Escolar Documentos
Profissional Documentos
Cultura Documentos
Presented By
Harry Mills / PRESENTATIONPRO
First Section
Introduction, Definition, Epidemiology,
Pathophysiology, Diagnosis
INTRODUCTION
Presented By
Harry Mills / PRESENTATIONPRO
EIPIDEMIOLOGY
1. The Expert Panel Report 3 Report 2007: Guidelines for the Diagnosis &Management of Asthma
2. Cote J, Cartier A, Robichand P. et al. Am J Respir Care Med. 1998;155:1509-1514.
3. Abdulwadud, Abramson M, Forbes A. et al. Respir Med. 1997; 91:524-529.
4. The National Scientific Committee of Bronchial Asthma. The Kingdom of Saudi
Presented By Arabia. Ministry of
Harry Mills
Health. The National Protocol for the Management of Asthma 3rd edition. / PRESENTATIONPRO
2000:2.
EIPIDEMIOLOGY
This means….
• In a class of 30 children, you can expect 2 to 3 students have asthma
• This number will vary depending on age & geographical location
Presented By
Harry Mills / PRESENTATIONPRO
PATHOPHYSIOLOGY
Bronchial Fixed
Symptoms Hyperreactivity Obstruction
Presented By
Harry Mills / PRESENTATIONPRO
PATHOPHYSIOLOGY
Asthma Etiology
Presented By
Harry Mills / PRESENTATIONPRO
Am J Pharm Educ. 2007 October 15; 71(5): 98.
PATHOPHYSIOLOGY
Asthma Triggers
Examples of these stimuli include:
Inhaled allergens
Respiratory viral infection
Smoke
Cold/Dry air
Smoke
Methacholine
Cockroaches
Other pollutants
Endogenous stimuli that can worsen asthma include:
Poorly controlled rhinitis
Sinusitis
GERD
Premenstrual asthma reported (exact hormonal mechanism is unknown)
Presented By
Harry Mills / PRESENTATIONPRO
PATHOPHYSIOLOGY
Presented By
Harry Mills / PRESENTATIONPRO
Am J Pharm Educ. 2007 October 15; 71(5): 98.
PATHOPHYSIOLOGY
10
5.0
ULN
2.5
1.0
Presented By
Harry Mills / PRESENTATIONPRO
Am J Pharm Educ. 2007 October 15; 71(5): 98.
PATHOPHYSIOLOGY
Asthma Attack
Normal Airway Function
Environmental Exposure
“Asthma Trigger”
Genetic predisposition
“Hyperreactive airways”
Repair? Injury
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Harry Mills / PRESENTATIONPRO
DIAGNOSIS
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Harry Mills / PRESENTATIONPRO
DIAGNOSIS
GENERAL
• Asthma is a disease of exacerbation & remission, so the patient may not have
any signs or symptoms at the time of exam
SYMPTOMS
• Dyspnea, chest tightness, coughing (particularly at night), wheezing, or a
whistling sound when breathing.
SIGNS
• Expiratory wheezing, dry hacking cough, or signs of atopy (allergic rhinitis &/or
eczema)
Other
• Spirometry demonstrates obstruction (FEV1/FVC < 80%) with reversibility
following inhaled SABA administration (at least a 12% improvement in FEV1)
Presented By
Harry Mills / PRESENTATIONPRO
DIAGNOSIS
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Harry Mills / PRESENTATIONPRO
RISK FACTORS FOR LIFE-THREATENING
ASTHMA AND DEATH FROM ASTHMA
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Harry Mills / PRESENTATIONPRO
Second Section
Management
SEQUENCE OF ASTHMA MANAGEMENT
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Harry Mills / PRESENTATIONPRO
THREE COMPONENTS OF ASSESSMENT & MONITORING
• Severity
– The chronicity & intrinsic intensity of the disease process
– Measured b/f receiving long-term control therapy (initial asthma assessment)
• Control
– The degree to which asthma’s manifestations are minimized & the goals of
therapy are met
– Guide decisions to maintain or adjust therapy
• Responsiveness
– The ease with which asthma control is achieved by therapy
Presented By
National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and
Harry MillsManagement of Asthma
/ PRESENTATIONPRO
(EPR-3) 2007.
SEVERITY: IMPAIRMENT AND RISK DOMAINS
Presented By
Harry Mills / PRESENTATIONPRO
SEVERITY, CONTROL, & RESPONSIVENESS
ARE RELATED
Select Appropriate
Therapy Step
Severity Classification
Presented By
Harry Mills / PRESENTATIONPRO
SEVERITY TABLE: HOW IS IT ORGANIZED?
Symptoms
Nighttime
awakening IMPAIRMENT DOMAIN
SABA use
Interference
with activity
Lung function
Presented By
SABA=short-acting β-agonist
Harry Mills / PRESENTATIONPRO
SEVERITY TABLE: HOW IS IT ORGANIZED?
