Asthma IntroducBon IntroducBon IntroducBon Anatomic AlteraBons

RSPT 2310 Asthma DMC = Degranula:on of mast cell MA = Mucus accumula:on HALV = Hyperinfla:on of alveoli Asthma MP = Mucus plug SMC = Smooth muscle constric:on RSPT 2310 Introduc:on Introduc:on •  The first evidence based asthma guidelines were published in 1991 by: •  Today, the NAEPP guidelines are structured around the following four components: –  Na:onal Asthma Educa:on and Preven:on Program (NAEPP)—under the coordina:on of the: •  Na:onal Heart, Lung, and Blood Ins:tute (NHLBI) of the Na:onal Ins:tutes of Health. 1. 
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Assessment and monitoring of asthma Pa:ent educa:on Control of factors contribu:ng to the asthma severity The pharmacologic treatments Introduc:on Anatomic Altera:ons of the Lungs •  The Global Ini:a:ve for Asthma (GINA) was launched in 1993 in collabora:on with the following organiza:ons: •  Smooth muscle constric:on of bronchial airways (bronchospasm) •  Bronchial wall inflamma:on •  Excessive produc:on of thick, whi:sh, bronchial secre:ons •  Mucus plugging •  Hyperinfla:on of alveoli (air-­‐trapping) •  In severe cases, atelectasis caused by mucus plugging –  Na:onal Heart, Lung, and Blood Ins:tute (NHLBI) of the Na:onal Ins:tutes of Health, and the –  World Health Organiza:on (WHO) 1 RSPT 2310 Asthma Epidemiology Epidemiology •  Asthma was firs recognized by Hippocrates more than 2000 years ago •  It remains one of the most common diseases encountered in clinical medicine •  Over the past decade the incidence of asthma has increased drama:cally •  It is es:mated that more than 25 million Americans have asthma •  About 500,000 Americans are hospitalized annually for severe asthma •  About 4000 die as a result of asthma annually •  According to the World Health Organiza:on, about 180,000 people worldwide die from asthma •  Among young children, asthma is about two :mes more prevalent in boys than girls •  A_er puberty, however, asthma is more common in girls Risk Factors Risk Factors •  Extrinsic asthma (Allergic or Atopic asthma) –  Asthma episodes clearly linked to the exposure of a specific allergen (an:gen): •  Extrinsic asthma is an immediate (Type I) anaphylac:c hypersensi:vity reac:on •  Extrinsic asthma is family related and usually appears in children and adults younger than 30 years old. •  It o_en disappears a_er puberty •  Because extrinsic asthma is associated with an an:gen-­‐an:body induced bronchospasm, an immunnologic mechanism plays an important role. •  House dust •  Mites •  Furred animal dander •  Cockroach allergen •  Fungi •  Molds •  Yeast Risk Factors •  Occupa:onal sensi:zers (Occupa:onal Asthma) •  Intrinsic asthma (Nonallergic or Nonatopic asthma) –  Asthma episode cannot be directly linked to a specific an:gen or extrinsic factor. –  Onset usually occurs a_er the age of 40 years 2 RSPT 2310 Asthma Risk Factors Risk Factors •  Obesity •  Sex • 
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–  The male sex is a risk factor for asthma in children • 
