Managing Asthma During Pregnancy and Lactation - PowerPoint Presentation

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Managing Asthma During Pregnancy and LactationMary McMahon, RNC, MSSlide2

Guidelines for Asthma during PregnancyNational Asthma Education and Prevention Program (NAEPP)Working Group Report on Managing Asthma during Pregnancy: Recommendations for Pharmacologic Treatment – Update 2004

American College of Obstetrician and Gynecologist (ACOG) Asthma in Pregnancy Bulletin 90, 2008, Reaffirmed 2012Slide3

Let’s Discuss…Asthma Control Management of Asthma during Pregnancy and LactationEducational Resources for Patients and ProfessionalsSlide4

Respiratory Physiology in Pregnancy

Changes in respiratory status occur more rapidly in pregnant patients than in nonpregnant patients

Respiratory Rate

Vital Capacity

Unchanged

Unchanged

Tidal Volume

Increased

Minute Ventilations

Increased

Minute Oxygen Uptake

Increased

Functional Residual

Capacity

Decreased

Residual

Volume of Air

Decreased

Airway Conductance

Increased

Total Pulmonary Resistance

ReducedSlide5

Effects of Pregnancy on AsthmaWhen women with asthma become pregnant:One-third of the patients improve,One-third worsen,

Last third remain unchangedSlide6

Effects of Asthma on PregnancyOne of the most common chronic medical problem that occurs during pregnancyApproximately 8% of pregnancy womenLet’s take a deep look at this……..Slide7

Asthma is Characterized byInflammation of the airways, with an abnormal accumulation of eosinophils, lymphocytes, mast cells, macrophages, dendritic cells, and myofibroblasts

.Leads to a reduction in airway diameter caused by smooth muscle contraction, vascular congestion, bronchial wall edema and thick secretions.Slide8

Airway Inflammation& Symptoms

Risk Factors

Inflammation

Airway

Hyperresonsiveness

Airway

Obstruction

Clinical

Symptoms

Adapted from NAEPP Expert Panel Report 2 & 3

Precipitating

FactorsSlide9

Clinical SymptomsCoughWheezeShortness of breath

Chest tightnessSlide10

Asthma ImpairmentFrequency and intensity of symptomsFunctional limitations

RiskLikelihood of asthma exacerbationsProgressive decline in lung functions

Risk of adverse effects from treatment

Adapted from NAEPP, Expert Report 3Slide11

What Are Goals of Treatment?Your patient should be able toParticipate in activities, including physical activity without asthma symptoms

Sleep through the night without asthma symptomsHave normal or near normal lung functionMinimal use of short-acting inhaled beta

2-agonistHave few, if any side effects from medication takenSlide12

Goals of Therapy:Asthma ControlReduce impairment

Prevent chronic and troublesome symptoms (e.g. coughing or breathlessness in the daytime, in the night or after exertion)Require infrequent use (<2 days a week) of SABA for quick relief of symptoms

Maintain (near) normal pulmonary functionMaintain normal activity levels (including exercise and other physical activity and attendance at work or school)Meet patients’ and families’ expectations of and satisfaction with asthma care

NAEPP Expert Panel Report 3Slide13

Goals of Therapy:Asthma ControlReduce risk

Prevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizationsPrevent progressive loss of lung function; blood oxygenation that ensures oxygen supply to fetus

Provide optimal pharmacotherapy with minimal or no adverse effects

NAEPP Expert Panel Report 3Slide14

Treatment Goal - Pregnant Asthma PatientTo provide optimal therapy to maintain control of asthma for maternal health and quality of live as well as for normal fetal maturation. Slide15

When Asthma is not ControlledMaternal health risks include:High Blood Pressure

Preeclampsia, which can affectPlacentaKidneysLiverBrainSlide16

When Asthma is not ControlledRisks to the Fetus include:Perinatal MortalityIntrauterine Growth Restriction

Preterm BirthLow Birth WeightSlide17

Differential DiagnosisPatients presenting with new respiratory symptoms during pregnancy; Is it......?Dyspnea

