Teach Asthma Management Teach Asthma Management (TAM)(TAM)

Provided by:

Generously supported by the Robert Wood Johnson FoundationSome slides adapted from Physician Asthma Care Education, developed by

Noreen Clark, University of Michigan, School of Public Health

Part I of II

Overview of Asthma

Michael Zacharisen, M.D.Allergist

Children’s Hospital of Wisconsin

OBJECTIVES:

Increase your knowledge of pediatric asthma epidemiology

Improve your clinical and community care of children with asthma and their families

Asthma Patient DemographicsUS Population = 277.8 Million (US Census, 3/01)Asthma Patients = 5.6% Prevalence (ALA, 2/01)

1. Morbidity & Mortality Weekly Report, 2001.2. Asthma Physician Market Dynamics Study, 2001.3. National Center for Health Statistics, 1986-1999.4. Scott Levin, PDDA, MAT 12/01.

Age1

Age 18 y

12.1 million

68%

Age 0-17 y

5.6 million 32%

Severe 18%

Moderatepersistent

34%Mild

persistent22%Mild

intermittent26%

17.7 million

patients with

asthma

2.7 m AA7.2%

4.2 million Hispanic11.7%

10.8 million Caucasian

5.4% prevalence

Patients With Asthma1

Severity2 Race3 Gender4

Male45%

Female55%

CDC Press Release

9 million children <18 have been diagnosed with asthma >4 million have had an asthma attack in the past 12

months 12% of children <18 have been diagnosed with asthma

Boys 14%, Girls 10%Poor families 16%, Not poor families 11%

www.cdc.gov/nchs released 3/2004

Burden of ASTHMA in Wisconsin

12% of adults and 8% of children have been told they have asthma (Overall = 9%)

5,000 asthma hospitalizations (2002)Costs of $36 million in 2002Average charge of $6,942/stay

22,418 asthma emergency department visitsCosts of $13.3 million in 2002

Wis. DHFS; PPH 45055 (03/04) http://dhfs.wisconsin.gov

Burden of ASTHMA in Wisconsin

80% report asthma symptoms in past 30 days Only 48% report having a routine health care visit for asthma in

past 12 months Only 40% report daily medication use In past 12 months:

14% adults had ED visit18% adults had limited daily activities due to asthma

Wis. DHFS; PPH 45055 (03/04) http://dhfs.wisconsin.gov

• Episodic and/or chronic symptoms of airway obstruction.

• Bronchial hyperresponsiveness to triggers.

• Evidence of at least partial reversibility of the airway obstruction.

• Alternative diagnoses are excluded.

A chronic inflammatory disease of the airways with the following clinical features:

Definition of Asthma

Epithelialdamage

Inflammatorycell infiltration

Vasculardilation

Mucous glandhypertrophy

Edema

Mucus

Thickening of basement membrane

Adapted from National Asthma Education and Prevention Program. Expert Panel Report. Guidelines for the Diagnosis and Management of Asthma. August 1991.

Changes in Airway Morphology in Asthma

Airway smoothmuscle

1970s–1980sBronchoconstriction

(Spirometry)

1980s–1990s

Inflammation(PC20, Inflam cells,

FeNO)

1990s–2000s

Remodeling

Relieve SymptomsPrevent Symptoms

Prevent AttacksPrevent Remodeling

Prevent SymptomsPrevent Attacks

Evolution of Asthma Paradigms

Bronchial Hyperreactivity Fixed

ObstructionSymptoms

A Lot Going On A Lot Going On Beneath The SurfaceBeneath The Surface

Airway inflammation

Airflow obstruction

Bronchial hyperresponsiveness

Symptoms

Expert Panel Report 2:Four Components ofAsthma Management

Measures of Assessment and Monitoring Control of Factors Contributing to

Asthma Severity

Pharmacologic Therapy

Education for a Partnership in Asthma Care

Component 1:

Initial Assessment and Diagnosis of Asthma

Determine that:Patient has history or presence of episodic symptoms of airflow

obstruction

Airflow obstruction is at least partially reversible

Alternative diagnoses are excluded

Methods for establishing diagnosis:

Detailed medical history

Physical exam

Spirometry to demonstrate reversibility

Component 1:

Initial Assessment andDiagnosis of Asthma (continued)

Does patient have history or presence ofepisodic symptoms of airflow obstruction? Wheeze, shortness of breath, chest tightness, or

cough Asthma symptoms vary throughout the day Absence of symptoms at the time of the

examination does not exclude the diagnosisof asthma

Initial Assessment andDiagnosis of Asthma (continued)

Is airflow obstruction at least partiallyreversible? Use spirometry to establish airflow obstruction:

FEV1 < 80% predicted;

FEV1/FVC <65% or below the lower limit of normal

Use spirometry to establish reversibility:FEV1 increases >12% and at least 200 mL after

using a short-acting inhaled beta2-agonist

Component 2:

Control of Factors Contributing to Asthma Severity

Assess exposure and sensitivity to: Inhalant allergens Occupational exposures

Ask specifically about work-related triggers

Irritants: Indoor air (including tobacco smoke) Air pollution

Component 2:Control of Factors

Contributing to Asthma Severity (continued)

Assess contribution of other factors:Rhinitis/sinusitisGastroesophageal refluxDrugs (NSAIDs, beta-blockers)Viral respiratory infectionsSulfite sensitivity

Pediatric Differential Diagnosis

Chronic sinusitis Vocal cord

dysfunction (VCD) Croup Tracheomalacia Pertussis TE fistula

Foreign bodyBronchiolitisCystic fibrosis / Ciliary dysfunctionGERDHyperventilation syndrome

Viruses and Asthma

Viral infections frequently cause wheezing30-60% of children will wheeze in 1st 5 yearsFrequent cause of asthma exacerbation

Unable to directly link viral infections with development of asthmaProven risk factors include:

Family history of asthmaEnvironmental smoke exposureHistory of severe bronchiolitis in 1st 18 months

Benchmarks of Good Asthma Control

Infrequent coughing or wheezing No shortness of breath or difficulty breathing No waking up at night due to asthma Normal physical activities No childcare or school absences due to asthma No missed time from work for parent or caregiver

AAAAI Guide

Classification Of Asthma Severity: Clinical Features Before Treatment

  Days with Symptoms

Nights with Symptoms

PEV or FEV1

STEP 4Severe

Persistent

Continual Frequent < 60

STEP 3Moderate Persistent

Daily > 5/month > 60% to <80%

STEP 2Mild

Persistent

3-6/week 3-4/month > 80%

STEP 1Mild

Intermittent

< 2/week < 2/month > 80%

Misclassification of Intermittent Asthma#

of P

atie

nts

400

600

800

1,000

Mild intermittent asthmabased on symptoms

and FEV1 alone

Mildintermittent

60%

Mildpersistent

22% Moderatepersistent

15% Severepersistent

3%

200

400

600

200

Classification of the same group but now based on symptoms, FEV1,

and medication use

Adapted from Liard. Eur Respir J. 2000;16:615-620.

n=4,362

953 patients

40%

Robertson et al. Pediatr Pulmonol. 1992;13:95-100.

0

5

10

15

20

25

30

35

40

Severe Moderate MildPatient AssessmentFindings from a cohort study reviewing all pediatric asthma-related deaths

(n=51) in the Australian state of Victoria from 1986 to 1989.

Pediatric Asthma Deaths: Patients With Mild Asthma Are Also at Risk

Patient Deaths

(%)

36%31% 33%

Functional status?

Daytime symptoms?

Missed work and/or school?

Nighttime awakenings?

Lung function?

AsthmaControl

Use of “quick relief” inhaler

and/or nebulizer?

Utilization of healthcare resources?

Patient self-report of control?

How Can Asthma Control Be Measured?

Inflammation?Direct or indirect?

Satisfaction with care?

Paradigm Shift in Asthma

Difficult to control

Asthma

ControlledUncontrolled

Adjusttherapy

Asthma Control and Steroid Doses After Early or Delayed Intervention

Patients with asthma started on budesonide were compared based on duration of asthma at budesonide initiation

Asthma for <2 yearsAsthma for 2 years

Outcomes assessed

Lung function: FEV1, PEFPersistent need for inhaled corticosteroidPersistent symptoms

Selroos et al. Respir Med. 2004;98:254-262.

Mean ICS Doses and Lung Function5 Years After Early or Delayed Intervention

Selroos et al. Respir Med. 2004;98:254-262.

412

93.995 825

84.5

87.2

Delayed TreatmentEarly Treatment

1000

900

800

700

600

500

400

300

200

100

0

Dos

e of

Inha

led

Ster

oid

% o

f Pre

dict

ive

FEV 1

, PEF

100

95

90

85

80

75

Inhaled steroidFEV1 % pred

PEF, % pred

Does chronic use of inhaled corticosteroids improve long-term outcomes for children with mild or moderate asthma, compared

to other asthma medications? “Strong evidence” established that inhaled corticosteroids

improve asthma control for children with mild-moderate asthma None of the alternatives “listed alphabetically” cromolyn,

leukotriene modifier, nedocromil, sustained release theophylline are as effective

“Low dose” inhaled corticosteroids are the “preferred” treatment for mild asthma

“Low dose” inhaled corticosteroids plus long acting inhaled beta2 agonists are the “preferred” treatment for moderate asthma

NIH Publication No. 02-5075, June 2002

Inhaled Glucocorticoids Versus Leukotriene Receptor Antagonists as Single Agent Asthma Treatment: Systematic

Review of Current EvidenceDucharme FM. BMJ 2003;326:621-625.