Symptoms
Nighttime
awakening
SABA use
Interference
with activity
RISK DOMAIN
Lung function Considers exacerbation severity, frequency, interval
RISK Exacerbations since last exacerbation, & potential link between FEV1
Presented By
requiring PO & relative annual
Harry risk
Mills / PRESENTATIONPRO
steroids
SEVERITY TABLE: HOW IS IT ORGANIZED?
Symptoms
Nighttime
awakening
SABA use
Interference
with activity
Lung function
Exacerbations ≥2/yr
RISK requiring PO Treatment Step
Presented By
steroids Step of treatment recommended for initial therapy,
Harry with follow-up in 2-6
Mills / PRESENTATIONPRO
wks
Component Classification of Asthma Severity (>12 yrs)
of Severity
Intermittent Persistent
Mild Moderate Severe
Symptoms <2 d/wk >2 d/wk but not Daily Throughout the
daily day
HS awake <2 d/mo 3-4x/mo >1x/wk but not nightly Often 7x/wk
Impairment
SABA use <2 d/wk >2 d/wk but not Daily Several times
daily & not >1x on per day
any day
Interference NONE Minor limitation Some limitation Extremely
with activity limited
Lung • Normal FEV1 • FEV1 : >80% • FEV1: >60% but <80% • FEV1: <60%
function predicted predicted
betn. exacer • FEV1/FVC: reduced 5% • FEV1/FVC:
• FEV1/FVC:
• FEV1: >80%
normal reduced 5%
predicted
• FEV1/FVC: N
RISK Exacerbations 0-1/yr ≥2/yr
requiring oral
Consider severity and interval since last exacerbation as they may fluctuate
steroids
over time in any severity category
Presented By
Recommended Step 1 Step 2 Step 3 Step 4 or 5
Harry Mills / PRESENTATIONPRO
Treatment Step
GOALS OF THERAPY
Decreasing Impairment
• Prevent symptoms
– No need for reliever medications (2x or less per week)
– No daytime symptoms (2x or less per week)
– No nighttime symptoms (2x or less per week)
• Maintain “normal” pulmonary function
• Maintain normal activity/lifestyle
– No limitations in daily activities
– No limitations in exercise
• Decrease ED visits and hospitalizations
• Prevent progressive loss of lung function
• Achieve maximal pharmacotherapeutic benefit with ADRs
Presented By
EPR-3 Harry Mills / PRESENTATIONPRO
GOALS OF THERAPY
Decreasing Risk
Presented By
EPR-3 Harry Mills / PRESENTATIONPRO
GOALS OF THERAPY:
Classification of Me
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EPR-3 Harry Mills / PRESENTATIONPRO
LONG-TERM CONTROL MEDICATIONS
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Harry Mills / PRESENTATIONPRO
LONG-TERM CONTROL: CORTICOSTEROIDS
Examples Indications Potential Adverse Effects
Inhaled • Beclomethasone • Long-term prevention of • Cough
• Budesonide symptoms • Dysphonia
• Fluticasone • Control of inflammation • Candidiasis
• Mometasone • Reduce need for PO CS
• Triamcinolone
Systemic • Methylprednisolone • Reversible metabolic disorders
• Prednisolone • Fluid retention
• Short-term control of • Mood alteration
persistent asthma • Hypertension
• Peptic ulcer
• Weight gain
Presented By
Harry Mills / PRESENTATIONPRO
TIPS ABOUT CSs
Presented By
Harry Mills / PRESENTATIONPRO
Adapted from 2007 NHLBI Expert Panel Guidelines (EPR-3)
ALBUTEROL VS LABA’S: PHARMACOKINETICS
Presented By
Harry Mills / PRESENTATIONPRO
LABA USE IN CHILDREN
• Salmeterol
– FDA approved for prevention of bronchospasm and EIB in
children as young as 4 years of age
– Dosage: one inhalation every 12 hours
• •Formoterol
– FDA approved for prevention of bronchospasm and EIB in
children as young as 5 years of age
– Dose: one 12mcg capsule via inhalation every 12 hours
Presented By
Harry Mills / PRESENTATIONPRO
LABA SAFETY
Presented By
Adapted from 2007 NHLBI Expert Panel Guidelines (EPR-3). Harry Mills / PRESENTATIONPRO
LONG-TERM CONTROL: IMMUNOMODULATOR
Presented By
Adapted from 2007 NHLBI Expert Panel Guidelines (EPR-3). Harry Mills / PRESENTATIONPRO
LONG-TERM CONTROL: LEUKOTRIENE MODIFIERS
Examples Indication Potential SEs
LTRA Montelukast • Possible initial therapy in mild persistent No specific SE identified
asthma as an alternative to ICS or
cromolyn
> Not superior to ICS alone
Zafirlukast • Possible adj. therapy to ICS at any • Reversible hepatitis
level of asthma severity • Rarely irreversible
> Not superior to LABA when combined hepatic failure
with ICS
5-LPO Zileuton • Control & prevention of symptoms in mild • Elevation of liver enz.
inhibitor persistent asthma for patients > 12y • Case reports of
• Combo with ICS in moderate persistent reversible hepatitis &
asthma for patients > 12y hyperbilirubinemia
Presented By
Harry Mills / PRESENTATIONPRO
Adapted from 2007 NHLBI Expert Panel Guidelines (EPR-3).
