Webinar:Managing Asthma in the

Job Corps StudentJohn Kulig, MD, MPH

Lead Medical Specialist

September 7th and 15th, 2011

Overview

Summary: This webinar will review the comprehensive outpatient management of asthma with the goals of improving asthma control and enhancing employability. This course is offered at an intermediate level. It will consist of lecture, a pre-test, post-test and a question and answer period. No prerequisite knowledge is required for this course.

Learning Objectives

After this presentation, participants will be able to: Describe the current National Heart Lung and Blood

Institute (NHLBI) Asthma Guidelines for classifying severity, control, and stepwise management of asthma.

Apply updated Job Corps Treatment Guidelines for management of students with asthma.

Implement case management for all Job Corps students with asthma.

Pre-Test

1. African American students have higher rates of

asthma than their white peers. True or False?

2. Twice daily use of an albuterol inhaler prevents wheezing in most students with persistent asthma. True or False?

3. Inhaled corticosteroids are the preferred first choice for controller medications. True or False?

4. Efficacy of albuterol diminishes with long-term use. True or False?

Definition of Asthma

reversible obstructive airway diseaseairway inflammationincreased airway responsiveness

Fast Facts

Every day in America:40,000 people miss school or work due to asthma 30,000 people have an asthma attack 5,000 people visit the emergency room due to asthma 1,000 people are admitted to the hospital due to asthma 11 people die from asthma

http://www.aafa.org

Key Points In 2009, the prevalence of asthma increased to 7.7% among adults, 9.6%

among all children, and 17.0% among black, non-Hispanic children. In 2008, approximately half of persons with asthma reported having had at

least one asthma attack during the preceding 12 months. Medical expenses associated with asthma amounted to $3,259 per person per

year during 2002--2007. Good control of asthma includes self-management training, appropriate use

of inhaled corticosteroids to prevent symptoms and attacks, and avoidance of environmental allergens and irritants. However, only approximately one third of persons with asthma had been given an asthma action plan as recommended.

Ref: MMWR May 6, 2011 / 60(17);547-552

Asthma Mortality Each day 11 Americans die from asthma. There are more than 4,000 deaths due to

asthma each year, many of which are avoidable with proper treatment and care. In addition, asthma is indicated as “contributing factor” for nearly 7,000 other deaths each year. 

Since 1980, asthma death rates overall have increased more than 50% among all genders, age groups and ethnic groups. The death rate for children under 19 years old has increased by nearly 80% percent since 1980. 

More females die of asthma than males, and women account for nearly 65% of asthma deaths overall. 

African Americans are three times more likely to die from asthma.  African American women have the highest asthma mortality rate of all groups, more than 2.5 times higher than Caucasian women.

http://www.aafa.org

Gonzalez v. Hanford Elementary School District

Jury Awards $9 million in Asthma Death at School

“A California jury that unanimously awarded a mother $9 million in damages for the death of her 11 year-old son from an asthma attack at school found the school district guilty of negligence for failing to inform parents of an unwritten school policy that would have allowed the child to carry an inhaler.”

May 2002

Current asthma prevalence among adults --- Behavioral Risk Factor Surveillance System, United States, 2009

Current asthma prevalence,* by age group,† sex, and race/ethnicity --- National Health Interview Survey, United States, 2001--2009

Current asthma prevalence,* by age group,† sex, and race/ethnicity --- National Health Interview Survey, United States, 2001--2009

Asthma Precipitants

Precipitants

allergens respiratory irritants respiratory infections physical exertion

cold air medications food additives emotional stress gastroesophageal reflux

Clinical Assessment

classification of asthma severity onset of wheezing/precipitant current medication regimen adherence office measurements of peak flow past severity—ER, hospitalization, ICU color, respiratory distress, vital signs auscultation of lungs objective measures: PEFR, pulse oximetry

Asthma Severity

Intermittent symptoms < 2 days a week nighttime awakenings < 2 times a month albuterol HFA use < 2 days a week no interference with normal activity normal FEV1 between exacerbations

Asthma Severity

Mild persistent symptoms > 2 days a week, but not daily nighttime awakenings 3-4 times a month albuterol HFA use > 2 days a week, but not daily, and

not more than one time on any day minor limitation of normal activity FEV1 > 80% of predicted

Asthma Severity

Moderate persistent symptoms daily nighttime awakenings > once a week, but not nightly albuterol HFA use daily some limitation of normal activity FEV1 > 60% but < 80% of predicted

Asthma Severity

Severe persistent symptoms throughout the day nighttime awakenings often 7 times a week albuterol HFA use several times per day extremely limited activity FEV1 < 60% of predicted

Classification of Asthma Control

Well controlled: symptoms < 2 days per week albuterol HFA use < 2 days per week

Not well controlled: symptoms > 2 days per week albuterol HFA use > 2 days per week

Very poorly controlled: symptoms throughout the day albuterol HFA use several times per day

Peak Flow Meters

Environmental Control Measures

eliminate indoor allergenshouse dust animal dander/salivamites cockroaches indoor moldsvacuum cleanershumidifiers

avoid outdoor allergenspollenmolds

avoid indoor irritants tobacco smokewood smoke strong odors/sprays air pollutants

Immunotherapy for Asthma

controversial in asthma effective in certain allergies monthly injections of allergen required 3 to 5 year course of treatment risk of anaphylaxis

