Download Asthma and Co-Morbid Conditions

Asthma: Co-Existing and CoMorbid Conditions
Richard F. Lockey, M.D.
Division of Allergy and Immunology
Department of Internal Medicine
University of South Florida
College of Medicine
and
James A. Haley Veterans’ Medical Center
Tampa, Florida
Learning Objectives
At the completion of this presentation, the
participant should be able to:
1. Have knowledge of co-existing and comorbid conditions of asthma
2. Understand that asthma cannot be properly
treated unless these conditions are
addressed
1. Food
2. Rhinosinusitis
a. Allergic
b. Non-allergic
c. Infectious
d. Nasal polyposis
e. Other
3. Gastroesophageal
Reflux Disease
(GERD)
4. Vocal Cord
Dysfunction (VCD)
5. Obesity
6. Osteopenia and
Osteoporosis
7.
8.
9.
10.
11.
12.
13.
14.
15.
Psychological Problems
Churg-Strauss Disease
Sleep Apnea
Pregnancy
COPD versus Asthma
Eczema
Smoking Cessation
Infection (Vaccination)
Bronchiectasis and Cystic
Fibrosis
16. Exercise-Induced Asthma
17. Others- Endocrine,
Conjunctivitis,Congestive Heart
Failure, Pulmonary Embolism,
Medications
18. Primary Ciliary Dyskinesia
Introduction
• Asthma is perhaps the most treatable of all
chronic diseases.
• For optimal outcomes, co-existing and comorbid conditions must be identified and
treated.
• Co-morbid conditions and their diagnosis and
treatment should be included in asthma
guidelines
Questions for patients with asthma (children and
adults as appropriate)
1. History + ask and think about co-morbid
conditions
2. Complete physical examination
3. Spirometry and flow volume loop, as
necessary
4. Risk factors for various co-morbid
conditions (almost everyone has risk
factors)
5. Psychological profile
Questions for patients with asthma (children and
adults as appropriate)
6. Sleep profile
7. Weight assessment
8. Smoking (drinking and drug) assessment
9. Diet – appropriate calcium and vitamin D.
Exercise (walk 1.5 miles) or stand (1.5 hours)
10. Dexa bone scan?
11. Rhinoscopy, as indicated
12. Vaccination assessment
13. Others as necessary
Risk factors for exacerbation of
difficult-to-treat asthma
39 had 3 severe exacerbations/yr
136 subjects
29 had 1 severe exacerbation/yr
Brinke , et al. Eur Respir J 2005; 26: 812.
Conclusions
1) Odds ratio (OR) associated with 3 exacerbations
a) severe sinus disease, OR 3.7
b) GERD, OR 4.9
c) URIs, OR 6.9
d) Psychological dysfunction, OR 10.8
e) Obstructive sleep apnea, OR 3.4
2) All patients with frequent exacerbations had 1/5
while 52% had 3/5
Brinke , et al. Eur Respir J 2005; 26: 812.
Risk Factors for Fatal Asthma
>>
Social history
- Low socioeconomic status or inner-city
residence
- Illicit drug use
- Major psychosocial problems
>> Co-morbidities
- Cardiac disease
- Other chronic lung disease
- Chronic psychiatric disease
-Adapted from NIH/NHLBI National Asthma Education and Prevention Program. Expert Panel
Report 3: guidelines for the diagnosis and management of asthma: Clinical practice guidelines.
Bethesda (MD): 2007
-Guilbert T et al. In Middleton 7th ed. Allergy: Principles and Practice, 2009, p 1323
Rhinosinusitis
Rhinosinusitis (Allergic,
Nonallergic, Infectious) and Asthma
Incidence and Association
1. Rhinitis (all kinds) linked to sinusitis
(rhinosinusitis) and to nasal polyps –
all of which are co-morbid conditions of
asthma
2. Up to 70% of patients with asthma also
present with rhinosinusitis.
