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Asthma Medication Administration Marcia Winston, MSN,CPNP,AE-C [email protected] The Children’s Hospital of Philadelphia Division of Pulmonary Medicine Clinical Management of Asthma NIH NHLBI NAEPP Expert Report 3 released in 2007 (1991, 1997, 2002) Level of Severity -EPR-3 To be determined at time of Diagnosis to Initiate Treatment Classification of level severity is based on assessment of: Number of days/week symptoms occur Number of night awakenings/month Interference with normal activity Peak Flow (PEFR) or FEV1 (forced expiratory volume in 1 second) Exacerbations requiring oral corticosteroids EPR-3 Classification of Asthma Severity Determines treatment Each age group (0-4 years of age, 5-11 years of age and 12adult) Six steps Long-term control: preferred and alternative Step 1 Intermittent asthma Step 2-6 Persistent asthma EPR-3: Goals of Therapy: Control of Asthma REDUCE IMPAIRMENT Prevent chronic and troublesome symptoms (in the daytime, at night, or after exertion) Maintain (near) normal pulmonary function Maintain normal activity levels (including exercise) Infrequent use of SABA </= twice a week NOT including pre-treatment of EIB Satisfy and meet patient/families expectations EPR-3: Goals of Therapy: Control of Asthma REDUCE RISK Prevent recurrent: Exacerbations E.R. visits Hospitalizations Prevent loss of lung function/for children prevent reduced lung growth Provide optimal pharmacotherapy with minimal or no adverse effects of therapy Medications to Treat Asthma Two major categories of medications are: Long-term control Quick relief QVAR/beclomethasone dipropionate HFA 40mcg, 80mcg/inhalation Pulmicort Flexhaler/budesonide 90 mcg and 180 mcg/inhalation Pulmicort Respules/budesonide 0.25mg/2ml, 0.5mg/2ml and 1mg/2ml nebulizer suspension Alvesco (ciclesonide) 80 mcg, 160 mcg/inhalation Flovent HFA/fluticasone propionate 44mcg, 110mcg, 220mcg/inhalation Asmanex Twisthaler/mometasone furoate 110mcg, 220mcg/inhalation Medications to Treat Asthma: Quick-Relief Used in acute asthma episodes, relieve symptoms Generally they are short-acting beta2-agonists: albuterol (ProAir HFA, Proventil HFA, Ventolin HFA) levalbuterol pirbuterol ipratropium Systemic corticosteroids Asthma: Under Control or Out of Control? Baylor Rule of Twos: Take quick relief medicine > 2 times/week Wake up at night due to asthma > 2 times/month Refill quick relief inhaler prescription more than 2 times/year *one albuterol MDI=200 puffs/medicine=100 two puff doses* Medication Administration Oral Metered dose inhaler (MDI) and spacer Dry powder inhaler(DPI) Air Compressor/Nebulizer Injection Asthma Devices: Medication Administration Metered dose inhalers (MDIs) w/CFC propellant have been discontinued Maxair (pirbuterol) will be off the market in 2013 Asthma Devices: Medication Administration Metered dose inhalers (MDIs) w/ HFA (as of 2008) require maintenance: priming and rinsing Medication Administration One way valve holding chambers Medication Administration Dry powder inhalers (DPI) Medication Administration Nebulizer/air compressor Medication Administration Nebulizer/air compressor InCheck Dial: Measures Inspiratory flow rate Medication Administration Air Compressor and Nebulizer: As per Rubin & Fink, “Aerosol Therapy for Children” Home versus hospital: not the same No published data supports the use of the blow-by technique Aerosol deposition studies suggest that virtually no drug enters the airway If not using a mouthpiece then the mask should be close fitting If the mask is not close fitting or patient is crying aerosol deposition can also be affected Respiratory Care Clinics of North America 7:2 June 2001 Asthma Out of Control *Frequent flyers* (symptoms, ER, hospital, over use of albuterol) Assess and re-assess: Observe patient’s medication administration technique, equipment and medications Ask directly about adherence, “How often do you miss a dose of your long-term control medicine?” Ask about the environment: pets and ETS. Consider alternative diagnosis/comorbid conditions Managing Asthma: Sample Asthma Action Plan Describes what medicines to use and actions to take when well and when symptomatic/for attacks and emergency instructions National Heart, Lung, and Blood Institute Resources Association of Asthma Educators-AAE: www.asthmaeducators.org National Asthma Education and Prevention Program (EPR3 Guidelines) www.nhlbi.nih.gov/about/naepp/index.htm