Transcript Document

Teach Asthma Management
(TAM)
Provided by:
Generously supported by the Robert Wood Johnson Foundation
Some slides adapted from Physician Asthma Care Education, developed by
Noreen Clark, University of Michigan, School of Public Health
Part I of II
Overview of Asthma
Michael Zacharisen, M.D.
Allergist
Children’s Hospital of Wisconsin
OBJECTIVES:


Increase your knowledge of pediatric asthma
epidemiology
Improve your clinical and community care of
children with asthma and their families
Asthma Patient Demographics
US Population = 277.8 Million (US Census, 3/01)
Asthma Patients = 5.6% Prevalence (ALA, 2/01)
Severe
18%
17.7
million
patients
with
asthma
Age 18 y
12.1
million
68%
Age 0-17 y
5.6 million
32%
Patients
With Asthma1
Age1
Moderate
persistent
34%
2.7 m AA
7.2%
4.2 million
Hispanic
11.7%
Mild
10.8 million
persistent
Caucasian
22%
5.4%
prevalence
Mild
intermittent
26%
Severity2
1. Morbidity & Mortality Weekly Report, 2001.
2. Asthma Physician Market Dynamics Study, 2001.
3. National Center for Health Statistics, 1986-1999.
4. Scott Levin, PDDA, MAT 12/01.
Race3
Male
45%
Female
55%
Gender4
CDC Press Release
9 million children <18 have been diagnosed with
asthma
 >4 million have had an asthma attack in the past 12
months
 12% of children <18 have been diagnosed with asthma
Boys 14%, Girls 10%
Poor families 16%, Not poor families 11%

www.cdc.gov/nchs released 3/2004
Burden of ASTHMA in Wisconsin
12% of adults and 8% of children have been told they have
asthma (Overall = 9%)
 5,000 asthma hospitalizations (2002)
Costs of $36 million in 2002
Average charge of $6,942/stay
 22,418 asthma emergency department visits
Costs of $13.3 million in 2002

Wis. DHFS; PPH 45055 (03/04) http://dhfs.wisconsin.gov
Burden of ASTHMA in Wisconsin
80% report asthma symptoms in past 30 days
 Only 48% report having a routine health care visit for asthma in
past 12 months
 Only 40% report daily medication use
 In past 12 months:
14% adults had ED visit
18% adults had limited daily activities due to asthma

Wis. DHFS; PPH 45055 (03/04) http://dhfs.wisconsin.gov
Definition of Asthma
A chronic inflammatory disease of the airways
with the following clinical features:
• Episodic and/or chronic symptoms of airway
obstruction.
• Bronchial hyperresponsiveness to triggers.
• Evidence of at least partial reversibility of the airway
obstruction.
• Alternative diagnoses are excluded.
Changes in Airway Morphology in Asthma
Mucous gland
hypertrophy
Edema
Epithelial
damage
Airway smooth
muscle
Inflammatory
cell infiltration
Mucus
Thickening
of basement
membrane
Vascular
dilation
Adapted from National Asthma Education and Prevention Program. Expert Panel Report.
Guidelines for the Diagnosis and Management of Asthma. August 1991.
Evolution of Asthma Paradigms
Symptoms
Bronchial
Hyperreactivity
Fixed
Obstruction
Relieve Symptoms
Prevent Symptoms
Prevent Attacks
Prevent Symptoms
Prevent Attacks
Prevent Remodeling
A Lot Going On
Beneath The Surface
Symptoms
Airflow
obstruction
Bronchial
hyperresponsiveness
Airway
inflammation
Expert Panel Report 2:
Four Components of
Asthma Management

Measures of Assessment and Monitoring

Control of Factors Contributing to
Asthma Severity

Pharmacologic Therapy

Education for a Partnership in Asthma Care
Component 1:
Initial Assessment and Diagnosis of Asthma

Determine that:
Patient has history or presence of episodic symptoms of airflow
obstruction
Airflow obstruction is at least partially reversible
Alternative diagnoses are excluded

Methods for establishing diagnosis:
Detailed medical history
Physical exam
Spirometry to demonstrate reversibility
Component 1:
Initial Assessment and
Diagnosis of Asthma (continued)
Does patient have history or presence of
episodic symptoms of airflow obstruction?

