Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Understanding Asthma, the Role of Allergens and Vocal Cord Dysfunction Christopher Mjaanes, MD Disclosures • Meda Pharmaceuticals Inc., Speakers Bureau – No direct conflict of interest Objectives • Understand the basic pathophysiology of asthma • Be able to distinguish between intermittent and persistent asthma • Understand the difference between asthma severity and asthma control • Recognize potential asthma triggers, particularly allergens • Determine different asthma management strategies, including medications • Be able to recognize vocal cord dysfunction • Distinguish between vocal cord dysfunction and asthma Asthma Background • Asthma prevalence in the US is rising, affecting 7.3% of the population in 2001 and 8.4% of the population in 2010 – This was 1 in 12 people in the US in 2010 • Current asthma affects children more than adults (9.5% vs 7.7%) and blacks more than whites or hispanics Source: National Surveillance of Asthma: United States, 2001-2010 Definition • Asthma is a chronic inflammatory disorder of the airways • Airway inflammation is an essential component of asthma – Not all airway inflammation is “allergic” although this type of asthma accounts for 80% of all asthma NAEPP 2007 Expert Panel Report 3 Summary Report 2007. Immunol 2007;120 (5): Supplement. J Allergy Clin Airway Inflammation • Features of asthmatic airway inflammation include: – – – – – Neutrophils – particularly seen in fatal asthma Eosinophils Lymphocytes Mast cell activation Epithelial cell injury • Airway inflammation contributes to airway hyperresponsiveness, airflow limitation, respiratory symptoms, and disease chronicity Hyperresponsiveness • There is a predisposition for the airways of asthmatics to “over-react” to stimuli • Colds, smoke, allergens, etc., trigger an exaggerated response with mucous production, inflammation and bronchospasm • Can be thought of as the “twitchiness” of the airways • Controlling inflammation can decrease (not eliminate) hyperresponsiveness Airflow Limitation • This is what makes asthma an obstructive lung disease • Many factors contribute to airflow limitation – Bronchospasm – Airway secretions and mucous plugging • In some patients, persistent changes in airway structure occur – Airway remodeling • Airway wall fibrosis, mucous hypersecretion, smooth muscle hypertrophy, and angiogenesis Pathophysiology • Gene interaction with environment • Important to the development and expression of asthma • Atopy, the genetic predisposition for IgE response to aeroallergens is strongest identifiable factor • Viruses cause exacerbations and contribute to the development National Education and Prevention Program. Expert panel report 3, www.nhlbi.nih.gov/guidelines/asthma/asthgdln/htn Diagnosis Key points • Episodic symptoms of airflow obstruction or hyperresponsiveness • Acute asthma symptoms are a manifestation of airflow limitation • Airflow obstruction is at least partially reversible (12% and 200 mL or more) • Alternative diagnoses are excluded (But other lung diseases often co-exist) NAEPP 2007 Expert Panel Report 3 Summary Report 2007. Allergy Clin Immunol 2007;120 (5): Supplement. J Diagnosis • History • • • • • There is no single symptom that indicates asthma Commonly reported symptoms include: cough, chest tightness, dyspnea and wheezing Symptoms are often worse at night and can awaken patients from sleep Cough, dyspnea and wheeze begin and persist after exercise, not during There is often an association between specific triggers and symptoms • Although both symptoms and triggers are individualspecific Diagnosis Additional Points • Eosinophilia in blood or sputum. (May be normal during corticosteroid treatment.) – More common in adults than children • Eosinophilic airway inflammation can be detected by exhaled nitric oxide testing • Positive allergy tests and elevated serum IgE level are common • Determination of obstruction and reversibility – Spirometry and peak flow measurement, pre- and post-bronchodilator Differential Diagnosis