ASTHMA CAPA 2012 Deborah - PowerPoint Presentation

Slide1

ASTHMA

CAPA 2012

Deborah

Hellyer

MD

Slide2

Objectives

Review Asthma – what is it

Control is possible

What is new? CTS 2012 Guidelines

Special considerations

ASA Triad

Occupational Asthma

Asthma in Pregnancy

Emergency treatment

Slide3

Asthma

An inflammatory disorder of the airways characterized by paroxysmal or persistent symptoms such as dyspnea, chest tightness, wheezing, sputum production and cough, associated with variable airflow limitation and a variable degree of

hyperresponsiveness

of airways to endogenous or exogenous stimuli

Slide4

Asthma Prevalence and Mortality

Source

: Masoli M et al. Allergy 2004

Slide5

Asthma Statistics

2.7 million Canadians have asthma

13% of Ontarians have asthma , 21% of Ontario children aged 0-14 have asthma

39% of people with asthma report limitation in physical activity

Asthma is the # 1 reason for children being hospitalized

Slide6

Pathology of Asthma

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI, 1995

Normal

Asthma

Asthma involves inflammation of the airways

Slide7

InducersAllergens, chemical sensitizers

Air pollution, viruses, occupational exposures

Inflammation

Airway

Hyperresponsiveness

Airflow Limitation

Symptoms

Cough, Wheeze, Chest tightness

Dyspnea

Triggers

Allergens, exercise, cold air, SO

2

particulates

Mechanisms: Asthma Inflammation

Slide8

Source: Peter J. Barnes, MD

Asthma Inflammation:

Cells and Mediators

Slide9

Source: Peter J. Barnes, MD

Asthma Inflammation:

Cells and Mediators

Slide10

Symptoms Suggestive of Asthma

Frequent episodes of breathlessness, chest tightness, wheezing or cough

Symptoms worse at night or the early morning

Symptoms develop with a viral respiratory tract infection, after exercise, or to exposure to

alloallergens

or irritants

Symptoms develop in young children after playing or laughing

Symptoms improve with bronchodilators or corticosteroids

Slide11

Differential Diagnosis

(Wheezing/Cough)

Post infectious Cough

Post Nasal Drip

COPD

Heart Failure

Angina

Lung CancerHyperventilation SyndromeVocal Cord Dysfunction

Slide12

Risk Factors Associated the Development of Asthma

Predisposing Factors

Atopy

Genetics

Gender

Causal Factors

Indoor Allergens

Occupational SensitizersOutdoor AllergensContributing FactorsAir PollutionDietLow Birth WeightRespiratory InfectionsSmoking

Slide13

How to Diagnose Asthma?

Supplement history with objective measures in lung function in children over six years of age

Reversible airway obstruction after bronchodilator or

Variable airflow limitation over time or

Airway

hyperresponsiveness

Assessing Allergic Status

Slide14

Breathing Tests

Spirometry Testing:

lung volumes in/out,

lung flow of air in/out

Peak Flow Monitoring:

lung flow of air in/out

Slide15

Pulmonary

Function Measurement

Children (> 6 years)

Adults

Preferred

spirometry

showing reversible airway obstruction

Reduced FEV1/FVCANDIncrease in FEV1 after bronchodilator or after a course of controller therapyLess than lower limit of normal based on age, height and ethnicityAND≥ 12%Less than lower limit of normal based on age, sex, height, ethnicity (<0.75-0.8)AND

≥ 12% (minimum ≥ 200 ml)Alternative PEF variabilityIncrease after bronchodilator or course of controller therapyORDiurnal Variation

≥ 20%

OR

Not recommended

60L/min

OR

8% based on twice daily readings

> 20% based on multiple daily readings

Alternative

Positive Challenge test

Methacholine

ORExercise ChallengePC20 < 4 mg/ml4 mg/ml – 16 mg/ml borderline

OR≥ 10-15% decrease in FEV1 post exerciseDiagnosis of Asthma Pulmonary Function Criteria

Slide16

1

Time (sec)

2

3

4

5

FEV

1

Volume

Normal Subject

Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)

Note: Each FEV

1

curve represents the highest of three repeat measurements

Typical

Spirometric

Tracing

Slide17

Measuring Airway Responsiveness

Slide18

Slide19

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Slide21

Approach to Management

Confirm diagnosis

Self management education including: environmental trigger avoidance, inhaler technique, adherence, action plan