Annesi-Maesano I. Allergy 1999;54 (suppl) 7-13
Rhinosinusitis (Allergic, Nonallergic,
Infectious) and Asthma
Incidence and Association
3. Allergic rhinitis can be a precursor of asthma
4. Deterioration of rhinitis symptoms
negatively impacts bronchial
responsiveness and conversely adequate
management of rhinitis improves asthma
5. Chronic sinus disease may be linked to
severe asthma
Bachert C et al. In: Middleton 7th ed. Allergy: Principles and
Practice, p 991
Rhinosinusitis (Allergic, Nonallergic,
Infectious) and Asthma
Incidence and Association
6. Postulated that perennial allergic
and non-allergic rhinitis rather than
seasonal rhinitis predisposes to
“sinusitis”
7. Controlling infectious sinusitis may
decrease asthma medication needs
Moss MH et al. In: Middleton 6th ed. Allergy: Principles and
Practice, 2003, p 1225
Nasal Polyps and Asthma
1. Nasal polyps unusual in atopic patients
2. 40 – 80% of aspirin-exacerbated asthma
subjects have nasal polyps and 15% of polyp
patients have aspirin-exacerbated asthma
3. Nasal polyps in 37 – 48% of patients with
cystic fibrosis (some patients have
concomitant asthma)
4. Bronchial hypersensitivity exists in many
patients with polyps
Bachert C et al. In: Middleton 7th ed. Allergy: Principles and
Practice, p 991
Gastroesophageal
Reflux Disease
(GERD)
Atypical symptoms of GERD
• Throat clearing
(feels like “cottonball” which cannot
clear)
• Globus
• Laryngospasm
• Dental erosion
-Mujica et al. Postgrad Med 1999
-DeVault et al. Am J Gastroenterol 1999
•
•
•
•
•
Chest pain
Hoarseness
Chronic cough
Sore throat
Wheezing
– 80% of subjects with
asthma may have GERD
Symptoms of GERD in Childhood
• Regurgitation especially after eating
• Signs of esophagitis (irritability, arching,
choking, gagging, feeding aversion)
Symptoms resolve in most by 12-24 mo
• Older children abdominal and chest discomfort
• Also, stridor, obstructive apnea, or lower
airway disease
Orenstein S et al. Nelson 17th ed., 1217
Prevalence of GERD in Children
• Abnormal pH probes common and many such
patients have no clinical symptoms
Chiquette et al. J Asthma 2002;39:135
Khoshoo et al. Chest 2003;123:1008
Sheikh et al. Pediatr Pulmonol 1999;28:181
Cochrane Data Base Review of
GERD Treatment for Asthma in Adults and
Children (2006)
• 12 randomized controlled trials of Rx for GERD in adults
and children
• 2 independent reviewers
• Interventions included proton pump inhibitors (6), H2
receptor antagonists (5), surgery and conservative
management (1)
• Temporal relationship in 4 trials found between asthma
and GERD
• Anti-reflux Rx did not consistently improve lung
function, asthma symptoms, nocturnal asthma and
medication use
• Conclusion: No overall improvement but subgroups may
gain benefit; albuterol use may be decreased
GERD and Chronic Rhinosinusitis
• Upper respiratory symptoms frequent among
subjects with symptomatic GERD Dx’d by
esophageal study
• GERD associated with chronic rhinosinusitis in
children and adults
-Theodoropoulos DS et al. Am J Resp Crit Care Med 2001;164:72-6
-Barbero GJ. Otolaryngol Clin North Am 1996;29:27-38
-Phipps CD et al. Arch Otolaryngol Head Neck Surg 2000;126:831-6
-Ulualp SO et al. Am J Rhinol 199;13:197-202
-DiBaise et al. Ann Int Med 1998;1291078-83
Vocal Cord Dysfunction
(VCD)
Vocal Cord Dysfunction (VCD)
Definition of VCD
• Paradoxical adduction (closure) of the vocal cords/
folds during inspiration and/or early expiration
• “Irritable larynx syndrome”
• Episodic laryngeal dysfunction triggered by irritant
exposures or can occur spontaneously with variable
clinical manifestations: chronic cough, frequent
throat-clearing, globus pharyngeus, choking
episodes, dysphonia, masquarades as asthma;
exercise–induced asthma, or complicates asthma
-Mikita JA, et al., All Asthma Proc 2006;27:411.
-Bahrainwala AH, et al., Curr Opin Pulm Med 2001;7:8.
-Byrd RP, et al., Postgrad Med 2000;108:37.