GERDChronic cough from postnasal dripBronchitisSlide18

GoalsWhat are the patient’s and family’s personal goals?Slide19

Asthma SeveritySevere persistent asthma 4Moderate persistent asthma 3

Mild persistent asthma 2Intermittent asthma 1Slide20

Classification of Asthma Severity and Control in Pregnant Patients

Components of Severity

Intermittent

Mild

Persistent

Moderate Persistent

Severe

Persistent

Impairment

Symptoms

<2 days/

wk

or less

>2 days/

wk

, not daily

Daily

Throughout the day

Nighttime awakenings

<2

Xs

/

mth

or less

>2

Xs

per month

More than once a week

Four times per week or more

SABA prn

<2 days/

wk

>2 days/

wk

, not daily, not >1 X/day

Daily

Several xs/day

Interference with normal activity

None

Minor limitation

Some limitation

Extremely limited

Lung function

Normal FEV

1

between exacerbations

FEV

1

>80%

FEV

1

/FVC normal

FEV

1

>80%

FEV

1

/FVC normal

FEV

1

>60%, but <80%

FEV

1

/FVC reduced 5%

FEV

1

<60%

FEV

1

/FVC reduced >5%

Risk

Exacerbations requiring oral steroids

0-1/yr

>2/yr

Recommended Step for

Initiating Treatment

Step 1

Step 2

Step 3

Step 4 or 5Slide21

Asthma SeverityDictates only initial therapy in the untreated patients.Intermittent asthma is appropriately treated with only short-acting beta-agonists for rescue and prevention of symptoms, such as those that occur with exercise.

Persistent asthma should be treated with inhaled corticosteroids (ICS). If symptoms or rescue inhaler use are daily, nighttime awakenings at least weekly, there is moderated interference with normal activities, or there is reduced pulmonary function when not having symptoms, then initial treatment should be medium doses of ICS or a combination of low-dose ICS and a long-acting inhaled beta-agonist.

Once the patient with asthma is receiving controller medication, further adjustments to asthma therapy are based on the level of asthma control.Slide22

SpirometryGet Valid Spirometry Results EVERY Time

DHHS (NIOSH) Publication No. 2011-135Slide23

Stepwise Approach to Asthma

Quick Relief Medication for all patients

Patient Education, Environmental Control, Comorbidities

Step

1

Step

2

Step

3

Step

4

Step

5

Step

6

Step

Up

Assess

Control

Step

Down

Int.

Asthma

Persistent Asthma

Long Term Control MedicationSlide24

Level of Asthma ControlWell-ControlledNot Well-Controlled

Very poorly controlledMany patients experience poor control of asthma

Adapted from NAEPP, Expert Report 3Slide25

Asthma Control Test

Simple self assessment questionnaire (takes few minutes)Patient fills out while waiting70-75% accuracy in determining level of asthma control

Validated & Guidelines recommendedEducates the goals of ‘Well Controlled’Slide26

Asthma Control Test5 items completed by the patient reflecting on the past 4 weeksDaytime and nighttime symptomsActivity limitationsRescue inhaler use

Add up: 0 - 25> 20: well controlled16 – 19: not well controlled

< 15: very poorly controlledSlide27
Slide28

A 23 year old patient, G1P0 at 11 wks with history of asthma was seen by her provider with recurrent cough and wheeze. She admits to waking twice per month with a cough and requiring albuterol twice per week. The provider knows that according to the EPR-3 guidelines, this woman’s level of asthma control would be classified as:

Very well controlledWell controlled

Not well controlledVery poorly controlledSlide29

Controlling Asthma TriggersSmokingAvoiding AllergensPollenDust mitesPet danderSlide30

Team Approach to Managing Asthma During PregnancyExpectant Mother and her familyObstetrical ProviderPrimary Care ProviderAsthma Specialist

Refer to a specialist if asthma is poorly controlled. Slide31

Asthma Action PlanEveryone with asthma should have an asthma action plan.Developed with patient and providerShows daily treatmentWhat kind of medicines to take

When to take medicinesHow to control asthma long termHow to handle worsening asthma When to call the doctor or go to the EDSlide32

U.S. FDA Pregnancy CategoriesPregnancy Category

Definition

AWell-controlled studies have failed to demonstrate a risk to the fetus.

BAnimal reproduction studies demonstrate an adverse effect on the fetus, There are no well-controlled studies in pregnant women. The potential benefits of this drug may outweigh the potential risks.

C

There is positive evidence of human fetal risk based on adverse reaction data from research or clinical experience. The potential

benefits of this drug may outweigh the potential risks.