Reliever therapy

Daily Controller therapy

Regular assessment of asthma control, including

spirometry

and PEF

Slide22

Asthma Management and Prevention Program

Goals of Long-term Management

Achieve and maintain control of symptoms

Maintain normal activity levels, including exercise

Maintain pulmonary function as close to normal levels as possible

Prevent asthma exacerbations

Avoid adverse effects from asthma medications

Prevent asthma mortality

Slide23

Reducing Exposure to

Environmental Tobacco Smoke

Evidence suggests an association between environmental tobacco smoke exposure and exacerbations of asthma among school-aged, older children, and adults.

Evidence shows an association between environmental tobacco smoke exposure and asthma development among pre-school aged children.

Slide24

Reducing Exposure to House Dust Mites

Use bedding encasements

Wash bed linens weekly

Avoid down fillings

Limit stuffed animals to those that can be washed

Reduce humidity level (between 30% and 50% relative humidity per EPR-3)

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI, 1995

Slide25

Reducing Exposure to Mold

Eliminating mold and the moist conditions that permit mold growth may help prevent asthma exacerbations.

Slide26

Reducing Exposure to Cockroaches

Remove as many water and food sources as possible to avoid cockroaches.

Slide27

Exercise

Exercise can cause asthma symptoms …

BUT

Asthma should

not

usually prevent you from exercising if you:

Keep your asthma under control

Warm-up before and cool-down after exercise

Take a “reliever” medicine 5–10 minutes before exercising, if needed

Slide28

Irritants - Air Pollution

Air pollution comes from many sources, including vehicles and industry

Highest pollution levels tend to be during the hot humid days of summer

To reduce exposure to air pollution, the following may help:

Reduce outdoor activity when pollution levels are high

Keep windows and doors closed when there

are high pollution levels (air conditioning

may be needed when it gets hot)

Slide29

Allergens - Mould

Moulds can be indoors in damp basements and bathrooms, and outdoors in damp weather

The following can help:

Clean mouldy areas well

Keep humidity around 35-45%

A de-humidifier can help, especially in damp basements

Get rid of clutter in the basement, to allow air to move freely

Ensure proper water drainage around your home

Keep bathroom dry and use fan to remove humidity

Seek professional help if indoor mould doesn’t go away or if there is a lot of mould

Limit outdoor activity when outdoor mould levels are high

Slide30

Allergens - Pollen

Pollens are tiny particles that come off trees, grass and weeds

If you are allergic to pollens, the following may help:

Keep windows and doors closed in home and car during pollen seasons (air conditioner is often needed when it’s hot outside)

After being outside for a long time during pollen season, shower and change clothes

Person with allergies should not mow the lawn

Slide31

Allergens - Pets

If a pet is making your asthma worse, the

best

option by far is to find it a new home

If it is not possible to find it a new home:

Keep pet out of bedroom always

Wash pet twice a week

Encase pillows and mattress in

allergy-proof covers

Remove carpeting if possible

Use a large HEPA* filter air cleaner in bedroom

Vacuum furniture regularly with vacuum equipped with a HEPA* filter, or central vacuum system with exhaust outside the house

*HEPA = High Efficiency Particulate Air

Slide32

Worse Case Scenario

Slide33

Slide34

Reliever Medications

Rapid-acting inhaled β

2

-agonists

Systemic glucocorticosteroids

Anticholinergics

Theophylline

Short-acting oral β2

-agonists

Slide35

Controller Medications

Inhaled glucocorticosteroids

Leukotriene modifiers

Long-acting inhaled β

2

-agonists in combination with inhaled glucocorticosteroids

Systemic glucocorticosteroids

Theophylline

Cromones

Anti-

IgE

Slide36

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age

Drug

Low Daily Dose (



g) Medium Daily Dose (

g) High Daily Dose (g) > 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

Beclomethasone

200-500 100-200

>500-1000 >200-400

>1000 >400

Budesonide

200-600 100-200

600-1000 >200-400

>1000 >400

Budesonide-Neb Inhalation Suspension

250-500

500-1000

>1000

Ciclesonide

80 – 160 80-160

>160-320 >160-320

>320-1280 >320

Flunisolide

500-1000 500-750

>1000-2000 >750-1250

>2000 >1250

Fluticasone

100-250 100-200

>250-500 >200-500

>500 >500

Mometasone furoate

200-400 100-200

> 400-800 >200-400

>800-1200 >400

Triamcinolone acetonide

400-1000 400-800

>1000-2000 >800-1200

>2000 >1200

Slide37

Regularly Reassess

Control

Spirometry

or PEF

Inhaler Technique

Adherence

Triggers and new exposures

MedicationsEnvironment – home and workComorbiditiesSputum eosinophils

Slide38

60% of Canadians with asthma do

not

have it under control

Why do so many people

let asthma affect them so much?

