Asthma Highlights

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Author:
ysimon
ID:
184249
Filename:
Asthma Highlights
Updated:
2012-11-18 17:03:32
Tags:
Asthma SABA LABA Glucocorticoid Steroid Inhaled
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Description:
Treatments of different medical conditions
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  1. Asthma Rx
    • Control triggers (tobacco, pollutants, sulfite sensitivity/foods, BBls, ASA, NSAIDs)
    • Control contributing conditions (GERD, Rhinitis
  2. Intermittent Asthma
    • Daytime asthma Sx 2 or fewer days/week
    • 2 or fewer nocturnal awakenings/month
    • Use of SABA to relief Sx fewer than 2 times/week
    • NO interference with nl activities between exacerbations
    • Normal FEV1 between exacerbations ( greater or equal to 80% of predicted nl)
    • Normal FEV1/FVC ratio between exacerbations (based on age-adjusted values) 
    • 1 or NO exacerbations needing po steroids/year
  3. Intermittent Asthma -Rx
    • STEP 1: Inhaled SABA 
    • prn Sx 
    • If trigger of Sx can be predicted (e.g. exercise-induce), 10 mnts gefore exposure to trigger
  4. Mild Persistent Asthma
    • Sx >2 times/week (but NOT daily)
    • 3-4 nocturnal awakenings/month 
    • Use of SABA for Sx relief >2/week (but NOT daily)
    • MINOR interference with nl activities
    • Normal FEV1 between exacerbations (greater or equal to 80% of predicted nl)
    • Normal FEVI/FVC ratio between exacerbations (based on age-adjusted values)
    • 2 or more exacerbations needing po steroids/years
  5. Mild Persistent Asthma -Rx
    • STEP 1: Inhaled SABA
    • prn Sx 
    • If trigger of Sx can be predicted (e.g. exercise-induce), 10 mnts gefore exposure to trigger

    STEP 2: Daily long-term controller medication = LOW-dose Inhaled Glucocorticoid
  6. Moderate Persistent Asthma
    • DAILY asthma Sx
    • >1 noctural awakening/week
    • DAILY need for SABA for Sx relief
    • Some limitation in nl activity
    • LOW FEV1 (60-80% of predicted nl)
    • LOW FEV1/FVC ratio (based on age-adjusted values)
    • 2 or more exacerbations needing po steroids/years
  7. Moderate Persistent Asthma -Rx
    • STEP 3:
    • LOW-dose Inhaled Glucocorticoid + LABA 
    • or 
    • MEDIUM-dose Inhaled Glucocorticoid 
  8. Severe Persistent Asthma
    • Asthma Sx throughout the day 
    • NIGHTLY nocturnal awakenings
    • Need for SABA for Sx relief several times/day
    • EXTREME limitation in nl activity
    • VERY LOW FEV1 (,60% of predicted nl)
    • LOW FEV1/FVC ratio (based on age-adjusted values)
    • 2 or more exacerbations needing po steroids/year
  9. Severe Persistent Asthma -Rx
    STEP 4:  MEDIUM-dose Inhaled Glucocorticoid + LABA

    STEP 5: HIGH-dose Inhaled Glucocorticoid + LABA
  10. ACUTE asthma exacerbation -definition
    Increased in Sx and/or Decreased Peak Expiratory Flow 
  11. ACUTE asthma EXACERBATION -Initiation of HOME Rx during an
    • SELF-administered:
    • SABA 2-6 puffs from metered dose inhaler, repeat every 20 mnts prn
    • or
    • SABA nebulizer treatment, repeat after 20 mnts prn
  12. ACUTE asthma EXACERBATION -EMERGENCY Rx INDICATIONS
    • Use of accessory mx of respiration
    • Brief, fragmented speech
    • Inability to lie supine
    • Profound diaphoresis
    • Agitation

    Severe Sx refractory to initial ER Rx

    Predictors of Imminent Respiratory ARREST = Inability to maintain resp effort, Cyanosis, AMS
  13. ACUTE asthma EXACERBATION -EMERGENCY Rx
    Inhaled SABA: Albuterol 2.5-5mg every 20mnts x 3 by nebulizer or 4-8 puffs by metered dose inhaler with spacer for up to 4h

