
Short-acting inhaled β2-agonistDaily use or increased use indicates need for additional long-term therapy
Treatment RegimenNote that the medications ordered for a
patient are associated with the severity rating of their asthma.
It is important to educate the patient on the correct administration of MDI’s and DPI’s to ensure adequate intake of the medications.
It is possible to control almost all asthma with medication and avoidance of triggers.
BibliographyDes Jardins, T. and Burton, G. (2006). Clinical Manifestations and Assessment of Respiratory Disease. St. Louis, Mo: Mosby Elsevier. pg. 197-206.
Guidelines for the Diagnosis and Management of Asthma (EPR-3). (2007) National Heart Lung and Blood Institute. Retrieved from http://www.nhlbi.nih.gov/guidelines/asthma/index.htm
Measuring Your Peak Flow Rate. (2012) American Lung Association. Retrieved from http://www.lung.org/lung-disease/asthma/living-with-asthma/take-control-of-your-asthma/measuring-your-peak-flow-rate.html
National Asthma Control Initiative. (2008) National Heart Lung and Blood Institute. Retrieved from http://www.nhlbi.nih.gov/health/prof/lung/asthma/naci/index.htm
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