D

Studies

in humans and animals have demonstrated fetal abnormalities. There is positive evidence of human fetal risk. The risks of this drug outweigh any benefit to its use.Slide33

How Medications Work?Bronchodilator

Anti-InflammatorySlide34

Stepwise Approach to Manage Asthma

Step Up

Step DownSlide35

Stepwise Approach to Asthma

Asthma Medications

Quick relief

Taken when asthma symptoms presentLong term control

Taken daily, even when asthma well controlledSlide36

Stepwise Approach to Asthma

Medications

Preferred treatmentAlternative treatmentConsider variability in response based on the individualSlide37

Stepwise Approach - 12 yrs-Adult (revised)

Quick Relief Medication for all patients (SABA)

Patient Education, Environmental Control, Comorbidities

Step 1

SABA

prn

Step 2

Preferred

ICS

(low dose)

Step 3

Preferred

ICS

(low dose)

Or ICS

(med dose)

&

LABA

Step 4

Preferred

ICS

(med dose)

&

LABA

Step 5

Preferred

ICS

(high dose)

&

LABA

+

Omalizumab

(if allergens)

Step 6

Preferred

ICS

(high dose)

+

LABA

+

Oral

Corticosteroid

And

Consider

Omalizumab

(if allergens)

Step

Up

Assess

Control

Step

Down

Int.

Asthma

Persistent Asthma

Long Term Control Medication

Adapted from NAEPP, Expert Report 3Slide38

Quick Relief MedicationAll levels of asthma severity require short-acting beta

2-agonist (SABA)Anyone with asthma can have a severe exacerbationSlide39

Short-Acting Beta2-Agonists

Used as a pretreatment before exerciseUsed to treat asthma symptomsIncreased use >2 days per week indicates inadequate asthma control

Regular use not recommendedSlide40

Long Term Control MedicationPreferred treatment

Inhaled SteroidsMost effective long term control medication for mild, moderate and severe persistent asthmaSlide41

Inhaled SteroidsImprove asthma control

Improve quality of lifeImprove spirometryDecrease airway hyper responsivenessPrevent exacerbations

Reduce severity of symptomsReduce systemic steroids, ED visits, hospitalizations and deathSlide42

Inhaled SteroidsMometasone

Twisthaler®Ciclesonide

MDIFluticasoneMDI

BudesonideFlexhaler ®, Respules

®

Beclomethasone

MDI (HFA propellant)Slide43

Adapted from NAEPP Expert Panel Report 3 & ACOG Bulletin No. 90

Comparative Daily DosageInhaled Corticosteroids

Medicine

Low Daily Dose

Med Daily Dose

High Daily Dose

Beclomethasone

HFA 40

80 mcg per puff

2-6 puffs

1-3 puffs

More than 6-12 puffs

More than 3-6 puffs

More than 12 puffs

More than 6 puffs

Budesonide DPI

200 mcg/inhalation

1-3 puffs

More than 3-6 puffs

More than 6 puffs

Flunisolide

250 mcg per inhalation

2-4 puffs

4-8 puffs

More than 8 puffs

Fluticasone HFA 44 mcg 110 mcg per puff,

220 mcg per puff

2-6 puffs

2 puffs

2-4 puffs

1-2 puffs

More than 4 puffs

More than 2 puffs

Fluticasone DPI 50 mcg

100 mcg per inhalation

250 mcg per inhalation

2-6 puffs

1-3 puffs

1 puff

3-5 puffs

2 puffs

More than 5 puffs

More than 2 puffs

Triamcinolone

75 mcg/

inh

Mometasone

DPI

200 mcg/

inh

4-10 puffs

1 puff

10-20 puffs

2 puffs

More than 20 puffs

More than 2 puffsSlide44

Inhaled SteroidsIncreased effect in lungs with decreased systemic side effects

Side effectsThrush (oral candidiasis)Sore throat

HoarsenessDry mouthSlide45

Combination TherapyPreferred treatment

Varies with ageThe combination of long-acting inhaled beta2

-agonists (LABA) added to low-to-medium doses of inhaled steroids leads to improvements in:Lung functionSymptoms

Reduced use of short-acting beta2-agonistsIncrease in inhaled steroid given equal weightSlide46

Anti-IGE TreatmentOmalizumabApproved for:

Poorly controlled moderate to severe persistent asthmaYear round allergiesIndividuals taking routine inhaled steroids

Not recommended to initiate during pregnancySlide47

Oral CorticosteroidsAction

- Reduces and prevents inflammationPillsPrednisone

MethylprednisoloneShort course to speed recovery with moderate to severe exacerbationSlide48

Medication Technique Is ImportantCheck inhalation technique at every visitSlide49

Medication Technique Is ImportantPatients should know

How to use the deviceHow to tell when the device is emptyHow to clean the device

www.NJHealth.orgSlide50

Maintaining Asthma ControlOnce asthma control achievedGradual reduction of pharmacotherapy (Step Down)

Monitor asthma control with the goal of providing optimal pharmacotherapy with minimal or no adverse effectsSlide51

Managing Exacerbations – Home TreatmentAssess SeverityInitial TreatmentResponse

GoodIncompletePoorFollow-upSlide52

Management of Exacerbations – Emergency Dept. and Hospital CareInitial AssessmentInitial Treatment depending on severityMild to mod exacerbationSevere