    Oxygen: Sufficient to maintain SaO2 at least of 92% (>95% in prego)

    IV access: bolus nl saline if prolonged episode to replace insensible losses

    Ipratropium Bromide: 500mcg by nebulizer every 20mnts x 3 or 8 puffs by metered dose inhaler with spacer every 20mnts for up to 3 hrs

    Systemic Glucocorticoids: Prednisone 40-60mg po.  If impending respiratory failure, Methylprednisolone 60-125mg IV

    Magnesium sulfate: If life-threatening exacerbation or refractory severe exacerbation after 1 hour of intensive bronchodilator, 2g IV over 20 mnts
  14. Ashtma Rx -Inhaled Short-Acting Beta Agonists (SABA)
    • Mainstay of Bronchodilator Rx
    • PNR use for Sx relief
    • Rx for all asthma levels

    • Albuterol (Proventil-HFA, Ventolin-HFA, ProAir-HFA) 90mcg/puff. 2 puffs every 4-6h prn or 10mnts before exercise. 
    • Levalbuterol (Xopenex-HFA) 45mcg/puff.  2 puffs every 4-6h prn. 
    • Metaproterenol 
    • Pirbuterol
  15. Asthma Rx -Inhaled glucocorticoids
    • Agents of choice for Persistent asthma.  Rx for PERSISTENT MILD, MODERATE, and SEVERE asthma. 
    • DAILY long-term controller medication
    • Inhaled delivery for Persistent Mild-Severe asthma
    • PO/IV delivery for ER Rx of acute asthma exacerbation

    Mometasone (Nasonex): ONCE-daily dosing. 2 prays (100mcg) in each nostril qd.  Prevention: 2 sprays (100mcg) in each nostril qd, starting 2-4 weeks before pollen season. 

    Budesonide (Rhinocort Aqua): Safe for PREGO.
  16. Asthma Rx -Combination Inhaled Glucocorticoid + LABA
    For treatment of Persistent MODERATE-SEVERE asthma 

    Budesonide/Formoterol HFA (Symbicort): Reliever and Controller med. 80mcg/4.5mcg 2 puffs bid.  160mcg/4.5mcg 2 puffs bid.  

    Mometasone/Formoterol HFA: 100mcg/5mcg  2 puffs bid. 200mcg/5mcg 2 puffs bid. 

    Fluticasone/Salmeterol HFA (Advair Diskus, Advair HFA): 45mcg/21mcg 2 puffs bid.  115mcg/21mcg 2 puffs bid. 230mcg/21mcg 2 puff bid. 

    Fluticasone/Salmeterol DPI: 100mcg/50mcg 1 inhalation bid.  250mcg/50mcg 1 inhalation bid. 500mcg/50mcg 1 inhalation bid.
  17. Example of Asthma Regimen -Intermittent asthma
    • Control triggers
    • Control contributing conditions

    Albuterol (Proventil-HFA, Ventolin-HFA, ProAir-HFA) 90mcg/puff 2 puffs every 4-6h prn or 10mnts before exercise

  18. Example of Asthma Regimen -Persistent Mild asthma
    • Control triggers
    • Control contributing conditions

    Albuterol (Proventil-HFA, Ventolin-HFA, ProAir-HFA) 90mcg/puff 2 puffs every 4-6h prn or 10mnts before exercise

    • Maintenance medication: Mometasone (Nasonex): ONCE-daily dosing. 2 prays (100mcg) in each nostril qd
  19. Example of Asthma Regimen -Persistent MODERATE asthma
    • Control triggers
    • Control contributing conditions

    Combination Inhaled Glucocorticoid/LABABudesonide/Formoterol HFA (Symbicort): Reliever and Controller med. 80mcg/4.5mcg 2 puffs bid.   
  20. Example of Asthma Regimen -Persistent SEVERE asthma
    • Control triggers
    • Control contributing conditions

    Combination Inhaled Glucocorticoid/LABA = Budesonide/Formoterol HFA (Symbicort): Reliever and Controller med.  160mcg/4.5mcg 2 puffs bid.

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