Asthma Medication Administration

Marcia Winston, MSN,CPNP,AE-Cwinstonm@email.chop.edu

The Children’s Hospital of PhiladelphiaDivision of Pulmonary Medicine

Clinical Management of Asthma

NIHNIHNHLBINHLBINAEPPNAEPPExpert Report 3 released in 2007 (1991, 1997, 2002)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 treatmentEach age group (0-4 years of age, 5-11 years of age and

12-adult)

Six stepsLong-term control: preferred and

alternativeStep 1 Intermittent asthmaStep 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:ExacerbationsE.R. visitsHospitalizations

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 HFA40mcg, 80mcg/inhalation

Pulmicort Flexhaler/budesonide90 mcg and 180 mcg/inhalation

Pulmicort Respules/budesonide0.25mg/2ml, 0.5mg/2ml and 1mg/2ml nebulizer

suspension

Alvesco (ciclesonide) 80 mcg, 160 mcg/inhalation

Flovent HFA/fluticasone propionate44mcg, 110mcg, 220mcg/inhalation

Asmanex Twisthaler/mometasone furoate110mcg, 220mcg/inhalation

Medications to Treat Asthma:Quick-Relief

Used in acute asthma episodes, relieve symptomsGenerally they are short-acting beta2-agonists:

albuterol (ProAir HFA, Proventil HFA, Ventolin HFA) levalbuterolpirbuterolipratropium 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

than2 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

National Heart, Lung, and Blood Institute

Describes what medicines Describes what medicines to use and actions to take to use and actions to take when well and when when well and when symptomatic/for attacks symptomatic/for attacks and emergency and emergency instructionsinstructions

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