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Infec:ons Exercise-­‐induced asthma Outdoor/Indoor air pollu:on Drugs, food addi:ves, and food preserva:ves Gastroesophageal reflux Sleep (nocturnal asthma) Emo:onal stress Perimenstrual asthma (catamenial asthma) Diagnosis •  The presence of any of these signs and symptoms should increase the suspicion of asthma: •  Wheezing—history of any of the following: –  Cough, worse par:cularly at night –  Recurrent wheeze –  Recurrent difficult breathing –  Recurrent chest :ghtness Diagnosis Diagnosis •  Symptoms occur or worsen at night, awakening the pa:ent •  Symptoms occur or worsen in a seasonal padern. •  The pa:ent also has eczema, hay fever, or a family history of asthma or atopic diseases. •  Symptoms occur or worsen in the presence of: –  Animals with fur –  Aerosol chemicals –  Changes in temperature –  Domes:c dust mites –  Drugs (aspirin, beta blockers) –  Exercise –  Pollens –  Respiratory (viral) infec:ons –  Smoke –  Strong emo:onal expression 3 RSPT 2310 Asthma Diagnosis Diagnos:c Tests •  Symptoms respond to appropriate an:-­‐asthma therapy. •  Pa:ent’s colds “go to the chest” or take more than 10 days to clear up. •  Spirometry •  Peak expiratory flow •  Responsiveness to metacholine, histamine, mannitol, or exercise challenge •  Posi:ve skin tests with allergens or measurement of specific IgE in serum Classifica:on of Asthma Severity by Clinical Features Before Treatment Classifica:on of Asthma Severity by Clinical Features Before Treatment •  Intermident •  Mild Persistent –  Symptoms less than once a week –  Brief exacerba:ons –  Nocturnal symptoms not more than twice a month •  FEV1 or PEF > 80% predicted •  PEF or FEV1 variability < 20% –  Symptoms more than once a week but less than once a day –  Exacerba:ons may affect ac:vity and sleep –  Nocturnal symptoms more than twice a month •  FEV1 or PEF > 80% predicted •  PEF or FEV1 variability < 20 -­‐ 30% Classifica:on of Asthma Severity by Clinical Features Before Treatment Classifica:on of Asthma Severity by Clinical Features Before Treatment •  Moderate Persistent •  Severe Persistent –  Symptoms daily –  Exacerba:ons may affect ac:vity and sleep –  Nocturnal symptoms more than once a week –  Daily use of inhaled short-­‐ac:ng β2-­‐agnonist •  FEV1 or PEF 60 -­‐ 80% predicted •  PEF or FEV1 variability > 30% –  Symptoms daily –  Frequent nocturnal asthma symptoms –  Limita:on of physical ac:vi:es •  FEV1 or PEF < 60% predicted •  PEF or FEV1 variability > 30% 4 RSPT 2310 Asthma Overview of the Cardiopulmonary Clinical Manifesta:ons Associated with Asthma The following clinical manifesta:ons result from the pathophysiologic mechanisms caused (or ac:vated) by • 
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Bronchospasm Excessive Bronchial Secre:ons Clinical Data Obtained at the Pa:ent’s Bedside The Physical Examination
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Vital Signs
  Increased
• 
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Respiratory rate (Tachypnea)
Heart rate (pulse)
Blood pressure
The Physical Examination (Cont’d)
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Use of accessory muscles of inspiration
Use of accessory muscles of expiration
Pursed-lip breathing
Substernal intercostal retractions
5 RSPT 2310 Asthma The Physical Examination (Cont’d)
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Increased anteroposterior chest diameter
  barrel
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 
The Physical Examination (Cont’d)
chest
Cyanosis
Cough and sputum production
The Physical Examination (Cont’d)
 
Chest Assessment Findings
  Expiratory
prolongation (I:E ratio > 1:3)
tactile and vocal fremitus
  Hyperresonant percussion not
  Diminished breath sounds
  Diminished heart sounds
  Wheezing and rhonchi
  Decreased
Pulmonary Function Test Findings
Moderate to Severe Asthmatic Episode
(Obstructive Lung Pathophysiology)
Forced Expiratory Flow Rate Findings
Clinical Data Obtained from Laboratory Tests and Special Procedures Pulmonary Function Test Findings
Moderate to Severe Asthmatic Episode