Wheeze, shortness of breath, chest tightness, or
cough

Asthma symptoms vary throughout the day

Absence of symptoms at the time of the
examination does not exclude the diagnosis
of asthma
Initial Assessment and
Diagnosis of Asthma (continued)
Is airflow obstruction at least partially
reversible?

Use spirometry to establish airflow obstruction:
FEV1 < 80% predicted;
FEV1/FVC <65% or below the lower limit of normal

Use spirometry to establish reversibility:
FEV1 increases >12% and at least 200 mL after
using a short-acting inhaled beta2-agonist
Component 2:
Control of Factors
Contributing to Asthma Severity

Assess exposure and sensitivity to:
Inhalant allergens
Occupational exposures
Ask specifically about work-related triggers
Irritants:
Indoor air (including tobacco smoke)
Air pollution
Component 2:
Control of Factors
Contributing to Asthma Severity

Assess contribution of other factors:
Rhinitis/sinusitis
Gastroesophageal reflux
Drugs (NSAIDs, beta-blockers)
Viral respiratory infections
Sulfite sensitivity
(continued)
Pediatric Differential Diagnosis
 Chronic sinusitis
 Vocal cord
dysfunction (VCD)
 Croup
 Tracheomalacia
 Pertussis
 TE fistula
Foreign body
Bronchiolitis
Cystic fibrosis /
Ciliary dysfunction
GERD
Hyperventilation
syndrome
Viruses and Asthma
 Viral infections frequently cause wheezing
30-60% of children will wheeze in 1st 5 years
Frequent cause of asthma exacerbation
 Unable to directly link viral infections with development
of asthma
Proven risk factors include:
Family history of asthma
Environmental smoke exposure
History of severe bronchiolitis in 1st 18 months
Benchmarks of Good Asthma Control






Infrequent coughing or wheezing
No shortness of breath or difficulty breathing
No waking up at night due to asthma
Normal physical activities
No childcare or school absences due to asthma
No missed time from work for parent or caregiver
AAAAI Guide
Classification Of Asthma Severity:
Clinical Features Before Treatment
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent
STEP 1
Mild
Intermittent
Days with
Symptoms
Nights with
Symptoms
PEV or
FEV1
Continual
Frequent
< 60
Daily
> 5/month
> 60% to
<80%
3-6/week
3-4/month
> 80%
< 2/week
< 2/month
> 80%
Misclassification of Intermittent Asthma
Adapted from Liard. Eur Respir J. 2000;16:615-620.
n=4,362
# of Patients
1,000
800
Mild
intermittent
60%
600
40%
953
patients
400
600
Mild
persistent
22%
400
200
200
Mild intermittent asthma
based on symptoms
and FEV1 alone
Moderate
persistent
15%
Severe
persistent
3%
Classification of the same group but now
based on symptoms, FEV1,
and medication use
Pediatric Asthma Deaths:
Patients With Mild Asthma Are Also at Risk
40
35
Patient 30
Deaths 25
(%)
36%
31%
33%
20
15
10
5
0
Severe
Moderate
Mild
Findings from a cohort study reviewing all pediatric asthma-related deaths
Patient Assessment
(n=51) in the Australian state of Victoria from 1986 to 1989.
Robertson et al. Pediatr Pulmonol. 1992;13:95-100.
How Can Asthma Control Be Measured?
Inflammation?
Direct or indirect?
Lung
function?
Nighttime
awakenings?
Utilization of
healthcare
resources?
Satisfaction
with care?
Functional
status?
Daytime
symptoms?
Asthma
Control
Missed work
and/or school?
Use of “quick
relief” inhaler
and/or
nebulizer?
Patient self-report
of control?
Paradigm Shift in Asthma
Asthma
Uncontrolled
Adjust
therapy
Difficult
to control
Controlled
Asthma Control and Steroid Doses After Early
or Delayed Intervention