Impending or actual respiratory arrestRepeat AssessmentLevel of ResponseSlide53

Transition of CareAdmit to Hospital Intensive CareAdmit to Inpatient UnitDischarge HomeSlide54

Key Patient Education MessagesTeach and reinforce at initial visit and follow upBasic facts about asthmaWell controlled asthma and patient's current level of control

Asthma Control TestAsk “How often are you using your SABA in a week?”Slide55

Key Patient Education Messages contRole of medicationsPatient skillsTake medication correctlyEnvironmental control measures

Self monitoringAsthma SymptomsUse of peak flowUse of written asthma action planSlide56

Patient Education LinksAsthma, Allergies and Pregnancy Tip to Remember American Academy of Allergy, Asthma & Immunology (AAAI) (2013) Home>Conditions & Treatments>

Library>Asthma Library>http://www.aaai.org/conditions- and-treatments/library/asthma-library/asthma,allergies

-and- pregnancy/TTR Pregnancy is Complicated by Allergies and Asthma American College of Allergy, Asthma & Immunology (ACAAI), 2010. Retrieved 08/13/2013

http://www.acaai.org/allergist/liv_man/pregnancy. Asthma during Pregnancy March of Dimes, 2011. Retrieved 08/13/2013

http://www.marchofdimes.com/pregnancy/asthma-during- pregnancy. Slide57

Current Studies Related to Asthma Interaction between obesity and asthmaDietary fat intake, may be an important modifier of airway inflammationAcetaminophen and folate may modify asthma risk, although more data are needed

The effects of vitamin D on asthma are (in theory) significant, more date to comeEXPECT Pregnancy Registry - XOLAIRR use prior to conception or during pregnancy Slide58

ConclusionsThe ultimate goal of asthma therapy in pregnancy is maintaining adequate oxygenation of the fetus be preventing hypoxic episodes in the mother.It is safer for pregnant women with asthma to be treated with asthma medications than it is for them to have asthma symptoms and exacerbations.Slide59

ReferencesAmerican College of Obstetricians and Gynecologists (ACOG). (2008). Asthma in pregnancy. ACOG Practice Bulletin No. 90. Obstet

Gynecol 2008 111:457-64American College of Obstetricians and Gynecologists (ACOG). (2008). ACOG releases new recommendations on the management of asthma during pregnancy. Retrieved from http://www.acog.org/about_acog/news_room/news_ releases/2008/

acog_releases. Retrieved 06/18/2013.Chambers, C., Asthma medications (2013) Clinician Reviews http://www.clinicianreviews.com/index.php?id=31613&type=98&tx_ttnews[tt_news]=216.

Retrieved 09/20/2013.Enriquez, R., Griffin, M., Carroll, K., Wu, P., Cooper, W.,

Gebretsadik

, T., …

Hartert

, T. (2007). Effect of maternal asthma and asthma control on pregnancy and perinatal outcomes. Journal of Allergy, Asthma & Immunology, 120(3), 625-630.

Murphy, A., Proeschal, A., Brightling, C., Wardlaw, A., Parvord, I., Bradding, P., et al. (2012). The relationship between clinical outcomes and medication adherence in difficult-to-control asthma. Thorax, 67, 751-753.Slide60

References contNational Institutes of Health; National Heart, Lung, and Blood Institute [NHLBI]. (2002). Asthma are: quick reference diagnosing and managing asthma –Revised 2012. Retrieved from http://nhlbi.nih.gov/guidelines/asthma/National Institutes of Health; National Heart, Lung, and Blood Institute [NHLBI]. (2005).

NAEPP working group report on managing asthma during pregnancy: Recommendations form pharmacologic treatment-Update 2004. Retrieved from http://nhlbi.nih.gov/health/prof/lung/asthma/ast.pregNational Institutes of Health; National Heart, Lung, and Blood Institute [NHLBI]. (2007). Expert Panel Report 3 (EPR-#): Guidelines for the diagnosis and management of asthma. Retrieved from http://nhlbi.nih.gov/guidelines/asthma/

Rance, K. & O’Laughlen, M. (2013) Managing asthma during pregnancy. Journal of the American Association of Nurse Practitioners, 25(2013), 513-521.

Schatz, M. & Dombrowskin, M., (2009). Asthma in pregnancy. NEJM 2009;360:1862-1869.Weinberger, S. & Schatz, M., (2012) In B.S. Bockner, X.J. Lockwood & H. Hollingswork (Eds), Management of asthma during pregnancy.

UpToDate. Retrieved from http://www.uptodateonline.comSlide61

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