Objective: To compare the safety and efficacy of leukotriene modifiers (LTM) with inhaled corticosteroids (ICS) as monotherapy in patients with asthma

Primary Outcome: Rate of exacerbations that required treatment with systemic corticosteroids

Secondary Outcomes: Lung function (FEV1, AM PEF), nocturnal awakenings, use of rescue ß2- agonist, withdrawal rates, days with symptoms, & adverse events

Results - Primary Outcome

Patients receiving LTM were 60% more likely to experience an exacerbation than those treated with ICS (11 trials; RR 1.6, 95% CI 1.2-2.2)

No difference in risk for exacerbations was found in the one pediatric trial reviewed (RR 0.78, 0.32-1.85)

Ducharme FM. BMJ 2003;326:621-625.

What are the long-term adverse effects of chronic inhaled corticosteroid use in children:

growth, bone density, ocular, HPA? “Strong evidence” shows that inhaled corticosteroids at

recommended doses do not have clinically significant or irreversible effects on these outcomes

Low to medium doses of inhaled corticosteroids have the potential to decrease growth velocity 1cm in the first year but this is NOT sustained, progressive, and may be reversible

Observational studies up to 6 years reveal no adverse effect on bone density, cataracts, glaucoma, or clinically significant HPA axis changes

NIH Publication No. 02-5075, June 2002

Dose, drug, &Dose, drug, &route dependentroute dependent

Corticosteroids for Asthma: Benefits and Risks

ReducesReducesinflammationinflammation

Most effectiveMost effectivelong-term control long-term control

medication for medication for asthma*asthma*

DecreasesDecreasesmorbidity / mortalitymorbidity / mortality

Generally knownGenerally knownand can beand can bemonitoredmonitored

BenefitsBenefits

RisksRisks

In patients with moderate persistent asthma who are on ICS, does the addition of another long-term control agent improve

outcomes? “Strong evidence” consistently indicates that the addition of a

long acting inhaled ß2 agonist leads to improvement in lung function, symptoms & reduced additional ß2 agonist use

Adding an LTM or theophylline to an ICS or doubling the ICS dose improves outcomes “but the evidence is not as substantial”

For children less than 5 the preferred treatment is low dose ICS + a long acting inhaled ß2 agonist or medium dose ICS

NIH Publication No. 02-5075, June 2002

What have we learned from all of the studies?

Lung function Symptoms Albuterol use Exacerbations Reduces need to increase ICS dose

low-dose ICS + LABA vs. “other therapy” results in:

Replicated numerous times by other investigatorsGreening et al. Lancet. 1994;344:219-224.Woolcock et al. Am J Respir Crit Care Med. 1996;153:1481-1488Nelson et al J Allergy Clin Immunology 2000;106:1088-1095

Infants and Young Children— When to Start Controllers

>3 episodes of wheezing in the last year and Parental history of asthma or physician diagnosis of eczema

Or 2 of the following Physician diagnosis of allergic rhinitis, wheezing apart from

colds, peripheral eosinophilia Courses of oral steroids more often than every 6 wk Symptoms >2x/wk, nocturnal symptoms >2x/mo

Principles of Maintenance Therapy

Start high. Step down once control is achieved. Maintain at lowest dose of medication that

controls asthma. Step up and down as indicated.

Step-down Therapy

Step down once control is achieved. After 2–3 mo. 25% reduction over 2–3 mo.

Follow-up monitoring Every 1–6 mo. Assess symptoms. Review medication use. Objective monitoring (PEFR or spirometery). Review medication.

Step-up Therapy

Indications: symptoms, need for quick-relief medication, exercise intolerance, decreased lung function.May need short course of oral steroids.

Continue to monitor.Follow and reassess every 1–6 mo.Step down when appropriate.