LONG-TERM CONTROL: LEUKOTRIENE MODIFIERS
Presented By
Harry Mills / PRESENTATIONPRO
Adapted from 2007 NHLBI Expert Panel Guidelines (EPR-3).
Low-Dose Fluticasone vs. Oral Montelukast
for First-Line Treatment of Persistent Asthma
Presented By
Busse W, et al. J Allergy Clin Immunol 2001;107:461-8. Harry Mills / PRESENTATIONPRO
Salmeterol vs. Oral Montelukast
in Patients Using ICS
Presented By
Harry Mills / PRESENTATIONPRO
Fish J, et al. Am J Respir Crit Care Med 2000;161-163:A203.
LEUKOTRIENE MODIFIERS: PLACE IN THERAPY
Presented By
Harry Mills / PRESENTATIONPRO
LONG-TERM CONTROL: METHYLXANTHINES
Presented By
Harry Mills / PRESENTATIONPRO
Adapted from 2007 NHLBI Expert Panel Guidelines (EPR-3).
METHYLXANTHINES: PLACE IN THERAPY
Presented By
Harry Mills / PRESENTATIONPRO
QUICK-RELIEF MEDICATIONS
Presented By
Harry Mills / PRESENTATIONPRO
Adapted from 2007 NHLBI Expert Panel Guidelines (EPR-3).
SHORT-TERM CONTROL: ANTICHOLINERGIC
Presented By
Harry Mills / PRESENTATIONPRO
Adapted from 2007 NHLBI Expert Panel Guidelines (EPR-3).
SHORT-TERM CONTROL:
SHORT-ACTING BETA2 AGONISTS (SABA)
Presented By
Adapted from 2007 NHLBI Expert Panel Guidelines (EPR-3). Harry Mills / PRESENTATIONPRO
Steps of Asthma Management
Step Up If Needed
Consider consultation at step 3.
Step 6
Step 5 Preferred:
Step 3 Step 4 Preferred: High-dose
Preferred: Preferred: High-dose ICS + LABA
Presented By
Harry Mills / PRESENTATIONPRO
EMERGENCY DEPARTMENT TREATMENT
Presented By
Harry Mills / PRESENTATIONPRO
EMERGENCY DEPARTMENT TREATMENT
– Treatment:
• O2 (Sa O2 90-95),
• Inhaled short-acting bronchodilator for all pts. (3 tx Q 20
min, continuous therapy an option)
• Consider anti-cholinergics
• Oral systemic corticosteroids (unresponsive to initial beta2
agonist therapy, moderate-to-severe asthma, people who
are on steroids)
• Systemic steroids administered when admitted
• Methylxanthines are not recommended?
Presented By
Harry Mills / PRESENTATIONPRO
EMERGENCY DEPARTMENT TREATMENT
– Treatment:
• Aggressive hydration NOT recommended for older children
and adults (may be necessary with infants and sm. children)
• Antibiotics NOT recommended unless infection present
(fever, purulent sputum)
• CPT NOT recommended
• Mucolytics NOT recommended
• Sedation NOT recommended
Presented By
Harry Mills / PRESENTATIONPRO
Hospitalization
Presented By
Harry Mills / PRESENTATIONPRO
ASTHMA MANAGEMENT DURING PREGNANCY
• Treatment:
– Emergency dept. treatment
– Intubation shouldn’t be delayed once ARF is identified
• Permission hypercapnia is recommended ventilator strategy
Presented By
Harry Mills / PRESENTATIONPRO
ASTHMA MANAGEMENT IN ER
• Lack of familiarity
• Lack of agreement
• Lack of self-efficacy
• Lack of outcome expectancy
• Presence of external barriers
– Lack of equipment or space
– Lack of time
– Lack of educational materials
– Lack of reimbursement
– Lack of appropriate infrastructure
Presented By
Harry Mills / PRESENTATIONPRO
Cabana MD, et al. Arch Pediatr Adolesc Med. 2001;155:1057-1062.
ASTHMA MANAGEMENT IN ER
• Lack of familiarity
• Lack of agreement
• Lack of self-efficacy
• Lack of outcome expectancy
• Presence of external barriers
– Lack of equipment or space
– Lack of time
– Lack of educational materials
– Lack of reimbursement
– Lack of appropriate infrastructure
Presented By
Harry Mills / PRESENTATIONPRO
Cabana MD, et al. Arch Pediatr Adolesc Med. 2001;155:1057-1062.
Questions
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Harry Mills / PRESENTATIONPRO