2012 asthma
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This document summarizes guidelines for diagnosing and managing asthma from the American Thoracic Society, National Asthma Education and Prevention Program, and Global Initiative for Asthma. It outlines defining features of asthma including airway inflammation and obstruction. Diagnosis involves assessing symptoms, lung function testing, and ruling out other causes. Goals of treatment are avoiding symptoms, limiting reliever medication use, and normal lung function through a stepwise treatment approach tailored to asthma severity and level of control.
2012 asthma
- 1. Asthma Control: GuidelineAsthma Control: Guideline BasedBased American Thoracic Society (ATS),American Thoracic Society (ATS), National Asthma Education and PreventionNational Asthma Education and Prevention Program (NAEPP), and Global Initiative for AsthmaProgram (NAEPP), and Global Initiative for Asthma (GINA)(GINA) Michael P. Pietila, MDMichael P. Pietila, MD Pulmonary, Critical Care and InternalPulmonary, Critical Care and Internal Medicine Yankton Medical Clinic, P.C.Medicine Yankton Medical Clinic, P.C. Assistant Professor Sanford School ofAssistant Professor Sanford School of Medicine at USDMedicine at USD
- 2. Professional RelationshipsProfessional Relationships I am a contracted speaker for:I am a contracted speaker for: – Merck PharmaceuticalsMerck Pharmaceuticals – Dey Pharma L.P. Bureau of COPD ResearchDey Pharma L.P. Bureau of COPD Research and Education to Advance Therapeuticand Education to Advance Therapeutic Excellence (BREATHE)Excellence (BREATHE) I will not be speaking specifically aboutI will not be speaking specifically about any of these companies products today.any of these companies products today.
- 3. Defining and Recognizing AsthmaDefining and Recognizing Asthma Netter’s Anatomy
- 4. Asthma EpidemiologyAsthma Epidemiology Estimated > 23 million AmericansEstimated > 23 million Americans – Prevalence 5-25% of populationPrevalence 5-25% of population Increasing prevalence and severityIncreasing prevalence and severity – USA and worldwideUSA and worldwide – Socioeconomics > geneticsSocioeconomics > genetics $14 Billion direct annual costs in USA$14 Billion direct annual costs in USA
- 5. EpidemiologyEpidemiology More common in males (equal after ageMore common in males (equal after age 20).20). Atopy – Skin test reactivity, elevated IgEAtopy – Skin test reactivity, elevated IgE levels, blood eosinophilia.levels, blood eosinophilia. Indoor allergens – dust mites, animalIndoor allergens – dust mites, animal dander.dander. Environmental pollution, occupationalEnvironmental pollution, occupational exposure.exposure. Respiratory infections.Respiratory infections. TOBACCO SMOKE.TOBACCO SMOKE.
- 6. Increasing Asthma MortalityIncreasing Asthma Mortality 500,000 hospitalizations per year in U.S.500,000 hospitalizations per year in U.S. 5-6,000 deaths per year5-6,000 deaths per year 1978 - beginning of increasing mortality1978 - beginning of increasing mortality Role of poverty (vs. race)Role of poverty (vs. race) – Access to health care, medications, educationAccess to health care, medications, education – Greater environmental exposureGreater environmental exposure – Importance of identifying persons with high risk ofImportance of identifying persons with high risk of deathdeath
- 7. Definition of AsthmaDefinition of Asthma • Obstructive lung disease with characteristicsObstructive lung disease with characteristics of:of: – Airway obstruction;Airway obstruction; reversiblereversible in most patientsin most patients – Chronic airwayChronic airway inflammation (eosinophils)inflammation (eosinophils) – IncreasedIncreased airwayairway responsivenessresponsiveness Onset of symptoms can occur at any ageOnset of symptoms can occur at any age NAEP - Guidelines for the Diagnosis and Management of Asthma 1991NAEP - Guidelines for the Diagnosis and Management of Asthma 1991
- 8. Guidelines for the Diagnosis and Management ofGuidelines for the Diagnosis and Management of AsthmaAsthma Key MessagesKey Messages Asthma is an inflammatory diseaseAsthma is an inflammatory disease Environmental factors are importantEnvironmental factors are important Objective measures are neededObjective measures are needed Health education is crucialHealth education is crucial Emphasis on recognition and avoidance ofEmphasis on recognition and avoidance of triggerstriggers Buist & Vollmer. NEJM 331:1584-5;1996Buist & Vollmer. NEJM 331:1584-5;1996 Asthma Guidelines 2007Asthma Guidelines 2007
- 9. Asthma Guidelines 2007Asthma Guidelines 2007 Components of severity:Components of severity: – Symptoms and objective testing.Symptoms and objective testing. – FEV1 and FEV1/FVC measurement.FEV1 and FEV1/FVC measurement. – Need for short-acting beta-agonist (SABA).Need for short-acting beta-agonist (SABA). – Nighttime awakenings.Nighttime awakenings. – Interference with normal activity.Interference with normal activity.
