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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