-Balkissoon R, In: Nonallergic Rhinitis, Baraniuk JN, Shusterman D (eds): Informa
Healthcare USA, Inc., New York, pp. 411, 2007.
VCD
posterior
Diagnostic Criteria
1) Paradoxical inspiratory
adduction of anterior 2/3
vocal folds on
laryngoscopy
2) ± Posterior diamondshaped glottic gap
3) Variable extrathoracic
obstruction on flow
volume loops
anterior
Spirometry and Flow Loop
• FEV1 (88% of predicted),
no bronchodilator response.
Flattened inspiratory
loop
Vocal Cord Dysfunction (VCD)
National Jewish Health
95 subjects with asthma and/or VCD
a. 42 had VCD alone
b. 53 had VCD with asthma
c. 28% had been intubated
d. Misdiagnosed with asthma for average
of 4.8 yrs
e. “Very sick patients” with VCD
Newman AB et al. Am J Resp Crit Care Med 1995;152:1382
Psychosocial Problems
Psychosocial Problems
• Stress is linked to many diseases – asthma is
no exception
• Stress may alter immune system in direction of
Th2 response
• Depression particularly dangerous – especially
for severe asthma
• Psychological problems are particularly
dangerous for a patient with severe asthma
Bloomberg GR, Chen E. Immunol Allergy Clin N Am 2005;25,83
Psychosocial Problems
• Stress associated with increased prevalence of
asthma
• Stress associated with increased exacerbations
• ? whether asthmatic children have significantly
more total anxiety disorders, lower selfesteem, greater functional impairment, past
school problems, past psychiatric illnesses, and
familial stress
-Guilbert T et al. In Middleton 7th ed. Allergy: Principles and Practice, 2009, pp 1319-1343
-Wright RJ et al. Am J Respir Crit Care Med 2002;165:358-365
-Sandberg S et al. Lancet 2000;356:982-987
Asthma and Sleep
Apnea
Asthma and Sleep Apnea
Definition
Obstructive Sleep Apnea Syndrome (OSAS) is:
1. Complete or partial collapse of the
upper airways during sleep with
consequent cessation of breathing
despite ongoing respiratory effort plus
coexistent daytime somnolence
2. Coexistent daytime somnolence
(disabling)
-Staevska MP, Baraniuk JN. Rhinitis and Sleep Apnea. In: Baraniuk J,
-Shusterman D (eds). Nonallergic Rhinitis, 2007, Informa Healthcare, New York,
449-472
Asthma and Sleep Apnea
-
Adult Symptoms
At least one of the following 3 observations:
1. Patient complaints of unintentional sleep
episodes during wakefulness,
daytime
sleepiness, unrefreshing sleep, fatigue, or
insomnia
2. Patient wakes up at night with breath
holding, gasping, or choking
3. Bed partner observes symptoms of loud
snoring and/or breathing interruptions
Staevska MP, Baraniuk JN. Rhinitis and Sleep Apnea. In: Baraniuk J,
Shusterman D (eds). Nonallergic Rhinitis, 2007, Informa Healthcare, New York,
449-472
Asthma and Sleep Apnea
Symptoms - Children
1. The caregiver reports snoring and/or labored or
obstructed breathing during sleep.
2. The caregiver observes at least one of the following:
- Paradoxical inward rib cage motion during
inspiration movement arousals
- Diaphoresis
- Neck hyperextension during sleep
- Excessive daytime sleepiness, hyperactivity, or
aggressive behavior
- Slow rate of growth
- Morning headaches
- Secondary enuresis
Staevska MP, Baraniuk JN. Rhinitis and Sleep Apnea. In: Baraniuk J, Shusterman D (eds).
Nonallergic Rhinitis, 2007, Informa Healthcare, New York, 449-472
Asthma and Sleep Apnea
Prevalence of Obstructive Sleep
Apnea-Hypopnea (OSAH) in Severe versus Moderate Asthma
1. 23 of 26 (88%) with severe asthma, 15 of 26
(58%) with moderate asthma, 8 of 26 (31%)
controls without asthma had apnea-hypopnea
index ≥ 15 events/hour
Using more restrictive criteria, 50% severe,
23% moderate, and 12% (control) of subjects
had obstructive sleep apnea (OSA)
2. No correlation between severity of sleepdisordered breathing and asthma severity
Julien JY et al. J Allergy Clin Immunol 2009;124:371-6
Asthma and Sleep Apnea
1. Risk of sleep apnea increases with nasal
obstruction, large adenoids and tonsils, and
elongated face.