Asthma Medications

long term control medications to prevent symptoms, maintain normal activity levels, and prevent exacerbations

quick relief medications to treat symptoms and exacerbations

all patients with persistent asthma require both classes of medication

Asthma Medication: Patient Concerns

fear of addiction belief that efficacy diminishes with long-term use confusing corticosteroids with anabolic steroids fear of side effects confusing preventive therapy with acute treatment of

symptoms

Quick Relief: Steps 1-6

short-acting bronchodilator: inhaled 2 agonists as need for symptoms

intensity of treatment depends on severity of exacerbation – up to 3 treatments at 20 minute intervals

increasing use of short-acting inhaled 2 agonists indicates the need for initial or additional long-term control therapy

Step 1

No daily medication needed SABA (albuterol HFA) only as needed

Step 2

One daily medication: inhaled corticosteroid - low dose (preferred) inhaled cromolyn or nedocromil oral leukotriene receptor antagonist oral sustained-release theophylline

Step 3

Daily medication: low dose inhaled corticosteroid plus long-acting

inhaled 2 agonist (preferred)

or medium dose inhaled corticosteroid (preferred) low dose inhaled corticosteroid plus oral leukotriene

receptor antagonist, theophylline or zileuton

Step 4

Daily medication: medium dose inhaled corticosteroid plus long-acting

inhaled 2 agonist (preferred)

medium dose inhaled corticosteroid plus oral leukotriene receptor antagonist, theophylline or zileuton

Step 5

Daily medication: high dose inhaled corticosteroid plus long-acting

inhaled 2 agonist (preferred)

and consider omalizumab for patients who have allergies

Step 6

Daily medication: high dose inhaled corticosteroid plus long-acting

inhaled 2 agonist plus oral corticosteroid (preferred)

and consider omalizumab for patients who have allergies

Short-Acting Inhaled 2 Agonists (SABA)

albuterol HFA (Ventolin/Proventil/ProAir) 2 puffs qid max

terbutaline (Brethaire) 2 puffs qid max pirbuterol (Maxair) 2 puffs qid max levalbuterol (Xopenex) inhalation solution

Inhaled Anticholinergic Bronchodilators

ipratropium bromide (Atrovent)2 puffs qid

ipratropium/albuterol (Combivent)2 puffs qid

both primarily indicated in adult COPD, not in asthma

Inhaled Mast Cell Stabilizers

cromolyn sodium (Intal)2-4 puffs qid

nedocromil (Tilade)2-4 puffs bid after control established

Inhaled Corticosteroids

beclomethasone (Qvar) budesonide (Pulmicort) - Respules/Turbuhaler flunisolide (Aerobid/Aerobid-M) fluticasone (Flovent 44/110/220) mometasone (Asmanex Twisthaler) triamcinolone (Azmacort)

Oral Corticosteroids

prednisone prednisolone methylprednisolone dosage 40-60 mg per day in single or two divided

doses for 3-10 days

Long-Acting Inhaled 2 Agonist (LABA) salmeterol (Serevent)

MDI aerosol - 2 puffs bid

DPI Diskus - 1 inhalation bid formoterol (Foradil)

DPI Aerolizer - 1 capsule bid

LABA for long-term control only leave inhaler at home

not indicated for quick relief use use LABA only in combination with inhaled corticosteroids

Combination Therapy fluticasone/salmeterol (Advair Diskus)

1 inhalation bidlow steroid dose: 100/50 mcgmedium steroid dose: 250/50 mcghigh steroid dose: 500/50 mcg

budesonide/formoterol (Symbicort)1 inhalation bidlow steroid dose: 80/4.5 mcghigh steroid dose: 160/4.5 mcg

Oral Leukotriene Modifiers

montelukast (Singulair)10 mg once qhs

zafirlukast (Accolate)20 mg bidone hour ac or two hours pc

zileuton (Zyflo)600 mg qidmonitor liver enzymes

Oral Sustained-Release Theophylline

sustained release preparations

(Theo-Dur/Uni-Dur/Uniphyl/Slo-Phyllin) 10-15 mg/kg/day divided q 8, 12, or 24 hr monitor steady state theophylline levels therapeutic peak blood level 5-15 mcg/mL

Omalizumab (Xolair)

recombinant DNA-derived monoclonal antibody patients > age 12 with moderate to severe persistent asthma

who have a positive skin test or in vitro reactivity to a perennial aeroallergen and whose symptoms are inadequately controlled with inhaled corticosteroids

pretreatment serum IgE level and body weight are used to determine doses and dosing frequency

given by subcutaneous injection every 2-4 weeks $10,000 - $30,000 cost per year

Oral Antihistamines

no longer contraindicated in asthma loratadine (Claritin/Alavert)

10 mg once qd cetirizine (Zyrtec)

10 mg once qd fexofenadine (Allegra)

180 mg once qd or 60 mg bid

Step Therapy

Step downreview treatment every 3 monthsgradual stepwise reduction in treatment may be possible

Step upif control not maintained, consider additional treatment

options first review patient medication technique, adherence and

environmental control

Post-Test

1. African American students have higher rates of asthma than their white peers. True or False?

2. Twice daily use of an albuterol inhaler prevents wheezing in most students with persistent asthma. True or False?

3. Inhaled corticosteroids are the preferred first choice for controller medications. True or False?

4. Efficacy of albuterol diminishes with long-term use. True or False?

Post-Test

1. African American students have higher rates of asthma than their white peers. True

2. Twice daily use of an albuterol inhaler prevents wheezing in most students with persistent asthma. False

3. Inhaled corticosteroids are the preferred first choice for controller medications. True

4. Efficacy of albuterol diminishes with long-term use. False