Download Asthma

Asthma
RITA ALL
NUR 652 PRIMARY CARE
ICD 9 CODES:
493.00 EXTRINSIC ASTHMA, UNSPECIFIED
493.90 ASTHMA, UNSPECIFIED, WITHOUT
MENTION OF STATUS ASTHMATICUS
493.92 ASTHMA, UNSPECIFIED, WITH
ACUTE EXACERBATION
Asthma- Definition
 Asthma is a chronic, reversible, inflammatory airway
disease
 Characteristics include bronchoconstriction that is
reversible, airway edema and hyperresponsiveness
 Recurrent bouts of breathlessness and wheezing, chest
tightening, and cough (can be worse at night)
 Can be highly unpredictable, from mild attack to
complete airway obstruction leading to death.
Asthma- Classification
4 major classifications : Based on daily activity, symptom
occurrences, use of rescue inhaler, and FEV levels
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Intermittent- no daily medication needed, rescue inhaler only
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There is no interference with daily activity

Symptoms may occur 2 or less days a week, with awakening from
sleep 2 or less nights a month
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Rescue inhaler used 2 or less days a week

Normal forced FEV between bouts, and greater than 80% during
episodes
Asthma- Classification

Mild persistent- One daily control med needed- low dose
inhaled corticosteroid, cromolyn, leukotriene modifier

There is minor interference with daily activity

Symptoms may occur 2 or more days a week, but not daily, with
awakening from sleep 3-4 nights a month

Rescue inhaler used 2 or more days a week

Greater than 80% FEV between and during episodes
Asthma- Classification

Moderate persistent- inhaled beta2 agonist PRN, daily control
medication- combination inhaled medium dose corticosteroid with
long acting bronchodilator; cromolyn; leukotriene modifier.

There is some interference with daily activity

Symptoms may occur daily, with awakening from sleep at least 1 night
a week, but not every night

Rescue inhaler used daily

60-80% FEV between and during episodes
Asthma- Classification

Severe persistent- inhaled beta2 agonist PRN, multiple daily control
medication- combination inhaled high dose corticosteroid with long
acting bronchodilator; cromolyn; leukotriene modifier, may need
long term corticosteroids.

There is major interference with daily activity

Symptoms occur throughout the day, with awakening from sleep every
night

Rescue inhaler used several times a day

Less than 60% FEV between and during episodes
Asthma- Pathophysiology
 Inflammatory cell infiltration
 Sub basement fibrosis
 Mucous hypersecretion
 Epithelial injury
 Smooth muscle hypertrophy
 Angiogenesis
 Airflow obstruction and bronchial responsiveness
Asthma Pathophysiology
Asthma- Etiology

Caused by extrinsic (environmental) and intrinsic (stress) triggers causing spontaneous
remittance or exacerbation.

Genetic predisposition- IgE mediated response to aeroallergens (atopy)- strongest identifiable
risk factor for asthma.

3 principle triggers:

