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Asthma, Long term goals: Prevent asthma exacerbations, avoid AEs from…
Asthma
Etiology and Pathology
Prevalence: 26.5 million people int he US (8.4% of the population; most common chronic disease in children; higher in lower income, blacks, and Puerto Ricans
Pathophysiology: Airflow obstruction related to smooth muscle bronchospasm, edema, and mucus hypersecretion
Risk factors: genetic predisposition, socioeconomic status, family size, exposure to secondhand tobacco smoke in infancy and in utero, allergen exposure, air pollution, RSV
Clinical Presentation
Chronic s/sx: SOA, chest tightness, coughing (particularly at night), wheezing, whistling sound while breathing
PE signs: rhonchi on auscultation, dry/hacking cough, atopy
Severity: lung function, s/sx, nighttime awakenings, inference with ADL (prior to therapy)
Acute severe s/sx: anxiety/distress, severe dyspnea, SOA, chest tightness/burning, unable to speak
PE signs: expiratory and inspiratory wheezing on auscultation, dry/hacking cough, tachypnea, tachycardia, pallor/cyanosis, hyperinflated chest
Treatment
Non-pharmacological
Control triggers (allergens, environment, cigarette smoke)
Engage in regular physical activity
Investigate possibility of occupational asthma and remove possible triggers in the workplace
Consider avoiding aspirin if believed to have aspirin-exacerbated respiratory disease
Pharmacologic Therapy
Short-Acting Rescue Therapy (Beta-2 agonist), for quick relief (all patients)
MOA
Interacts selectively with beta-2 receptors on bronchial smooth muscle to achieve bronchodilation
Regimen
Albuterol: Inhalation: 90 mcg/actuation PRN; Nebulization: 2.5 mg q4-6h PRN; need to give with an ICS to reduce risk for exacerbations
Adverse Effects
Increased agitation (excitement, nervousness, tremor), URTI's, rhinitis, bronchospasm, tachycardia, HTN
Special Populations
Sx of CNS stimulation, hyperactivity, and insomnia more frequent in younger children
PD/PK
Onset of action within minutes, duration 4-6 hours, half-life 3.8-5 hours, metabolizd by liver and excreted in urine
Warnings/Precautions
Rare, paradoxical bronchospasm and hypersensitivity reactions may occur
Use with caution in patients with CV disease, diabetes, glaucoma, hyperthyroidism, hypokalemia, renal impairment, and seizures
Education/counseling
Inhaler (aerosol): shake well and prime the inhaler before use. Through the inhaler away when dose count reaches 0.
Dry powder inhaler: medication will be released by breathing in a deep, fast breath.
Non-major side effects inlcude headache, dizziness, or nervousness
Monitoring
FEV1, peak flow, pulmonary function tests; monitor BP and HR
FIRST LINE: ICS Low or moderate dose (plus short acting SABA)
PK/PD/PGX: Aerosal delivery is variable based on delivery device (10-60%); Log linear dose-response between different agents; systemic Cl is rapid, extensive first pass metabolism, dose-dependent systemic effects
Metabolism (DDI): CYP3A4 inhibitors can increase serum levels of ICS
MOA:
Controls the rate of protein synthesis, slows the migration of PNMs, reverses capillary permeability and lysosomal stabilization to prevent/control inflammation
Adverse events:
Throat irritation, topical candidiasis, dysphonia
Regimen: Low Dose Beclomethasone 80-240 mcg; Budesonide DPI 180-540 mcg; fluticasone propionate MDI 88-264 mcg; Moderate: Beclomethasone MDI 240/480 mcg, Budesonide 540/1080 mcg, Fluticasone propionate 264/440 mcg
The preferred agent for long-term control
Monitoring:
Monitor for sx of exacerbation, FEV1, peak flow, BMD, s/sx of HPA axis suppression/adrenal insufficiency
Warnings/Precautions:
May cause HPA axis suppression in younger children on pts receiving prolonged treatment.
A gradual tapering might be required prior to discontinuing medication.
When transferring to oral inhalation therapy from systemic, previously suppressed allergic conditions can be unmasked (taper to ICS)
Special Populations
Children under 5 (not all agents have been studied/approved)
For Pregnant women it is safer for the child if the mother receives therapy rather than have exacerbations
Budesonide preferred; low doses are optimal
Older Adults if treated with long-term ICS, osteoporosis and cataract risk should be evaluated
Education/counseling
Not used to quickly relieve symptoms, rinse mouth after use, use as prescribed (even if feeling better)
High Dose ICS or ICS plus LABA (if low/moderate dose ICS is ineffective)
For Moderate Persistent Asthma
Last line:: referral to specialist (for moderate asthma)
Corticosteroids
Biologics
MOA: target IgE antibodies and cytokines to reduce inflammation
IV and SQ administration
LTRAs and Theophylline are not effective add ons
Allergan Immunotherapy
Acute
exacerbations:
FEV1 >= 40% (mild to moderate): achieve O2 sat >=90%, give SABA x3 doses w/i first hour, oral systemic corticosteroids, then SABA q1h
FEV1 <40% (severe): achieve O2 sat >=90%, give high dose SABA plus ipratropium q20min or continuously for 1h, oral systemic corticosteroids
Respiratory arrest: intubate with 100% O2, SABA and ipratropium, IV corticosteroids, admit to ICU
Diagnosis
Does Patient have symtpoms of Asthma?
Symptoms:
-wheezing, SOB, chest tightness, cough varying over time and in intensity AND variable expiratory outflow limitation
If YES, do history and physical exam support diagnosis of Asthma?
History of symptoms plus wheezing on auscultation
Perform Spirometryw/ reversibility test
-FEV/FVC below normal
-FEV1 increase by >12% after inhaling a bronchodilator
-FEV1 increases by > 12% or 200 mL after 4 weeks of anti-inflammatory treatment
Treat for Asthma
Repeat at a later date if initial spirometry results do not support asthma diagnosis, but no other diagnosis is apparent
Goals of Therapy
Short term goals:
Achieve and maintain control of symptoms.
Maintain normal activity levels, including exercise
Follow-up/Monitoring
Follow-up every 1-6 months (depending on severity of asthma to assess asthma control, lung function, exacerbations, inhaler technique, adherence, medication adverse effects, quality of life, and patient satisfaction with care
Monitor inhaler technique periodically (especially with a new inhaler) and counsel on correct usage of their inhaler
Long term goals: Prevent asthma exacerbations, avoid AEs from asthma medications and prevent asthma mortality.