of Asthma Dependent on Patient Age • Children – Bronchiolitis and bronchitis – Foreign body aspiration – Pneumonia – GERD – Malacia (tracheal or laryngeal) – Cystic fibrosis – VCD • Adults – – – – – – – – – – – COPD Bronchiectasis Sarcoidosis Bronchitis Chronic cough Pulmonary embolism Heart Failure GERD Tumor Aspration VCD A word about severity and control… • Asthma severity is used to establish initial therapy – Severity: the intrinsic intensity of the disease process. Severity is measured most easily and directly in a patient not receiving long-termcontrol therapy • This is NOT modifiable – Control: the degree to which the manifestations of asthma (symptoms, functional impairments, and risks of untoward events) are minimized and the goals of therapy are met. Severity and Control • Both severity and control include the domains of current impairment and future risk • Impairment: frequency and intensity of symptoms and functional limitations the patient is experiencing or has recently experienced • Risk: the likelihood of either asthma exacerbations, progressive decline in lung function (or, for children, reduced lung growth), or risk of adverse effects from medication The Four Components of Asthma Management • Assessment and monitoring of control • Education for partnership in care • Control of environmental and co-morbid factors • Pharmacologic therapy NAEPP 2007 Expert Panel Report 3 Summary Report 2007. Clin Immunol 2007;120 (5): Supplement. J Allergy Goals of Asthma Control • Reduce impairment. • Prevent chronic symptoms. • Use short acting beta agonists infrequently. • Maintain normal or optimal pulmonary function. • Maintain normal activity. • Meet patients’ and families’ expectations of and satisfaction with asthma care . NAEPP 2007 Expert Panel Report 3 Summary Report 2007. J Allergy Clin Immunol 2007;120 (5): Supplement. Goals of Asthma Control • Reduce risk. • Prevent exacerbations and minimize need for ED visits or hospitalization. • Prevent/reduce progressive loss of lung function. • Provide optimal pharmacotherapy with minimal adverse effects NAEPP 2007 Expert Panel Report 3 Summary Report 2007. J Allergy Clin Immunol 2007;120 (5): Supplement. Assessment and Monitoring • Identify precipitating factors • • Including environmental control measures Monitor at each follow up • Identify comorbidities • Re-assess at each follow up • Classify severity of both impairment and risk NAEPP 2007 Expert Panel Report 3 Summary Report 2007. J Allergy Clin Immunol 2007;120 (5): Supplement. Periodic Assessment Measures • • Signs and symptoms History of exacerbations • • • • Adherence to pharmacotherapy Spirometry is essential for monitoring control Quality of life questionnaires • • Acute care visits, hospitalizations, systemic steroids Asthma Control Test (ACT) Patient-provider communication and satisfaction NAEPP 2007 Expert Panel Report 3 Summary Report 2007. J Allergy Clin Immunol 2007;120 (5): Supplement. Additional Assessment Measures • Effectiveness of environmental control • • • • • Anti-dust Mites Measures Pets (and mice) Water damage and humidity Occupational exposures Airborne irritants: • Volatile organic chemicals • Tobacco smoke Control of Environmental Factors • • • • • Identify allergens by history, skin and/or in vitro testing Reduce exposure if possible Avoid exposure to tobacco smoke and other environmental irritants Repair water damage Avoid humidifiers and prolonged use of dehumidifiers NAEPP 2007 Expert Panel Report 3 Summary Report 2007. Allergy Clin Immunol 2007;120 (5): Supplement. J Major Environmental Allergens • • • • • Indoor Dust mite Cockroach Cat and dog Mouse and rat Mold • • • • Outdoor Grass pollen Weed pollen Tree pollen Mold Importance of Allergic Sensitization in Asthma • In the US, ~56% of acute asthma cases are attributable to allergy • Specific allergen sensitization is a more important risk factor than total IgE • Greater than 80% of school age children with asthma are sensitized to ≥1 common aeroallergen • The greater the number of positive skin tests the more