Allergens and environmental factors-

Infections- URI’s, RSV
Psychological factors- stress

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Molds, animal dander, pollen, dust, smoke, beta-blockers, or aspirin containing products, temperature changes
Also can be caused by certain drugs : Betablockers, aspirins, new evidence suggests a Tylenol connection (Soferman,
et al, 2013)
obesity, reflux
Inflammation allows for hyper-reactivity of the bronchi, limiting airflow, causing the symptoms
of wheezing, chest tightness, cough and difficulty breathing
Incidence
 Affects 5-10% of population
 7 million children, one of the most common childhood
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chronic diseases, highest in 5-17 years old
30 million Americans, 300 million globally and growing
More common in boy youths
More common in adult women, African American
African Americans have a higher rate of mortality,
possibly due to access of care, low income, compliance
with treatment plans (Halterman, et al, 2011)
Increase in prevalence, hospitalization, and death in the
past 20 years
5500 deaths annually due to asthma in the US
Clinical findings
 Accurate history very important
 May be normal
 General appearance:
 Signs of respiratory distress or use of accessory muscles
 Rhinitis
 Nasal polyps
 Swollen turbinates
 Wheezing
 Prolonged expiratory phase
 Cough
 Shortness of breath
Differential Diagnosis- Children
 Upper Airway
 Allergic rhinitis
 Sinusitis
 Airway Obstruction
 Foreign body aspiration
 Vocal cord dysfunction
 Vascular ring/ laryngeal web
 Laryngotracheomalacia
 Airway obstruction from lymph nodes or tumor
 Small airway obstruction
 Viral bronchiolitis (up until age of 2- most common RSV)
 Recurrent cough
 GERD
 Aspiration
Differential Diagnosis- Adults
 COPD
 CHF
 PE
 Tumor
 Pulmonary infiltration with eosinophilia
 Medications such as ACE inhibitors
 Vocal cord dysfunction
Social/ Environmental Considerations
 Adolescents have a poor rate of compliance
 Those with mild symptoms are least like to get ongoing
preventative care, have an action plan, or know what to
do or when to initiate therapy when symptoms occur
 Chronic illness self image issues
 Those that are uninsured or have lack of access to quality
of healthcare will have poorer outcomes
 Cost of medication:
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Albuterol $50
Pulmicort $175
Flovent $170
Singlair $185
Laboratory Tests
 Labs: not necessary, but may show eosinophilia, or
elevated IgE, ABG’s to determine hypoxemia.
 Spirometry: Normal testing doesn’t rule out asthma.
Measures forced vital capacity and forced expiratory
volume in 1 sec. A reduced ratio of fev1/fvc with
reversibility of 12% after bronchodilator use establishes
diagnosis.
 Bronchoprovocation with use of methacholine,
histamine, cold air, or exercise is the only definitive
diagnostic test.
 Peak expiratory flow rates cannot determine diagnosis
Management/ Treatment Guidelines- Non
pharmacologic
 Identification of triggers
 Controlling exposures
 Identify those at risk for reaction to aspirins or
NSAIDS, beta- blockers, avoid exposure
 Food allergies and sulfites in food can precipitate
symptoms
 Daily monitoring of peak expiratory flow record it on
a record with any symptoms
 Written instructions including crisis plan
Management/ Treatment guidelinesPharmacologic
 First line:
 Short acting beta agonist
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Anticholinergic agents
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Quick relief of symptoms, and prevent exercise induced asthma
Albuterol, xopenex, alupent, maxair
Use with aerochamber or spacer for increased efficacy with decreased side
effects as compared to neb treatments.
Ipratropium bromide (atrovent), used in combination with SABA for acute
treatment
Systemic corticosteroids
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Can be used in all patients with acute asthma exac.
In mod to severe asthma as adjunct
Prednisolone 1-2 mg/kg/d for 7 days in adults and 3 days for children.
Management/ Treatment guidelinesPharmacologic
 Second line (for long term control):
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Inhaled corticosteroids- preferred long term therapy for persistent
asthma and during pregnancy (flovent, pulmicort)
Long acting beta agonists- not to be used alone, or severe outcomes
including death may occur. Salbutamol or Formoterol
Combination products- preferred in moderate persistent asthma, if
inhaled corticosteroids alone are not helpful (advair)
Leukotriene receptor agonists- not preferred for mild persistent.
Singulair
Lipoxygenase pathway inhibitor- Alternative, not preferred for
adjunctive treatment in adults.
Theophylline- not preferred as adjunt to inhaled corticosteroids
Cromolyn sodium and nedocromil are alternatives, but not preferred
Immunodilators- Adjunctive therapy, Omalizumab- for allergies and
severe persistent
Complications
 Atelectasis