Acute Exacerbations

Principle: Gain control as quickly as possible.Treat all asthma exacerbations promptly

and aggressively. Inhaled ß2-agonist inhalants for quick relief Access to quick relief medication Written action plan

IndicationsMedicationsWhen to contact physician or emergency medical services

Short course of oral corticosteroids

Acute ExacerbationsOffice Management

Assess severity. Symptoms, signs, lung function, pulse oximetry (if

available)

Oxygen recommended Short acting ß2-agonist inhalant every 20–30 min Ipratropium—metered-dose inhaler, inhalation solution Corticosteroid—orally, intravenous if vomiting Intravenous favored if dehydrated Follow-up—hours (phone) to 1–7 d

Step 1Mild Intermittent

No Daily Medication

Step 2 Mild Persistent

Preferred: Low-dose ICS

Step 3Moderate Persistent

Step 4Severe Persistent

Alternative: Cromolynor LTRA

Preferred:Low-dose ICS +

LABA or Medium-dose ICS

(+ LABA if needed) Alternative:

Low- to Med-dose ICS + LTRA or

Theophylline

High-dose ICS + LABA

(+ systemiccorticosteroids

if needed)

Stepwise Approach to Therapy for Children 5 Years

ICS = inhaled corticosteroid; LABA = long-acting 2-agonist; LTRA = leukotriene receptor antagonist

NIH/NHLBI Guideline Update. June 2002. NIH Publication No. 02-5075.

ICS = inhaled corticosteroid; LABA = long-acting 2-agonist; LTM = leukotriene modifier; SR = sustained release.

Stepwise Approach to Therapy for Adults and Children >5 Years

Alternative:Cromolyn, LTM, Nedocromil, or

SR Theophylline

Step 1Mild Intermittent

No Daily Medication

Step 2 Mild Persistent

Preferred:Low-dose ICS

Step 3Moderate Persistent

Step 4Severe Persistent

High-dose ICS + LABA

(+ systemiccorticosteroids

if needed)

Preferred:

Alternative: ICS With No LABAor Low- to Med-dose

ICS + LTM or Theophylline

Low- to Med-dose ICS + LABA

( to med-dose ICS+ LABA if needed)

NIH/NHLBI Guideline Update. June 2002. NIH Publication No. 02-5075.

Tools to Improve Asthma Documentation & Quality Care

Living with Asthma Questionnaire Asthma Control Test Progress Note Template Asthma Action Plan

More QI information see:www.eqipp.orgwww.improvingchroniccare.org

Medication Adverse Effects

Short & Long-Acting Bronchodilators

Increased heart rate, tremors, headache (last short time)

Cromolyn / Tilade Rare, may have throat irritation

Leukotriene Modifiers GI upset

Inhaled Corticosteroids Thrush, dysphonia, high doses may have systemic effects

Systemic Corticosteroids Many - Increased appetite, stomachache, mood changes, fluid retention, diabetes, osteoporosis

Education for Partnership in Care

Develop a written asthma management planAgree on therapy goals Outline daily treatment and monitoring measuresPrepare an action plan to handle worsening symptoms

Provide routine education on patient self-managementHow and why to take medicationsCorrect technique for devicesPeak flow or symptom monitoringFactors that worsen asthma and actions to take

Asthma Medications and Devices

Rhonda J. Duerst, RRT-NPS, AE-CChildren’s Hospital of Wisconsin

Objective:

Teach caregivers to administer daily anti-inflammatory control medications as needed and quick relief medicines for patients with persistent asthma

Asthma Can be Managed

With proper therapy, the child can be symptom free

Goal is to use the least amount of medication as possible, increasing on an as-needed basis

Long-term goal of reducing or even stopping regular medications

Emphasis on as little as possible address parents’ fears of over-medication and dependence

What makes Asthma Management so hard for Parents and Children?

Here today, gone tomorrow: periods of symptoms interspersed with symptom-free periods

Daily medicines even when feeling well Unpredictability: don’t know exactly what triggers the episode Complicated medication plan varies with symptom intensity

and disease severity Need to monitor asthma symptoms Fears about medication side-effects Medication only part of the plan, trigger reduction also

needed.

Explaining How to Take Medicines

Clinician Message:Demonstrate use of

inhaler and spacerShow how to use peak

flow meterGive step-by-step

instructions

Parent Message:Feel comfortable

with “technology”Know how and

where to get equipment

What to do if you run out of medicine

Fears About Asthma Medicines

39% Believe medicines are addictive

36% Believe medicines are not safe to take over a long period

58% Believe regular use will reduce effectiveness

Quick Relief Medicines

Act fast, generally within 15-20 minutes Relaxes the smooth muscles around the bronchial tubes Parents need to know how often child is using Must have available at all times Is only medicine that helps child breathe quickly

ASTHMA MEDICATIONS Beta 2 agonists - bronchodilators

Albuterol (Proventil, Ventolin)Pirbuterol (Maxair)Levalbuterol (Xopenex)Terbutaline (Brethine)Metaproterenol (Alupent)