severe the patient’s asthma Arbes S et al, JACI 2007 Nov 120: 1139-45. Gergen PJ et al, JACI 2009 Sept 124: 447-53. Carroll WD et al, Arch Dis Childhood 2006 May 91: 405-9. Major Outdoor Allergens • Pollen from grasses, trees, weeds, and mold spores. • Pollen and mold counts vary geographically and by season. • Seasonal peaks in pollens cause allergic rhinitis (“hay fever”) and can exacerbate asthma. • The National Allergy Bureau (NABTM) maintains a current and user friendly website of pollen counts • http://www.aaaai.org/global/nab-pollen-counts.aspx • Pollen counts are predicted to rise with climate change Burge HA, Rogers CA. Outdoor allergens. Environ Health Perspect. 2000;108(S4):653 Shea KM, et al. Climate change and allergic disease. J Allergy Clin Immun. 2008;122(3):443–53 http://www.vcbio.science.ru.nl/en/virtuallessons/pollenintro/ Follow-up and Monitoring • 1 to 6 month intervals, depending on degree of control • Evaluate patient’s symptoms, satisfaction and compliance • Include spirometry to assess control and guide step-up or step-down drugs NAEPP 2007 Expert Panel Report 3 Summary Report 2007. Allergy Clin Immunol 2007;120 (5): Supplement. J Vocal Cord Dysfunction (PVFM) • Incidence is unknown • Newman et al., 40% of adults seen for refractory asthma had PVFM – 30% in combination with asthma – 10% as sole diagnosis • Among healthy, physically active adolescents and young adults the incidence has been reported to be between 8% and 27% • Reported in up to 5% of Olympic athletes Description • Upper airway obstruction • Adduction of the true vocal folds – Primarily on inhalation • Sometimes during exhalation • Usually very abrupt onset • Spectrum of presentation – Severe respiratory distress to mild dyspnea Symptoms/Signs More common: • Difficulty breathing – “Air hunger” • Throat or neck tightness • Cough • Stridor or laryngeal wheezing • Lightheadedness • Dizziness Other: • Dry cough • Chest tightness • Neck/chest retractions • Dysphagia • Globus pharyngeus • Choking • Suffocating • Dysphonia • Intermittent aphonia • Throat clearing • Paresthesias of hands, feet, around mouth Self-reported Triggers • Upper respiratory infections • Eating • Talking • Laughing • Singing • Coughing • Acid Reflux • Physical Exertion • • • • Post-nasal Drip Weather Changes Emotional Stress Strong Scents – E.g., perfume • • • • Smoke Fumes Solvents Air Pollution Hicks, et al. Prim Care Clin Office Pract. 35 (2008): 81-103 Pathophysiology • PVFM – Non-physiologic closure of the true vocal folds on inspiration with or without concommitant closure on expiration • Adduction may be complete, along the entire length of the cords • Adduction may be along the anterior two-thirds leaving a “posterior chink” – Expiratory-only closure may be a PVFM variant Differential Diagnosis • Infectious – Croup, epiglottitis, laryngitis, pertusis, etc. • Inflammatory – Wegener’s granulomatosis, laryngeal sarcoid, etc. • Traumatic – Caustic ingestion, thermal injuries, etc. • Allergic – Atypical asthma, anaphylaxis, exercise-induced asthma, hereditary angioedema, etc. • Pulmonary – Asthma, COPD, gastric or laryngopharyngeal reflux with aspiration, hyperventilation syndrome, etc. • Congenital anomalies – Laryngomalacia, laryngeal cleft, subglottic stenosis, intrathoracic vascular ring, laryngeal web • Psychiatric and Neurologic Diagnosis • Diagnosis relies on four areas: – Clinical history and physical exam – Pulmonary function testing – Measures of oxygenation – Provocation testing with laryngoscopy Vocal Cord Dysfunction Clinical History • Patients point to or grab their throat when describing symptoms • May have worsening of symptoms when using metered-dose or dry powder inhalers • May have some relief when using nebulized medications • Symptoms of hyperventilation may be reported in up to 76% of patients • Common associated risk factors or triggers* Risk Factors/Triggers • Female gender • GERD • Upper Airway Inflammation – Rhinitis, sinusitis, etc. • Prior traumatic event involving breathing – Near drowning, suffocation, etc. • Competitive