Patients with asthma started on budesonide were
compared based on duration of asthma at
budesonide initiation
Asthma for <2 years
Asthma for 2 years

Outcomes assessed
Lung function: FEV1, PEF
Persistent need for inhaled corticosteroid
Persistent symptoms
Selroos et al. Respir Med. 2004;98:254-262.
Mean ICS Doses and Lung Function
5 Years After Early or Delayed Intervention
Inhaled steroid
FEV1 % pred
900
93.9
Dose of Inhaled Steroid
800
95
825
100
PEF, % pred
95
700
600
500
90
87.2
412
84.5
400
85
300
200
80
100
0
Early Treatment
Selroos et al. Respir Med. 2004;98:254-262.
Delayed Treatment
75
% of Predictive FEV1, PEF
1000
Does chronic use of inhaled corticosteroids improve long-term
outcomes for children with mild or moderate asthma, compared
to other asthma medications?
“Strong evidence” established that inhaled corticosteroids
improve asthma control for children with mild-moderate asthma
 None of the alternatives “listed alphabetically” cromolyn,
leukotriene modifier, nedocromil, sustained release
theophylline are as effective
 “Low dose” inhaled corticosteroids are the “preferred”
treatment for mild asthma
 “Low dose” inhaled corticosteroids plus long acting inhaled
beta2 agonists are the “preferred” treatment for moderate
asthma

NIH Publication No. 02-5075, June 2002
Inhaled Glucocorticoids Versus Leukotriene Receptor
Antagonists as Single Agent Asthma Treatment: Systematic
Review of Current Evidence
Ducharme FM. BMJ 2003;326:621-625.
Objective: To compare the safety and efficacy of
leukotriene modifiers (LTM) with inhaled corticosteroids
(ICS) as monotherapy in patients with asthma
 Primary Outcome: Rate of exacerbations that required
treatment with systemic corticosteroids
 Secondary Outcomes: Lung function (FEV1, AM PEF),
nocturnal awakenings, use of rescue ß2- agonist, withdrawal
rates, days with symptoms, & adverse events

Results - Primary Outcome

Patients receiving LTM were 60% more likely to
experience an exacerbation than those treated with ICS
(11 trials; RR 1.6, 95% CI 1.2-2.2)

No difference in risk for exacerbations was found in the
one pediatric trial reviewed (RR 0.78, 0.32-1.85)
Ducharme FM. BMJ 2003;326:621-625.
What are the long-term adverse effects of chronic inhaled
corticosteroid use in children:
growth, bone density, ocular, HPA?



“Strong evidence” shows that inhaled corticosteroids at
recommended doses do not have clinically significant or
irreversible effects on these outcomes
Low to medium doses of inhaled corticosteroids have the
potential to decrease growth velocity 1cm in the first year but
this is NOT sustained, progressive, and may be reversible
Observational studies up to 6 years reveal no adverse effect
on bone density, cataracts, glaucoma, or clinically significant
HPA axis changes
NIH Publication No. 02-5075, June 2002
Corticosteroids for Asthma:
Benefits and Risks
Dose, drug, &
route dependent
Reduces
inflammation
Decreases
morbidity / mortality
Most effective
long-term control
medication for
asthma*
Benefits
Generally known
and can be
monitored
Risks
In patients with moderate persistent asthma who are on ICS,
does the addition of another long-term control agent improve
outcomes?