Explain About Quick-Relief Medications

Provider message:–Quick-relief medications relax the muscles after they have tightened during an attack –Parents are in charge of helping their children breathe through the quick-relief medications

–Quick- relief medications act fast, so that breathing is easy again within minutes

Parent Message: –Know that medicines will open up lungs and child won’t suffocate–Know that reaction is not instant; may take a few minutes–Quick relief medicines are parents’ ticket to helping child breathe

Communication Tip for Quick-Relief Medications

Use a physical example: Unclamp fist to show how medicines work

Ask parent about fears they have regarding child’s asthma episode

Discuss concerns parents may have about medications Jitteriness; anxiety & other side effects parents may fear

(“dependence”) Be accurate about risks but reinforce message that medicines

work!

Explaining about Long-term Control Medications

Provider Message: –Anti-inflammatory medicines don’t relieve symptoms–Do reduce inflammation and prevent frequent or severe episodes–Needed if symptoms more than 2X/week in day or 2X/month at night–Effective only if taken regularly

Parent Message:–Anti-inflammatory meds are like a flu shot, to help keep away the “bad” asthma episodes –Anti-inflammatory medicines are like vitamins; they need to be taken all the time, even if not sick

Communication Tips about Long-term Control Medicines

Explain the different types of controllers (parents want to know the names), and why more than one may be used

Convey clearly information about any risks or side effects Discuss fears about medication “dependence”

Low Doses of Inhaled Corticosteroids do not cause side effects

Not the same as the body-building steroids Emphasize safety of the medications when used as

prescribed on the plan.

ASTHMA MEDICATIONS

Long-acting beta 2 agonistsSalmeterol (Serevent)Formoterol (Foradil)

Combine with ICS (ADVAIR available)

Corticosteroids Inhaled (ICS)

Beclomethasone (Vanceril, Beclovent, Q-VAR)Budesonide (Pulmicort)Flunisolide (Aerobid)Fluticasone (Flovent, ADVAIR)Triamcinolone acetonide (Azmacort)

SystemicPrednisone/PrednisoloneMethylprednisolone (Solu-Medrol, Medrol)

ASTHMA MEDICATIONS Mast cell stabilizers

Cromolyn sodium (Intal)Nedocromil (Tilade)

AnticholinergicIpratropium bromide (Atrovent)

MethylxanthinesTheophyllineAminophylline

ASTHMA MEDICATIONS Leukotriene inhibitors

Oral, QD-BIDMontelukast (Singulair)Zafirlukast (Accolate)Zileuton (Zyflo)Some evidence of effectiveness in preventing premenstrual

asthma exacerbations1 1. J Allergy Clin Immunol 1999;104:585-8.

Teaching Checklist

Use of inhaler/spacer Use of nebulizer Use of Peak Flow Meter Give step by step directions Instruct how/where to get

spacers/nebs/PFM

Instruct what to do if run out of medicine or can’t get devices

Ask parent/child to demonstrate technique at each visit

Reassure parent about using alternative treatments with medications

Spacers/Holding Chambers

Spacers/Holding Chambers

Recommended with all medium to high dose ICS Enhance delivery, especially with children Improves coordination and medication delivery

some provide auditory feedback Minimize adverse effects from ICS

decrease oral bioavailabilityreduce oral candidias (thrush)dysphonia, and bad taste

©1998, Respironics Inc.

©1998, Respironics Inc.

Without Without SpacerSpacer

With With SpacerSpacer

Dry Powder Inhalers (DPI)

Spacers can not be used with DPI Turbuhaler®, Diskus®, Aerolizer™ Must be able to do mouthpiece treatment Deep rapid inhalation

Peak Flow

Meters

Peak Flow Monitoring

Provides objective information Documents personal best Detects worsening asthma before changes occur Useful only if breathing is monitored regularly Indicates need for quick-relief medications Assists in precipitant identification Aids in communication

Determine Personal Best Peak Flow

Take peak flow reading at least once per day for 2-3 weeks Measure peak flow at these times:

Between noon and 2pm each dayEach time quick-relief meds are taken for symptomsAny other time your doctor suggests

Use same peak flow meter over time Important Component of written action plan

Proper PF Technique

1- Set meter to Zero2- Stand up straight3- Take deep breath in4- Blow out hard & fast5- Repeat two more times6- Record your highest number

Teaching Peak Flow

Instruct in how to establish child’s personal best Demonstrate to child/parent how to set child’s zones (red,

yellow & green) Help parent establish a routine for peak flow measurements Remind parent to adjust medications according to peak flow

number Encourage parent to bring PF diary with to all appointments