(Obstructive Lung Pathophysiology)
Lung Volume & Capacity Findings
6 RSPT 2310 Asthma Arterial Blood Gases
Asthmatic Episode
Mild to Moderate Stages
Acute Alveolar Hyperventilation with Hypoxemia
(Acute Respiratory Alkalosis)
pH
PaC02
↑
↓
HCO3
Pa02
↓ (slightly)
↓
Arterial Blood Gases
Asthmatic Episode
Severe Stage
Acute Ventilatory Failure with Hypoxemia
(Acute Respiratory Acidosis)
pH
PaC02
↓
↑
HCO3
Pa02
↑ (Slightly)
↓
Abnormal Laboratory Tests and
Procedures
Oxygenation Indices
Moderate to Severe Stages
 
QS/QT
D02
V02
C(a-v)02
02ER
Sv02
↑
↓
N
N
↑
↓
Sputum examination
  Eosinophils
  Charcot-Leyden
crystals
of mucus from small airways (Kirschman
spirals)
  IgE level (elevated in extrinsic asthma)
  Casts
7 RSPT 2310 Asthma Radiologic Findings
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Chest radiograph
  Increased
anteroposterior diameter (barrel chest)
(dark) lung fields
  Depressed or flattened diaphragms
  Translucent
GINA GINA •  The Global Ini:a:ve for Asthma (GINA) was launched in 1993 in collabora:on with the following organiza:ons: •  GINA’s specific goals are the following: –  Na:onal Heart, Lung, and Blood Ins:tute (NHLBI) of the Na:onal Ins:tutes of Health, and the –  World Health Organiza:on (WHO) –  Increase awareness of asthma and its public health consequences –  Promote iden:fica:on of reasons for the increased prevalence of asthma –  Promote study of the associa:on between asthma and the environment –  Reduce asthma morbidity and mortality –  Improve management of asthma –  Improve availability and accessibility of effec:ve asthma therapy GINA GINA •  GINA’s specific goals are the following: •  Provides a user friendly, evidence-­‐based program for the management of asthma –  Increase awareness of asthma and its public health consequences –  Promote iden:fica:on of reasons for the increased prevalence of asthma –  Promote study of the associa:on between asthma and the environment –  Reduce asthma morbidity and mortality –  Improve management of asthma –  Improve availability and accessibility of effec:ve asthma therapy –  Use of the evidence-­‐based guidelines provided by NAEPP –  Resources gathered worldwide from asthma experts and researchers 8 RSPT 2310 Asthma GINA’s Five Components of Asthma Care
Component 1: Develop Patient/Doctor
Partnership
Component 5: Special Considerations in Managing Asthma
•  Avoid risk factors
•  Take medications correctly
•  Understand the difference between “controller
medications” and “reliever” medications (also called
rescue medications)
•  Monitor the status using symptoms and, if relevant,
PEFR
•  Recognize signs that asthma is worsening and take
action
•  Seek medical help as appropriate
Component 2: Identify and Reduce
Exposure To Risk Factors
Component 3: Assess, Treat, and
Monitor Asthma
Component 1: Develop Patient/Doctor Partnership
Component 2: Identify and Reduce Exposure to Risk
Factors
Component 3: Assess, Treat, and Monitor Asthma
Component 4: Manage Asthma Exacerbations
Table 12-1 Controller Medications Commonly Used to
Treat Asthma Excerpts
Generic Name
Brand Name
Inhaled Corticosteroids
Beclomethasone dipropionate
QVAR
Triamcinolone acetonide
Azmacort
Flunisolide
Aerobid, AeroBid-M
Flunisolide hemihydrate
Aerospan
Fluticasone propionate
Flovent HFA, Flovent Diskus
Ciclesonide
Alvesco
Budesonide
Pulmicort Turbuhaler
Mometasone Furate
Asmanex Twisthaler
Table 12-1
Controller Medications
Commonly Used to Treat Asthma
Excerpts (Cont’d)
Generic Name
Brand Name
Systemic Corticosteroids
Prednisone
Deltasone
Methylprednisolone
Medrol, Solu-Medrol