“Strong evidence” consistently indicates that the addition of a
long acting inhaled ß2 agonist leads to improvement in lung
function, symptoms & reduced additional ß2 agonist use
Adding an LTM or theophylline to an ICS or doubling the ICS
dose improves outcomes “but the evidence is not as
substantial”
For children less than 5 the preferred treatment is low dose
ICS + a long acting inhaled ß2 agonist or medium dose ICS
NIH Publication No. 02-5075, June 2002
What have we learned from all of the studies?
low-dose ICS + LABA vs. “other therapy” results in:





 Lung function
 Symptoms
 Albuterol use
 Exacerbations
Reduces need to increase ICS dose
Replicated numerous times by other investigators
Greening et al. Lancet. 1994;344:219-224.
Woolcock et al. Am J Respir Crit Care Med. 1996;153:1481-1488
Nelson et al J Allergy Clin Immunology 2000;106:1088-1095
Infants and Young Children— When to Start
Controllers
>3 episodes of wheezing in the last year and
 Parental history of asthma or physician diagnosis of eczema

Or 2 of the following
 Physician diagnosis of allergic rhinitis, wheezing apart from
colds, peripheral eosinophilia
 Courses of oral steroids more often than every 6 wk
 Symptoms >2x/wk, nocturnal symptoms >2x/mo
Principles of Maintenance Therapy

Start high.
 Step down once control is achieved.
 Maintain at lowest dose of medication that
controls asthma.
 Step up and down as indicated.
Step-down Therapy
Step down once control is achieved.
 After 2–3 mo.
 25% reduction over 2–3 mo.
Follow-up monitoring
 Every 1–6 mo.
 Assess symptoms.
 Review medication use.
 Objective monitoring (PEFR or spirometery).
 Review medication.
Step-up Therapy

Indications: symptoms, need for quickrelief medication, exercise intolerance,
decreased lung function.
May need short course of oral steroids.
 Continue to monitor.
Follow and reassess every 1–6 mo.
Step down when appropriate.
Acute Exacerbations
Principle: Gain control as quickly as possible.
Treat all asthma exacerbations promptly
and aggressively.
 Inhaled ß2-agonist inhalants for quick relief
 Access to quick relief medication
 Written action plan
Indications
Medications
When to contact physician or emergency medical services
 Short course of oral corticosteroids
Acute Exacerbations
Office Management
Assess severity.

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
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


Symptoms, signs, lung function, pulse oximetry (if
available)

Oxygen recommended
Short acting ß2-agonist inhalant every 20–30 min
 Ipratropium—metered-dose inhaler, inhalation solution
 Corticosteroid—orally, intravenous if vomiting
Intravenous favored if dehydrated
Follow-up—hours (phone) to 1–7 d
Stepwise Approach to Therapy
for Children 5 Years
Step 4
Severe Persistent
Step 3
Moderate Persistent
Step 2
Mild Persistent
Step 1
Mild Intermittent
Preferred:
Low-dose ICS
No Daily
Medication
Alternative:
Cromolyn
or LTRA
Preferred:
Low-dose ICS +
LABA or
Medium-dose ICS
(+ LABA if needed)
High-dose ICS +
LABA
(+ systemic
corticosteroids
if needed)
Alternative:
Low- to Med-dose ICS
+ LTRA or
Theophylline
ICS = inhaled corticosteroid; LABA = long-acting 2-agonist; LTRA = leukotriene receptor antagonist
NIH/NHLBI Guideline Update. June 2002. NIH Publication No. 02-5075.
Stepwise Approach to Therapy
for Adults and Children >5 Years
Step 4
Severe Persistent
Step 3
Moderate Persistent
Step 2
Mild Persistent
Step 1
Mild Intermittent
No Daily
Medication
Preferred:
Low-dose ICS
Alternative:
Cromolyn, LTM,
Nedocromil, or
SR Theophylline
Preferred:
Low- to Med-dose
ICS + LABA
( to med-dose
ICS+ LABA if
needed)
High-dose ICS +
LABA
(+ systemic
corticosteroids
if needed)
Alternative:
 ICS With No LABA
or Low- to Med-dose
ICS + LTM or
Theophylline
ICS = inhaled corticosteroid; LABA = long-acting 2-agonist; LTM =
leukotriene modifier; SR = sustained release.
NIH/NHLBI Guideline Update. June 2002. NIH Publication No. 02-5075.
Tools to Improve Asthma Documentation &
Quality Care