Slide39

Do not know what

good

asthma control is

Do not realize that you

can

get good control of asthma

May not think that their asthma is bad enough to need treatment (even mild asthma often needs daily medicines)

Worried about taking medicines every day, about side effects, and costs

It may be hard to avoid triggers (eg. pets, smoke, dust mites in the bed, carpets, moulds, pollen)

Possible reasons …

Slide40

Asthma Management and Prevention Program

Factors Involved in Non-Adherence

Medication Usage

Difficulties associated with inhalers

Complicated regimens

Fears about, or actual side effects

Cost

Distance to pharmacies

Non-Medication Factors

Misunderstanding/lack of information

Fears about side-effects

Inappropriate expectations

Underestimation of severity

Attitudes toward ill health

Cultural factors

Poor communication

Slide41

ASTHMA CONTROL

Characteristic

Frequency or Value

Daytime Symptoms

< 4 days/week

Night time symptoms

< 1 night/week

Physical ActivityNormalExacerbationsMild, infrequentAbsence from work/schoolNoneNeed for fast acting beta2 agonist< 4 doses/weekFEV1 or PEF

≥ 90% personal bestPEF diurnal variation< 10-15%Sputum eosinophils<2-3%

Slide42

Asthma Diary - Sample

Slide43

Asthma Action Plan - Sample

Warning Signs

What to Do

Green Light

I feel Good!

I

am not coughing!

I sleep well!

I have lots of energy!

Green Zone

Take my regular controller

Carry my blue reliever

Exercise /play

everyday

Yellow Light

I am

coughing/wheezing

I use my reliever 3 or more times I don’t feel good!Yellow Zone Follow my action plan Use my controller

Get lots of rest Go get help!Red Light I am breathing fast I have trouble walking/ talking I am coughing lots Red Zone Asthma is dangerous!!!Take my reliever!Go Get Help from an adult or call 911!

Slide44

Step 1 – As-needed reliever medication

Patients with occasional daytime symptoms of short duration

A rapid-acting inhaled

β

2

-agonist is the recommended reliever treatment (

Evidence A

)When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)

Treating to Achieve Asthma Control

Slide45

Step 2 – Reliever medication plus a single controller

A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (

Evidence A

)

Alternative controller medications include leukotriene modifiers (

Evidence A

) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids

Treating to Achieve Asthma Control

Slide46

Step 3 – Reliever medication plus one or two controllers

For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting

β

2

-agonist either in a combination inhaler device or as separate components (

Evidence A

)

Inhaled long-acting

β

2

-agonist must not be used as monotherapy

For children, increase to a medium-dose inhaled glucocorticosteroid (

Evidence A

)

Treating to Achieve Asthma Control

Slide47

Additional Step 3 Options for Adolescents and Adults

Increase to medium-dose inhaled glucocorticosteroid (

Evidence A

)

Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (

Evidence A

)Low-dose sustained-release theophylline (Evidence B)

Treating to Achieve Asthma Control

Slide48

Step 4 – Reliever medication plus two or more controllers

Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled

β

2

-agonist (

Evidence A

)

Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled

β2-agonist (Evidence B)

Treating to Achieve Asthma Control

Slide49

Treating to Achieve Asthma Control

Step 5 – Reliever medication plus additional controller options

Addition of oral glucocorticosteroids to other controller medications may be effective (

Evidence D

) but is associated with severe side effects (

Evidence A

)

Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)

Slide50

Treating to Maintain Asthma Control

Stepping up treatment in response to loss of control

Rapid-onset, short-acting or long-acting inhaled

β

2-agonist bronchodilators provide temporary relief.

Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy

Slide51

Treating to Maintain Asthma Control

Stepping up treatment in response to loss of control

Use of a combination rapid and long-acting inhaled

β

2

-agonist (

e.g.,

formoterol) and an inhaled glucocorticosteroid (

e.g.,

budesonide

) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations (

Evidence A

)

Doubling the dose of inhaled

glucocortico

-steroids is not effective, and is not recommended (

Evidence A

)

Slide52

Treating to Maintain Asthma Control

Stepping down treatment when asthma is controlled

When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (

Evidence B

)

When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (

Evidence A

)

Slide53

Treating to Maintain Asthma Control

Stepping down treatment when asthma is controlled

When controlled on combination inhaled

glucocorticosteroids

and long-acting inhaled

β

2

-agonist,

reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting

β

2

-agonist (

Evidence B

)

If control is maintained, reduce to low-dose inhaled

glucocorticosteroids

and stop long-acting

β

2

-agonist (Evidence D)

Slide54

Assess Patient Risk

Features that are associated with increased risk of adverse events in the future include:

Poor clinical control

Frequent

exacerbations

in past year

Ever admission to critical care for asthma

Low FEV

1

, exposure to cigarette smoke, high dose medications

Slide55

Assessment of Future Risk

Risk of exacerbations, instability, rapid decline in lung function, side effects

Features that are associated with increased risk of adverse events in the future include:

Poor clinical control

Frequent exacerbations in past year

Ever admission to critical care for asthma

Low FEV

1, exposure to cigarette smoke, high dose medications

Any exacerbation should prompt review of maintenance treatment

Slide56

Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness

Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV

1

or PEF)

Severe exacerbations are potentially life-threatening and treatment requires close supervision

Asthma Management and Prevention Program

Component 4: Manage Asthma Exacerbations

Slide57

Primary therapies for exacerbations:

Repetitive administration of rapid-acting inhaled

β

2

-agonist

Early introduction of systemic glucocorticosteroids

Oxygen supplementation

Closely monitor response to treatment with serialmeasures of lung function

Asthma Management and Prevention Program

Component 4: Manage Asthma Exacerbations

Slide58

CTS Asthma Guidelines 2012

Role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy

The initiation of adjunct therapy to ICS for uncontrolled asthma

The role of single inhaler ICS/long acting beta

2

agonist as a reliever

Escalation of controller for acute loss of asthma control as a part of self management

Slide59

Sputum Eosinophil

Counts

Sputum

Eosinophils

are not normally present in healthy,

nonatopic

Increased in asthmatics exposed to aeroallergens

Decline within 3-7 days of ICS Normal sputum eosinophilic counts <2-3% of a differential sputum count Maybe useful in guiding treatmentRecommendation – monitoring sputum eosinophils in adults in addition toStandard methods of control

Slide60

FeNO levels

Biological mediator produced in the airways

Produced through a reaction catalyzed by inducible NO

synthetase

Upregulated

in the presence of airway inflammation

Correlates with

eosinophilic airway inflammationConfounding effect of atopic status, smoking and concomitant ICS treatmentRecommendation cannot be endorsed – insufficient evidence

Slide61

Slide62

Adjunct Therapies with LABAs and LTRAs

Initiation of adjunct therapy with uncontrolled asthma despite adherence to low dose ICS in adults and medium dose ICS in children

In adults with asthma not achieving control with low dose ICS, addition of a LABA; alternative increase ICS to medium or start LTRA

In children not achieving control on medium ICS add in LABA or LTRA; also should be referred to a specialist

Slide63

Efficacy of single ICS/LABA Recommendations

Do not recommend use as a reliever in lieu of FABA in adults with no maintenance therapy

Use of a SABA as a reliever in individuals with mild asthma on ICS

monotherapy

In exacerbation prone individuals >12 yrs with moderate asthma on a fixed ICS/LABA; use of

budesonide

/

formoterol as a reliever

Slide64

Mild Persistent Asthma

Recommend daily ICS in lieu of starting intermittent ICS at the onset of an acute loss of asthma control

Safest and minimal effective ICS dose be prescribed to minimize side effects in all age groups

Slide65

What is the efficacy of escalating ICS dose in acute loss of asthma control?