Hydrocortisone
Solu-Cortef
Prednisolone
Opapred
9 RSPT 2310 Asthma Table 12-1
Controller Medications
Commonly Used to Treat Asthma
Excerpts (Cont’d)
Generic Name
Brand Name
Long-Acting β2-Agents (LABA)
Table 12-1
Controller Medications
Commonly Used to Treat Asthma
Excerpts (Cont’d)
Generic Name
Brand Name
Inhaled Corticosteroids & Long-Acting β2-Agents
Salmeterol
Serevent
Fluticasone/sameterol
Advair Diskus
Formoterol
Foradil
Budesonide/formoterol
Symbicort
Arformoterol
Brovana
Table 12-1
Controller Medications
Commonly Used to Treat Asthma
Excerpts (Cont’d)
Generic Name
Brand Name
Table 12-1
Controller Medications
Commonly Used to Treat Asthma
Excerpts (Cont’d)
Generic Name
Brand Name
Mast-cell-Stabilizing Agents
Cromolyn sodium
Intal
Nedocromil
Tilade
Table 12-1
Controller Medications
Commonly Used to Treat Asthma
Excerpts (Cont’d)
Generic Name
Brand Name
Leukotriene Inhibitors
(antileukotrienes)
Zafirlukast
Accolate
Montelukast
Singulair
Zileuton
Zyflo
Table 12-1
Controller Medications
Commonly Used to Treat Asthma
Excerpts (Cont’d)
Generic Name
Brand Name
Monocolonal Antibody
Omalizumab
Xolair
Xanthine Derivatives
Oxtriphylline
Choledyl SA
Aminophylline
Aminophylline
Dyphylline
Dylix, Lufyllin
10 RSPT 2310 Asthma Table 12-2
Reliever Medications
Reliever Medications
(Rescue Medications)
Commonly Used to Treat Asthma
Excerpts (Cont’d)
Commonly Used to Treat Asthma
Excerpts (Cont’d)
Generic Name
Brand Name
Ultra Short-Acting Bronchodilator Agents
Epinephrine
Adrenaline CL
Epinephrine Mist
Primatene Mist
Racemic epinephrine
MicroNefrin
Isoetharine
Isoetharine
Table 12-2
Table 12-2
(Rescue Medications)
Reliever Medications
Generic Name
Brand Name
Short-Acting Adrenergic Bronchodilator Agents (SABA)
(β2-Agents)
Metaproternol
Alupent
Albuterol
Proventil, Ventolin, AccuNeb,
Proair
Pributerol
Maxair Autohaler
Levalbuterol
Xopenex
Table 12-2
Reliever Medications
(Rescue Medications)
(Rescue Medications)
Commonly Used to Treat Asthma
Excerpts (Cont’d)
Commonly Used to Treat Asthma
Excerpts (Cont’d)
Generic Name
Brand Name
Antcholinergic
(COPD)
Ipratropinum Bromide
Atrovent
Tiotropium
Spirvia
Component 4: Manage Asthma
Exacerbations
Generic Name
Brand Name
β2-Agents & Anticholinergic Agents
Ipratropium and albuterol
Table 12-3
Combivent, DuoNeb
Classification of Severity of Asthma Exacerbations
Excerpts
Mild
Moderate
Severe
Respiratory
arrest
imminent
Symptoms
Breathless
Walking
Talking
Can lie down Prefers
sitting
At rest
Hunched
forward
Erratic resp.
or apnea
Talk in
Sentences
Words
Silent
Phrases
11 RSPT 2310 Asthma Table 12-3
Classification of Severity of Asthma Exacerbations
Excerpts
Mild
Moderate
Severe
Table 12-3
Respiratory
arrest
imminent
Signs
Classification of Severity of Asthma Exacerbations
Excerpts
Mild
Moderate
Severe
Respiratory
arrest
imminent
Wheeze
Moderate,
often only
end
expiration
Loud
Usually loud Absence of
wheeze
Pulse/min
< 100
100-120
>120 (adult)
Signs
Respiratory
rate
Increased
Use of
Usually not
accessory
muscles
Increased
Often > 30/
min
Erratic resp.
or apneic
Usually
Usually
Paradoxical
throracoabdominal
movement
Component 5: Special Considerations
in Managing Asthma--Excerpts
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Pregnancy
Surgery
Rhinitis, Sinusitis, and Nasal Polyps
Occupational Asthma
Respiratory Infection
Gastroesophageal reflux
Aspirin-induced asthma
Anaphylaxis
Bradycardia
Respiratory Care Treatment Protocols
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Oxygen Therapy Protocol
Bronchopulmonary Hygiene Therapy
Protocol
Aerosolized Medication Protocol
Mechanical Ventilation Protocol
12