Approach to Asthma

Click ,to edit Master subtitle style By Dr Mohammed Faizy, MD, DTCD Pulmonologist Safa Makkah Polyclinic, Riyadh

Asthma
Asthma is a chronic (long-term) lung disease that inflames and narrows the airways. Asthma causes recurring periods of wheezing (a whistling sound when you breathe), chest tightness, shortness of breath, and coughing. The coughing often occurs at night or early in the morning.

Click to edit Master subtitle style

Differential Diagnosis

Upper airway diseases Allergic rhinitis and sinusitis Obstructions involving large airways Foreign body in trachea or bronchus Vocal cord dysfunction Vascular rings or laryngeal webs Laryngotracheomalacia, tracheal stenosis, or bronchostenosis Enlarged lymph nodes or tumor Obstructions involving small airways Viral bronchiolitis or obliterative bronchiolitis Cystic fibrosis Bronchopulmonary dysplasia Heart disease Other causes Aspiration Medication induced Anemia Abdominal tumors Deconditioning / obesity Neurological conditions

Modified NAEP Asthma Severity Classification

Mild Asthma Brief (<1 h) symptomatic exacerbations < twice/week PEFR > 80% of personal best FEV1 > 80% of predicted when asymptomatic No nocturnal symptoms

Modified NAEP Asthma Severity Classification

Moderate Asthma Symptomatic exacerbations > twice/week Exacerbations affect activity levels Exacerbations may last for days PEFR,FEV range from 60% to 80% of predicted Regular medications necessary to control symptoms

Modified NAEP Asthma Severity Classification

Severe Asthma Continuous symptoms/frequent exacerbations limit activity levels PEFR,FEV <60% of expected, and are highly variable Regular oral corticosteroids necessary to control symptoms

Asthma Management & Prevention

Asthma in Children

Asthma in Pregnant Women

Effects of Pregnancy on Asthma

No evidence to suggest that pregnancy has a predictable effect on underlying asthma Two prospective studies (1998) of more than 500 women found about equal thirds of the group either improved, remained unchanged or clearly worsened Again baseline asthma severity correlated with asthma morbidity during pregnancy

Mild asthma 13% had exacerbation Moderate 26 % had exacerbation Severe 50% had exacerbation

Effects of Asthma on Pregnancy

Controversial results in terms of preeclampsia, cesarean delivery, prematurity, IUGR, and perinatal mortality rate Generally unless there is severe disease, asthma has relatively minor effects on pregnancy outcome Most studies show slight increase of incidence of preeclampsia, pre-term labor, low birthweight infants and perinatal mortality

Effects of Asthma on Pregnancy

A prospective study by Dombrowski (2000), preterm delivery was not increased among pregnancies complicated by asthma compared to non-asthmatic controls. However, the majority of women in the study with severe asthma showed an increase of preterm labor by two fold. Status asthmaticus characterized by resp failure substantially increases maternal and perinatal mortality Bracken (2003) found preterm delivery only slightly increased with asthma while IUGR increased with severity of asthma

Antenatal Management

Asthma history

Severity of symptoms Nocturnal symptoms

Pregnant patients with mild well controlled asthma may receive routine prenatal care Moderate and Severe asthma will need more frequent visits and consider referral in severe cases

Referral Indications

To Asthma/Allergy subspecialist

Diagnosis is severe, persistent asthma Diagnosis is unclear More complete allergy evaluation is desired Asthma is not under control even after appropriate avoidance measures are taken and medications have been adjusted and redirected Life threatening exacerbation

Management

Ultimate goal is prevention of hypoxic episodes to mother and fetus Relies on four components

Objective measures for accurate monitoring Minimizing asthma triggers Patient education Pharmacologic therapy

Patient Education

Understanding that asthma control is important to fetal well being Reduction of triggers Understanding of basic medical management including self monitoring

Beta agonists

Mild asthma Acute exacerbations Rapid onset of action Can cause tremor, tachicardia, and palpitations

Inhaled Corticosteroids

Preferred for persistent asthma Goal is to reduce dependence on beta agonists for symptomatic relief Significantly reduce hospitalization in both pregnant and non pregnant women Side effects

Short term steroid use

Reversible increases in glucose, decreases potassium, fluid retention with weight gain, mood alterations including rare psychosis, hypertension, peptic ulcers, aseptic necrosis of the femur, and very rare allergic reactions Height and growth, immune suppression, hypertension, cataracts, and hirsutism

Long term steroid use

Step Therapy

Least number of medications needed to control symptoms should be used Increase number and frequency of medications with increasing severity Systemic corticosteroids are indicated for exacerbations not responding to initial beta agonist therapy regardless of asthma severity

Home Management of Acute Asthma Exacerbations

Use inhaled albuterol two to four puffs and check PEFR in 20 minutes If PEFR <50% predicted or symptoms are severe: obtain emergency care If PEFR 50% to 70% predicted: Repeat albuterol treatment, check PEFR in 20 minutes If PEFR remains <70% predicted: Contact caregiver or go for emergency care If PEFR >70% predicted: Continue inhaled albuterol (two to four puffs q3 4h for 6-12h as needed) If decreased fetal movement: Contact caregiver or go for emergency care

Emergency Assessment and Management of Asthma Exacerbations

Initial Evaluation

History Examination PEFR Oximetry Fetal monitoring if potentially viable

Emergency Assessment and Management of Asthma Exacerbations

Initial treatment

Inhaled beta2 agonist (3 doses over 60-90 minutes) Oxygen to maintain saturation > 95% If no wheezing and PEFR or FEV1 > 70% baseline, discharge with follow up

Emergency Assessment and Management of Asthma Exacerbations

If oximetry <50% FEV1, <1.0 liter, or PEFR < 100 liters/min upon presentation Continue nebulized albuterol Start intravenous corticosteroids Obtain arterial blood gases Admit to intensive care unit Possible intubation

Emergency Assessment and Management of Asthma Exacerbations

If PEFR or FEV1 > 40% but <70% baseline after beta 2 agonist

Obtain arterial blood gases Continue inhaled beta 2 agonist every 1-4 hours Start intravenous corticosteroids in most cases Hospital admission in most cases

Labor and Delivery

Asthma usually quiesent thought to be due to increase in cortisol Continue regular asthma medications Adequate hydration and analgesia to reduce bronchospasm Stress doses of corticosteroids are indicated for patients given systemic steroids within preceding four weeks

Labor and Delivery (continued)

Establish baseline PEFR on admit and serially thereafter if symptoms develop Prostaglandin E1 and E2 may be used for cervical ripening, PPH Hemabate may cause bronchospasms and should be avoided