athletics • Excessive voice demands – Singing, drama, public speaking, telecommunications • Severe emotional stress • Playing a wind instrument Psychologic Factors • 1842, Dunglison reported first cases of PVFM; called “hysteric croup” • 1975, Patterson called the disease Munchausen’s stridor • Anxiety has been seen in up to 34% of adults and 25% of kids with respiratory disorders* • Estimated 20% of PVFM attacks are triggered by stress in the general population – Increased PVFM in soldiers as a reaction to combat – Increased PVFM in highly, competitive athletes • Approximately 5% of US Olympic athletes with VCD† * Hicks, et al. Prim Care Clin Office Pract. 2008;35: 81-103 † Rundell KW, et al. Chest. 2003;123:468-74 Treatment • Multidisciplinary approach • Guided by comorbidities • Patient education is critical – Avoidance/minimization of triggers – Direct visualization enhances patient understanding and engagement in treatment • Acute episode management • Chronic management Acute Treatment • Patient reassurance • Breathing techniques: panting, sniffing, pursed-lip breathing on exhalation, nasal inhalation • Heliox therapy (70:30, 80:20) • Anxiolysis • Consider nebulized lidocaine Chronic Management • Comorbid disease management • Speech therapy – – – – Patient education Supportive counseling Respiratory restraining Management and suppression of laryngeal abusive behaviors – Voice therapy – Desensitization to specific irritants • Psychotherapy if indicated Selected References • National Heart, Lung and Blood Institute Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma. Full Report 2007. Bethesda, Maryland: National Institutes of Health, US Department of Health and Human Services, National Heart, Lung and Blood Institute; 2007. • Hicks M, Brugman SM, Katial R. Vocal Cord Dysfunction/Paradoxical Vocal Fold Motion. Prim Care Clin Office Pract. 35 (2008): 81-103. Post-Test: Q1 Which of the following cells do not contribute to airway inflammation in asthma? A. B. C. D. Neutrophils Lymphocytes Red blood cells Eosinophils Q2 Which of the following are essential features of asthma? A. Airway inflammation B. Airway “twitchiness”/hyperresponsiveness C. Airway obstruction D. All of the above Q3 Which is not a symptom of asthma? A. Cough B. Wheezing C. Stridor D. Shortness of breath E. Response to albuterol Q4 A 18 year old male reports coughing and chest tightness 3 to 4 days per week, nighttime cough about once per week and albuterol (which clears his symptoms) use twice per week. His asthma is: A. Persistent B. Intermittent C. A figment of his imagination Q5 You can change your patient’s severe asthma to mild asthma by giving them more prednisone? A. True B. False Q6 Which is NOT a common outdoor allergen? A. Rose flower pollen B. Birch tree pollen C. Alternaria D. Ragweed pollen Q7 You determine that the 27 year old female you are seeing has mild persistent asthma. She has never been on controller therapy. Which is the most appropriate first line control medication? A. Fluticasone/salmeterol, 250/50 , BID B. Budesonide, 90 mcg, once daily C. Omalizumab, IM, twice monthly D. Montelukast 10 mg plus Fluticasone, 220 mcg, nightly Q8 The 16 year old soccer player you are seeing reports severe shortness of breath, coughing and wheezing within 1 to 2 minutes of starting to run, which improves within minutes of resting only to return as soon as he runs again. His most likely issue is: A. Exercise induced bronchospasm B. Vocal cord dysfunction C. GERD with aspiration Q9 Which is not a recommended environmental control to reduce indoor allergen exposure? A. Cover pillows and mattress with anti-dust mite encasements B. Remove animals from the home C. Remove flowering plants from the home when pollinating D. Eliminate potential sources of water damage and mold Q10 Which is not a risk factor/trigger for vocal cord dysfunction? A. Gastroesophageal reflux B. Post-nasal drainage from allergies C. Competitive athletics D. Answering post-test questions about VCD in a relaxing, no-pressure-added conference setting