Children and adults on maintenance ICS

monotherapy

do not routinely double their dose of ICS as part of the written action plan at the onset of an episode of acute loss of asthma control

Trial increasing ICS maintenance dose by 4-5 fold for 7-14 days (history of severe exacerbations in past requiring systemic steroids

Slide66

Oral Corticosteroids

Prednisone dose and duration in adults should be individualized based on previous response

Dose of 30-50 mg/day for at least 5 days

Slide67

Asthma Management and Prevention Program

Special Considerations

Special considerations are required to

manage asthma in relation to:

Pregnancy

Surgery

Rhinitis, sinusitis, and nasal polyps

Occupational asthmaRespiratory infections

Gastroesophageal refluxAspirin-induced asthma

Anaphylaxis and Asthma

Slide68

Samters Triad (AERD)

Aspirin Exacerbated Respiratory Disease

Asthma, Nasal

Polyposis

, ASA sensitivity

5%-20% asthmatics; symptoms occur 30

mins

to 3 hours after ingestionPerturbations of the arachidonic acid metabolism and a resulting imbalance between proinflammatory and antiinflammatory mediators, leading to chronic airway inflammationLeukotriene modifying agents

Slide69

Occupational Asthma

Think occupation in a newly diagnosed adult asthmatic or difficult to control asthma

If diagnosed early and removed from exposure asthma resolves

If remains in exposure loss of lung function

Slide70

Slide71

Slide72

Slide73

Previous severe exacerbation (eg

, intubation or ICU admission)

Two or more hospitalizations for asthma in the past year

Three or more emergency department visits for asthma in the past year

Hospitalization or emergency department visit for asthma in the past month

Use of more than two canisters of short-acting beta agonist per month

Difficulty perceiving asthma symptoms or severity of exacerbations

Low socioeconomic status, inner city residence, illicit drug use, major psychosocial problemsComorbidities, such as cardiovascular, chronic lung, or psychiatric diseaseRisk Factors For Fatal Asthma Attack

Slide74

Slide75

Severity Assessment

Clinical Findings

Pulsus

Paradoxus

Accessory muscle usage

Diaphoresis

Breathlessness when supinePeak Flow< 200Gas ExchangeHypoxemiaHypercapnea

Slide76

Slide77

Slide78

Treatment

Inhaled Beta agonists

Inhaled

anticholinergics

Glucocorticosteroids

Magnesium Sulfate

Nonconventional therapies

Helium OxygenLeukotriene receptor antagonistsIneffective therapiesMethylxantines –theophyllineInhaled glucocorticosteroidsEmpiric antibiotics

Slide79

Asthma and Pregnancy

Worse 35%, improve 28%, unchanged 33%

FVC, FEV

1

, PEF do not change

RV, FRC decrease; TLC decrease 3

rd

trimesterMV, TV increase circulating progesteronePaO2 100-106 mmHg; PaCO2 28-30mmHg – compensated respiratory alkalosisExacerbations 20-36% middle trimesterSmall but statistically significant perinatal mortality, preterm delivery, LBWNeed to control asthma

Slide80

Summary - whirlwind

Asthma control is achievable

Patient education and self management is the key

Aim for the lowest medications, keep it simple

Monitor, monitor and monitor

Resources – CTS guidelines, GINA guidelines

Slide81

Breath of Life

Slide82

Slide83

Levels of Asthma Control

(Assess patient impairment)

Characteristic

Controlled

(All of the following)

Partly controlled

(Any present in any week)

Uncontrolled

Daytime

symptoms

Twice or less

per

week

More than

twice

per

week

3 or more features of partly controlled asthma present in any week

Limitations of activities

None

Any

Nocturnal symptoms / awakening

None

Any

Need for rescue / “reliever” treatment

Twice or less

per

week

More than

twice

per week

Lung function

(PEF or FEV

1

)

Normal

< 80% predicted or personal best (if known) on any day

Assessment of Future Risk

(risk of exacerbations, instability, rapid decline in lung function, side effects)

Slide84

controlled

partly controlled

uncontrolled

exacerbation

LEVEL OF CONTROL

maintain and find lowest controlling step

consider stepping up to gain control

step up until controlled

treat as exacerbation

TREATMENT OF ACTION

TREATMENT STEPS

REDUCE

INCREASE

STEP

1

STEP

2

STEP

3

STEP

4

STEP

5

REDUCE

INCREASE

Slide85

Slide86

Shaded green - preferred controller options

TO STEP 3 TREATMENT, SELECT ONE OR MORE

:

TO STEP 4 TREATMENT, ADD EITHER