Living with Asthma Questionnaire
 Asthma Control Test
 Progress Note Template
 Asthma Action Plan
More QI information see:
www.eqipp.org
www.improvingchroniccare.org
Medication
Adverse Effects
Short & Long-Acting
Bronchodilators
Increased heart rate, tremors,
headache (last short time)
Cromolyn / Tilade
Rare, may have throat irritation
Leukotriene Modifiers
GI upset
Inhaled Corticosteroids
Thrush, dysphonia, high doses may
have systemic effects
Systemic Corticosteroids
Many - Increased appetite,
stomachache, mood changes, fluid
retention, diabetes, osteoporosis
Education for Partnership in Care
 Develop a written asthma management plan
Agree on therapy goals
Outline daily treatment and monitoring measures
Prepare an action plan to handle worsening symptoms
 Provide routine education on patient self-management
How and why to take medications
Correct technique for devices
Peak flow or symptom monitoring
Factors that worsen asthma and actions to take
Asthma Medications and Devices
Rhonda J. Duerst, RRT-NPS, AE-C
Children’s Hospital of Wisconsin
Objective:

Teach caregivers to administer daily antiinflammatory control medications as needed and
quick relief medicines for patients with persistent
asthma
Asthma Can be Managed




With proper therapy, the child can be symptom free
Goal is to use the least amount of medication as
possible, increasing on an as-needed basis
Long-term goal of reducing or even stopping
regular medications
Emphasis on as little as possible address parents’
fears of over-medication and dependence
What makes Asthma Management so hard for
Parents and Children?







Here today, gone tomorrow: periods of symptoms
interspersed with symptom-free periods
Daily medicines even when feeling well
Unpredictability: don’t know exactly what triggers the episode
Complicated medication plan varies with symptom intensity
and disease severity
Need to monitor asthma symptoms
Fears about medication side-effects
Medication only part of the plan, trigger reduction also
needed.
Explaining How to Take Medicines

Clinician Message:
Demonstrate use of
inhaler and spacer
Show how to use peak
flow meter
Give step-by-step
instructions

Parent Message:
Feel comfortable
with “technology”
Know how and
where to get
equipment
What to do if you run
out of medicine
Fears About Asthma Medicines
39% Believe medicines are addictive
36% Believe medicines are not safe to take over a
long period
58% Believe regular use will reduce effectiveness
Quick Relief Medicines





Act fast, generally within 15-20 minutes
Relaxes the smooth muscles around the bronchial
tubes
Parents need to know how often child is using
Must have available at all times
Is only medicine that helps child breathe quickly
ASTHMA MEDICATIONS

Beta 2 agonists - bronchodilators
Albuterol (Proventil, Ventolin)
Pirbuterol (Maxair)
Levalbuterol (Xopenex)
Terbutaline (Brethine)
Metaproterenol (Alupent)
Explain About Quick-Relief Medications

Provider message:
–Quick-relief medications
relax the muscles after they
have tightened during an
attack
–Parents are in charge of
helping their children breathe
through the quick-relief
medications
–Quick- relief medications
act fast, so that breathing is
easy again within minutes

Parent Message:
–Know that medicines will
open up lungs and child
won’t suffocate
–Know that reaction is not
instant; may take a few
minutes
–Quick relief medicines are
parents’ ticket to helping
child breathe
Communication Tip for Quick-Relief Medications
Use a physical example: Unclamp fist to show how medicines
work
 Ask parent about fears they have regarding child’s asthma
episode
 Discuss concerns parents may have about medications
Jitteriness; anxiety & other side effects parents may fear
(“dependence”)
 Be accurate about risks but reinforce message that medicines
work!