 Pneumonia
 Pneumomediastinum
 Pneumothorax
 Medication specific side effects/adverse reactions
 Respiratory failure
 Death
Follow up
 Step down therapy gradually, visits in 1-6 months
depending on symptoms and response to treatment
 Review short term and long term goals
 Review daily self management plan
 Medication adjustment based on symptoms
Counseling/ Education
 Smoking cessation
 Prevention of second hand smoke exposure
 Removal or modification of allergens/ irritant
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triggers in living space
Allergen immunotherapy
Treat allergic rhinitis
Use of inhalers with aerochambers
When to use rescue inhaler (role of medications)
Flu vaccine annually
Asthma action plan
 Asthma action plan
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Self monitoring of symptoms
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Self monitoring of peak flow measurements
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When to call provider
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When to go to emergency room
Asthma Treatment Plan
Consultation/ Referral
 Referral to allergist or pulmonologist if:
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Unclear if true asthma
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Additional patient education needed
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If other diagnoses exist: Rhinitis, GERD, Sinusitis, OSA
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If bronchoprovocation or skin testing is needed
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For consideration of immunotherapy or anti- IgE therapy
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Poorly controlled asthmatics with moderate to severe persistent asthma
or multiple ECC visits
Multiple choice questions
 1. What drug class is the most effective rescue therapy
for acute asthma symptoms?
a.
b.
c.
d.
Short acting beta agonist
Anticholinergic agent
Systemic corticosteroids
Inhaled corticosteroids
2. Which is not a commonly associated condition of asthma?
a.
b.
c.
d.
Obesity
Allergic Rhinitis
Eczema
Diabetes
Multiple choice questions
 3. Which is not an environmental risk factor for
asthma?
a.
b.
c.
d.
Genetic predisposition
Viral infections
Tobacco smoke
Animal dander
4. The physical exam on a patient with asthma:
a.
May be normal
b.
May show accessory muscle use
c.
Eczema may be present
d. All of the above
Multiple choice questions
 5. Which test would be appropriate for diagnosis of
asthma?
a.
b.
c.
d.
Spirometry
CBC
Bronchoprovocation
Peak expiratory flow rates
6. Which person would be least likely to be diagnosed with asthma?
a.
African American Male age 6
b.
Caucasian male aged 70
c.
African American female aged 48
d.
2 year old caucasian boy with recent RSV
Multiple choice questions
 7. A 7 year old asthmatic male is questioned about his asthma
control. His mom reports he only requires his inhaler once
weekly, and is rarely awakened by symptoms at night. Which
class of asthma would he fall into based on info provided?
a.
b.
c.
d.
Mild persistent
Intermittent
Moderate persistent
Severe persistent
8. What result may be found on a blood test for an asthmatic patient?
a.
low WBC count
b.
Elevated potassium
c.
Elevated IgE
d.
Low sed rate
Multiple choice questions
 9. Which would not be found in a patient with
Severe persistent asthma?
a.
b.
c.
Symptoms throughout the day
Use of albuterol inhaler several times of day
Mild limitations to daily activity
10. Which statement regarding asthma is true?
a. Chronic, reversible airway disease
b. Chronic, irreversible airway disease
c. Acute, intermittent, airway disease
References
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Burns, C. (2013). Pediatric Primary Care (5th ed.) Philadelphia: Elsevier Saunders.
Dunphy, L. (2011). Primary Care (3rd ed.). Philadelphia: FA Davis and Co.
Domino, F. (2013). The 5 Minute Clinical Consult 2014 (22nd ed.). Philadelphia: Lippincott
Williams & Wilkins.
Halterman, J. S., Riekert, K., Bayer, A., Fagnano, M., Tremblay, P., Blaakman, S., & Borrelli, B.
(2011). A pilot study to enhance preventive asthma care among urban adolescents with
asthma. Journal of Asthma, 48(5), 523-530.
Juel, C. T. B., & Ulrik, C. S. (2013). Obesity and Asthma: Impact on Severity, Asthma Control,
and Response to Therapy. Respiratory care, 58(5), 867-873.
Melén, E., & Pershagen, G. (2012). Pathophysiology of asthma: lessons from genetic research
with particular focus on severe asthma. Journal of internal medicine, 272(2), 108-120.
Rosenthal, E. (2013, October 13). Paying til it hurts. New York Times. Retrieved from
http://www.nytimes.com/2013/10/13/us/the-soaring-cost-of-a-simple-breath.html.
Tapp, H., Hebert, L., & Dulin, M. (2011). Comparative effectiveness of asthma interventions
within a practice based research network. BMC health services research, 11(1), 188.
UTD (2013). Asthma treatment guidelines. Retrieved from http://www.uptodate.com/