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RITA ALLNUR 652 PRIMARY CARE
ICD 9 CODES:493 .00 EXTRINSIC ASTHMA, UNSPECIFIED493.90 ASTHMA, UNSPECIFIED, WITHOUT
MENTION OF STATUS ASTHMATICUS493.92 ASTHMA, UNSPECIFIED, WITH
ACUTE EXACERBATION
Asthma
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
Intermittent- no daily medication needed, rescue inhaler only
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
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-
Molds, animal dander, pollen, dust, smoke, beta-blockers, or aspirin containing products, temperature changes Infections- URI’s, RSV Psychological factors- stress
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 population7 million children, one of the most common childhood
chronic diseases, highest in 5-17 years old30 million Americans, 300 million globally and growingMore common in boy youthsMore common in adult women, African AmericanAfrican 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 importantMay be normalGeneral 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
COPDCHFPETumorPulmonary infiltration with eosinophiliaMedications such as ACE inhibitorsVocal cord dysfunction
Social/ Environmental Considerations
Adolescents have a poor rate of complianceThose 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 issuesThose that are uninsured or have lack of access to
quality of healthcare will have poorer outcomesCost of medication:
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 triggersControlling exposuresIdentify those at risk for reaction to aspirins
or NSAIDS, beta- blockers, avoid exposureFood allergies and sulfites in food can
precipitate symptomsDaily monitoring of peak expiratory flow
record it on a record with any symptomsWritten instructions including crisis plan
Management/ Treatment guidelines- Pharmacologic
First line: Short acting beta agonist
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.
Anticholinergic agents Ipratropium bromide (atrovent), used in combination with SABA for acute
treatment
Systemic corticosteroids 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 guidelines- Pharmacologic
Second line (for long term control): 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
AtelectasisPneumoniaPneumomediastinumPneumothoraxMedication specific side effects/adverse
reactionsRespiratory failureDeath
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 cessationPrevention of second hand smoke exposureRemoval or modification of allergens/ irritant
triggers in living spaceAllergen immunotherapyTreat allergic rhinitisUse of inhalers with aerochambers When to use rescue inhaler (role of
medications)Flu vaccine annually
Asthma action plan
Asthma action plan
Self monitoring of symptoms
Self monitoring of peak flow measurements
When to call provider
When to go to emergency room
Asthma Treatment Plan
Consultation/ Referral
Referral to allergist or pulmonologist if:
Unclear if true asthma
Additional patient education needed
If other diagnoses exist: Rhinitis, GERD, Sinusitis, OSA
If bronchoprovocation or skin testing is needed
For consideration of immunotherapy or anti- IgE therapy
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. Short acting beta agonistb. Anticholinergic agentc. Systemic corticosteroidsd. Inhaled corticosteroids
2. Which is not a commonly associated condition of asthma?
e. Obesityf. Allergic Rhinitisg. Eczemah. Diabetes
Multiple choice questions
3. Which is not an environmental risk factor for asthma?a. Genetic predispositionb. Viral infectionsc. Tobacco smoke d. Animal dander
4. The physical exam on a patient with asthma:e. May be normal f. May show accessory muscle useg. Eczema may be presenth. All of the above
Multiple choice questions
5. Which test would be appropriate for diagnosis of asthma?a. Spirometryb. CBCc. Bronchoprovocationd. Peak expiratory flow rates
6. Which person would be least likely to be diagnosed with asthma?
e. African American Male age 6f. Caucasian male aged 70g. African American female aged 48h. 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. Mild persistentb. Intermittentc. Moderate persistentd. Severe persistent
8. What result may be found on a blood test for an asthmatic patient?e. low WBC countf. Elevated potassiumg. Elevated IgEh. Low sed rate
Multiple choice questions
9. Which would not be found in a patient with Severe persistent asthma?a. Symptoms throughout the dayb. Use of albuterol inhaler several times of dayc. Mild limitations to daily activity
10. Which statement regarding asthma is true?a. Chronic, reversible airway diseaseb. Chronic, irreversible airway diseasec. Acute, intermittent, airway disease
References
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 fromhttp://www.uptodate.com/