2. Rhinitis appears to increase the risk of
obstructive sleep apnea.
3. Many other risk factors associated with sleep
apnea include obesity, gastroesophageal reflux,
endocrine problems, and others.
Asthma and Infection
(Vaccination)
Influenza
• Influenza is a trigger for the development of
asthma as well as exacerbates asthma
• Influenza infection leads to decline in lung
function. It increases the risk of
hospitalization and death in patients with
COPD
– May cause up to 30% of COPD
exacerbations/year
Influenza Vaccine
• An injectable trivalent, inactivated viral vaccine (TIV)
composed of seasonal H3N2, H1N1, and Influenza B
• A live attenuated vaccine (LIAV) is also available
• Studies show no increase in symptoms after
vaccination
• Low to medium dose ICS does not affect vaccine
responsiveness
– High dose ICS does decrease response to Influenza
B
• Current evidence is conflicting on the effectiveness of
influenza vaccination in preventing morbidity and
mortality in COPD and asthma
• Influenza vaccination is recommended in asthmatics
and COPD based upon the known complications of
influenza infection
CDC. MMWR: Recommendations and Reports 2009;58:1-52 (RR-8)
Streptococcus pneumoniae
• Colonization occurs frequently in patients with
COPD and asthma and increases the risk for
exacerbation as well as invasive disease
• Currently, a 23-valent polysaccharide vaccine
(PPV-23) is recommended for use in:
– Adults ≥ 65
– ≥ 2 years whom are at risk for invasive disease
• Revaccination is recommended for:
– ≥ 65 if previous dose was given at age < 65
– Patients at risk for invasive disease
– Should be given no sooner than 5 years after
previous dose
-Talbot T et al. N Engl J Med 2005;352:2082-90
-Juhn YJ et al. J Allergy Clin Immunol 2008;122:719-23
Streptococcus pneumoniae
• The risk of pneumonia is 11% to 17% in
two studies of asthma.
• The Advisory Committee on Immunization
Practices (ACIP) recommends all adults
with asthma(19-64 yrs) receive the vaccine
for S. pneumoniae (PPV-23).
-Talbot T et al. N Engl J Med 2005;352:2082-90
-Juhn YJ et al. J Allergy Clin Immunol 2008;122:719-23
-Jung J et al. J Allergy Clin Immunol 2010;125;217-21
Pertussis
• 5,000-7,000 cases occur each year in the U.S.
• Adults can serve as a reservoir for infection of
children due to waning immunity
• Infection with B. pertussis can lead to
exacerbations of both asthma and COPD
• A combination vaccine of tetanus, diphtheria,
and pertussis [Adacel (TdaP)] is recommended
in these patients as a single dose vaccination
for adults age 19-64
– Vaccination has been shown to reduce the number
of cases by 44%
CDC. MMWR: Recommendations and Reports 1997;46:1-25(RR-7)
CDC. MMWR: Recommendations and Reports 2006;55:1-37 (RR-17)
Herpes Zoster
• Reactivation of Varicella Zoster leads to significant
morbidity in aging adults, and patients on high dose
inhalational or oral steroids (<20mg/day prednisone)
may be at higher risk.
• Zostavax has been shown to reduce the incidence of
herpes zoster reactivation by 51.3% and post-herpetic
neuralgia by 66.5%.
• Recommended for all adults (60 and older) as a single
dose. Also recommended for all asthmatics and
patients with COPD, 60 years and older if on ≤
20mg/day of prednisone (or equivalent
glucocorticosteroid).
CDC. MMWR: Recommendations and Reports 2008;57:1-30 (RR-5)
Conclusions
• Asthma is perhaps the most treatable of all
chronic diseases.
• For optimal outcomes, co-existing and comorbid conditions must be identified and a
appropriately treated.
• Co-existing and co-morbid conditions should
be part of asthma guidelines