Explaining about Long-term Control Medications

Provider Message:
–Anti-inflammatory medicines
don’t relieve symptoms
–Do reduce inflammation and
prevent frequent or severe
episodes
–Needed if symptoms more
than 2X/week in day or
2X/month at night
–Effective only if taken
regularly

Parent Message:
–Anti-inflammatory meds
are like a flu shot, to help
keep away the “bad” asthma
episodes
–Anti-inflammatory
medicines are like vitamins;
they need to be taken all the
time, even if not sick
Communication Tips about Long-term Control
Medicines
Explain the different types of controllers (parents want to
know the names), and why more than one may be used
 Convey clearly information about any risks or side effects
 Discuss fears about medication “dependence”
Low Doses of Inhaled Corticosteroids do not cause side
effects
Not the same as the body-building steroids
 Emphasize safety of the medications when used as
prescribed on the plan.

ASTHMA MEDICATIONS

Long-acting beta 2 agonists
Salmeterol (Serevent)
Formoterol (Foradil)
Combine with ICS (ADVAIR available)
Corticosteroids

Inhaled (ICS)
Beclomethasone (Vanceril,
Beclovent, Q-VAR)
Budesonide (Pulmicort)
Flunisolide (Aerobid)
Fluticasone (Flovent, ADVAIR)
Triamcinolone acetonide
(Azmacort)

Systemic
Prednisone/Prednisolone
Methylprednisolone (SoluMedrol, Medrol)
ASTHMA MEDICATIONS



Mast cell stabilizers
Cromolyn sodium (Intal)
Nedocromil (Tilade)
Anticholinergic
Ipratropium bromide
(Atrovent)
Methylxanthines
Theophylline
Aminophylline
ASTHMA MEDICATIONS

Leukotriene inhibitors
Oral, QD-BID
Montelukast (Singulair)
Zafirlukast (Accolate)
Zileuton (Zyflo)
Some evidence of effectiveness in preventing premenstrual
asthma exacerbations1
1. J Allergy Clin Immunol 1999;104:585-8.
Teaching Checklist





Use of inhaler/spacer
Use of nebulizer
Use of Peak Flow Meter
Give step by step directions
Instruct how/where to get
spacers/nebs/PFM
Instruct what to do if run out
of medicine or can’t get
devices
 Ask parent/child to
demonstrate technique at
each visit
 Reassure parent about using
alternative treatments with
medications

Spacers/Holding
Chambers
Spacers/Holding Chambers
Recommended with all medium to high dose ICS
 Enhance delivery, especially with children
 Improves coordination and medication delivery
some provide auditory feedback
 Minimize adverse effects from ICS
decrease oral bioavailability
reduce oral candidias (thrush)
dysphonia, and bad taste

Without Spacer
©1998,
Respironics
Inc.
With Spacer
©1998,
Respironics Inc.
Dry Powder Inhalers (DPI)
Spacers can not be used with DPI
 Turbuhaler®, Diskus®, Aerolizer™
 Must be able to do mouthpiece treatment
 Deep rapid inhalation

Peak
Flow
Meters
Peak Flow Monitoring







Provides objective information
Documents personal best
Detects worsening asthma before changes occur
Useful only if breathing is monitored regularly
Indicates need for quick-relief medications
Assists in precipitant identification
Aids in communication
Determine Personal Best Peak Flow
Take peak flow reading at least once per day for 2-3 weeks
 Measure peak flow at these times:

Between noon and 2pm each day
Each time quick-relief meds are taken for symptoms
Any other time your doctor suggests
Use same peak flow meter over time
 Important Component of written action plan

Proper PF Technique
1- Set meter to Zero
2- Stand up straight
3- Take deep breath in
4- Blow out hard & fast
5- Repeat two more times
6- Record your highest number
Teaching Peak Flow





Instruct in how to establish child’s personal best
Demonstrate to child/parent how to set child’s zones (red,
yellow & green)
Help parent establish a routine for peak flow measurements
Remind parent to adjust medications according to peak flow
number
Encourage parent to bring PF diary with to all appointments