- 10. Diagnosing AsthmaDiagnosing Asthma Symptoms and Medical HistorySymptoms and Medical History – Wheezing, cough, difficult breathing and chestWheezing, cough, difficult breathing and chest tightnesstightness Symptoms worse at night/on awakeningSymptoms worse at night/on awakening Seasonal patternSeasonal pattern Eczema, hay fever, family historyEczema, hay fever, family history Triggers – animal fur, chemicals, temperatureTriggers – animal fur, chemicals, temperature change, dust mites, drugs, exercise, pollen, URI,change, dust mites, drugs, exercise, pollen, URI, smokesmoke Symptoms respond to anti-asthma therapySymptoms respond to anti-asthma therapy Colds “go to the chest” or last > 10 days.Colds “go to the chest” or last > 10 days. Pocket Guide for Asthma Management and Prevention 2011
- 11. Asthma PhenotypesAsthma Phenotypes Intermittent/PersistentIntermittent/Persistent – Mild/Moderate/SevereMild/Moderate/Severe Adult onset wheezingAdult onset wheezing – Primary asthma and secondary causesPrimary asthma and secondary causes – Tends to me more severeTends to me more severe Occupational asthmaOccupational asthma Neutrophilic inflammationNeutrophilic inflammation
- 12. Diagnostic TestsDiagnostic Tests No single test can secure a diagnosis ofNo single test can secure a diagnosis of asthmaasthma Spirometry is the most helpful, preferredSpirometry is the most helpful, preferred method for establishing diagnosis.method for establishing diagnosis. – Increase in FEV1 of > 12% and 200 ml afterIncrease in FEV1 of > 12% and 200 ml after inhaled bronchodilator.inhaled bronchodilator. – Many asthma patients are negative andMany asthma patients are negative and repeat testing is advised.repeat testing is advised.
- 13. Diagnostic TestingDiagnostic Testing Peak expiratory flow (PEF) – aid inPeak expiratory flow (PEF) – aid in diagnosis and management.diagnosis and management. – Compare to patient's previous best effortCompare to patient's previous best effort – 60 L/min improvement after BD or diurnal60 L/min improvement after BD or diurnal variation in PEF of more than 20%variation in PEF of more than 20% Bronchoprovaction testing.Bronchoprovaction testing. – Methacholine, histamine or inhaled mannitolMethacholine, histamine or inhaled mannitol Skin testing or specific IgE testing forSkin testing or specific IgE testing for allergens.allergens.
- 14. Diagnostic ChallengesDiagnostic Challenges Cough variant asthmaCough variant asthma – Chronic cough, often at nightChronic cough, often at night Exercise induced bronchospasmExercise induced bronchospasm – Exercise challengeExercise challenge Asthma in the elderlyAsthma in the elderly – COPD vs asthmaCOPD vs asthma Occupational asthmaOccupational asthma – Must correlate symptoms with occupationMust correlate symptoms with occupation
- 15. Goals of TherapyGoals of Therapy Avoid troublesome symptoms night andAvoid troublesome symptoms night and dayday Use little or no reliever medsUse little or no reliever meds Have productive and physically active lifeHave productive and physically active life Have (near) normal lung functionHave (near) normal lung function Avoid serious attacksAvoid serious attacks
- 16. Initiating TherapyInitiating Therapy Determine level of severity.Determine level of severity. Consider interval since last exacerbation.Consider interval since last exacerbation. – Fluctuations in severity and frequency may occur.Fluctuations in severity and frequency may occur. Risk assessment:Risk assessment: – Exacerbations requiring oral corticosteroids:Exacerbations requiring oral corticosteroids: 0-1 per year in intermittent (low risk) patient.0-1 per year in intermittent (low risk) patient. > or equal to 2 per year in persistent (higher risk) patient.> or equal to 2 per year in persistent (higher risk) patient. Keep in mind the patients baseline FEV1.Keep in mind the patients baseline FEV1. Initiate treatment in a stepwise fashion.Initiate treatment in a stepwise fashion. – Reevaluate level of control in 2-6 weeks.Reevaluate level of control in 2-6 weeks.
- 19. Asthma CareAsthma Care Patient/doctor relationshipPatient/doctor relationship – Avoid triggers, understand and take meds, recognizeAvoid triggers, understand and take meds, recognize symptoms and seek advice in timely fashionsymptoms and seek advice in timely fashion Identify and reduce exposure to riskIdentify and reduce exposure to risk – Smoke, drugs, dust, fur, pollens, moldSmoke, drugs, dust, fur, pollens, mold Assess, treat and monitorAssess, treat and monitor – Stepwise approach, Ongoing monitoring q 3 monthlyStepwise approach, Ongoing monitoring q 3 monthly when stable, within 2 weeks after exacerbation.when stable, within 2 weeks after exacerbation. Manage exacerbationsManage exacerbations
- 20. Stepwise ApproachStepwise Approach If disease is poorly controlledIf disease is poorly controlled – First evaluate for adherence to treatments andFirst evaluate for adherence to treatments and avoidance of triggersavoidance of triggers – Consider a step up treatmentsConsider a step up treatments If disease is well controlledIf disease is well controlled – Step down treatmentsStep down treatments Medications must be adjusted based onMedications must be adjusted based on response to treatment and control of underlyingresponse to treatment and control of underlying disease, not on a fixed timetable.disease, not on a fixed timetable. – If a medicine is not effective after 3 months, it shouldIf a medicine is not effective after 3 months, it should be stoppedbe stopped
- 24. Moderate to Severe PersistentModerate to Severe Persistent AsthmaAsthma Daytime symptoms daily and nighttimeDaytime symptoms daily and nighttime symptoms at least weekly.symptoms at least weekly. Using their rescue inhaler at least onceUsing their rescue inhaler at least once daily.daily. FEV1 < 80% of predicted.FEV1 < 80% of predicted. FEV1/FVC ratio reduced by 5% fromFEV1/FVC ratio reduced by 5% from baseline.baseline.
- 25. Moderate to Severe PersistentModerate to Severe Persistent AsthmaAsthma Moderate to High dose InhaledModerate to High dose Inhaled Corticosteroids (ICS) are the cornerstoneCorticosteroids (ICS) are the cornerstone of treatment.of treatment. – Higher potency preparations require fewerHigher potency preparations require fewer puffs and encourage compliancepuffs and encourage compliance – Under dosing of ICS will result in poorerUnder dosing of ICS will result in poorer controlcontrol
- 26. Managing DiseaseManaging Disease Add in a Long Acting Beta Agonist (LABA)Add in a Long Acting Beta Agonist (LABA) – Most pts in the severe category require at least 2 controllerMost pts in the severe category require at least 2 controller agentsagents – Should NEVER be used as monotherapyShould NEVER be used as monotherapy Leukotriene antagonists are also an option:Leukotriene antagonists are also an option: – Limited evidence in literatureLimited evidence in literature – Montelukast, Zafirlukast, ZiluetonMontelukast, Zafirlukast, Zilueton TheophyllineTheophylline – Limited role, controller agent only, not as efficacious as LABA’sLimited role, controller agent only, not as efficacious as LABA’s If symptoms are severe add oral corticosteroids.If symptoms are severe add oral corticosteroids. – 5-7 days if normal FEV1, 14-21 days if reduced FEV15-7 days if normal FEV1, 14-21 days if reduced FEV1 Consider treatment with IgE antibody.Consider treatment with IgE antibody.
- 27. Oral GlucocorticoidsOral Glucocorticoids Most potent and effective controller agent.Most potent and effective controller agent. – Reserve for severe disease and those withReserve for severe disease and those with reduced FEV1, use lowest dose possiblereduced FEV1, use lowest dose possible – Should see an improvement in FEV1 of 15%Should see an improvement in FEV1 of 15% after 2-3 weeksafter 2-3 weeks – If requiring oral GC’s every 2-3 monthsIf requiring oral GC’s every 2-3 months consider daily low dose (5-10 mg)consider daily low dose (5-10 mg)
- 28. Follow-upFollow-up 4 to 8 week intervals.4 to 8 week intervals. – Use a questionnaire to evaluate controlUse a questionnaire to evaluate control Asthma Control Test (ACT)Asthma Control Test (ACT) – Consider spirometry if worsening symptomsConsider spirometry if worsening symptoms or a step down in careor a step down in care
- 31. Xolair: What is That?Xolair: What is That? Xolair (Omalizumab): Is an recombinantXolair (Omalizumab): Is an recombinant monoclonal anti-IgE antibody designed tomonoclonal anti-IgE antibody designed to treat moderate to severe allergytreat moderate to severe allergy associated asthma.associated asthma. – Must demonstrate sensitization to an allergen.Must demonstrate sensitization to an allergen. – Inadequate control with inhaled steroids.Inadequate control with inhaled steroids.
- 32. Asthma Guidelines 2007Asthma Guidelines 2007 Xolair therapy:Xolair therapy: – Reduce the need for systemic and inhaledReduce the need for systemic and inhaled glucocorticoids.glucocorticoids. – Reduce the number of exacerbations, especiallyReduce the number of exacerbations, especially severe exacerbations.severe exacerbations. – No effect on FEV1 values.No effect on FEV1 values. – Given via SubQ route q 2 to 4 weeks.Given via SubQ route q 2 to 4 weeks. – 850 patients radomized850 patients radomized 25% reduction in rate of exacerbation25% reduction in rate of exacerbation Overall response rate 30-50%Overall response rate 30-50% 12 week trial should be offered12 week trial should be offered Hanania, et al;Ann Intern Med 2011;154:573
- 33. Co-Morbid IllnessCo-Morbid Illness Allergic rhinitis – treat with nasal GC’s ifAllergic rhinitis – treat with nasal GC’s if surgical disease refer to ENTsurgical disease refer to ENT GERD – treat with PPI if patient isGERD – treat with PPI if patient is symptomatic from GERDsymptomatic from GERD Vocal cord dysfunction (VCD)- referral toVocal cord dysfunction (VCD)- referral to qualified speech therapistqualified speech therapist OSA – study in sleep lab and treat asOSA – study in sleep lab and treat as indicatedindicated
- 34. Special ConsiderationsSpecial Considerations PregnancyPregnancy – Variable, safeVariable, safe ObesityObesity – Weight loss helpsWeight loss helps SurgerySurgery – PFT’s, if < 80% FEV1PFT’s, if < 80% FEV1 steroids helpsteroids help Chronic sinus/rhinitisChronic sinus/rhinitis – Treating these willTreating these will improve asthmaimprove asthma OccupationalOccupational URI’sURI’s GERGER – More common inMore common in asthma but treatmentasthma but treatment doesn’t reducedoesn’t reduce morbiditymorbidity ASA inducedASA induced – 28%28% AnaphylaxisAnaphylaxis
- 35. SummarySummary Accurate and complete history andAccurate and complete history and physical is crucial.physical is crucial. Objective testing – spirometry,Objective testing – spirometry, methacholine challenge, peak flows,methacholine challenge, peak flows, serum studies.serum studies. Classify the patient.Classify the patient. Step care.Step care. Reevaluation/follow-up.Reevaluation/follow-up.
- 36. SummarySummary Written action planWritten action plan Proper inhaler techniqueProper inhaler technique Trigger avoidanceTrigger avoidance Inhaled GC’s are cornerstone of therapyInhaled GC’s are cornerstone of therapy LABA’s should be added nextLABA’s should be added next LTA’s or theophylline followLTA’s or theophylline follow Consider IgE antibody in proper subsetConsider IgE antibody in proper subset Treat comorbid illnessesTreat comorbid illnesses