Therapeutics: Asthma 2
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. What would you like to do?
What Education should you provide to an asthma patient?
Med roles, use (Fast acting vs long term use)and skills, Enviro/Trigger Control
Describe the Approach to therapy for asthma:
Stepwise = step up based on severity, step down after control is established
What are the Quick relief drugs for asthma?
SABA (sympathomymetics) or systemic corticosteroids
What are the SABAs?
Albuterol (preferred), Pirbuterol, Levabuterol
What are the Systemic corticosteroids for rescue relief?
Cortisone, Hydrocortisone, Prednisone, Prednisolone, Methylprednisone, Traimcinolone
What is the Role/mechanism of corticosteroids in asthma?
Restore B-receotr density in the lungs post tachyphylaxis
What are the Long term control therapies for asthma?
- Anti-inflammatories(ICS, Mast CS, LM) = preferred
- Bronchodilators (LABA, Theo)
When should you not use long term control drugs for asthma?
Never used for Short term control
What are the Anti-inflammatory drugs for asthma?
ICS, Mast cell stabilizers and Leukotriene modifiers
What are the ICSs?
Beclomethasone, Fluticasone, Budesonide, Mometasone, Ciclesonide
What are the Mast CSs?
What are the Leukotriene modifiers?
Zafirlukast, montelukast, Zileuton
What are the long term control Bronchodilators?
LABA, Theophylline and maybe long acting anticholinergics
What are theLABAs?
Salmeterol, formoterol, indacaterol, arformoterol
What are the potential Causes of asthma exacerbations?
- Sinusitis or rhinitis
When you Obtain history & PE for a patient having an exacerbation, what information should you gather?
- Onset time
- precipitating factors
- current medications
- past exacerbations
- concurrent diseases
How do you Perform a functional assessment of a patient having an exacerbation?
- Look at PEFR diary
- O2 sat
- Obtain PEFR pre/post SABA
What labs should you look at with a patient who is having an exacerbation?
- CBC (infection screen)
- Chest x-ray (maybe)
- Theophilline conc. (if on)
What groups are at theGreatest risk of mortality from an asthma exacerbation?
- Infants under a year
- History of life-threatening events
- <10% improvement in PEFR
- PCO2 > 40 mmHg
What are th General Txs for a patient undergoing an exacerbation?
- B2 agonist for all
- Systemic Corticosteroid pulse for most
- O2 therapy
- Anticholinergics n COPD patients
What characteristics does a mild exacerbation have?
Dyspnea only w/ activity + PEF > 70%
How do you treat a mild exacerbation?
HOME Tx = increase frequency of SABA or maybe PO systemic corticosteroids
What characteristics does a moderate exacerbation have?
Dyspnea limits ADL + PEF 40-69%
How do you treat a moderate exacerbation?
Requires office visit, increase frequency of SABA (=only get mod relief), probably will get Oral systemic corticosteroids
What characteristics does a severe exacerbation have?
Interferes with conversation + PEF <40%
How do you treat a severe exacerbation?
Requires ED visit, only partial or less relief from SABA, NEED oral systemic corticosteroids
What characteristics does a life-theatening exacerbation have?
Life threatening = Can’t speak, perspiring + PEF <25%
How do you treat a life-threatening exacerbation?
Requires ED visit/ICU, No relief from SABA, NEED IV corticosteroids
What means do we have of Monitoring asthma on a regular basis (at home)?
Peak expiratory Flow Rate
What are the Requirements for use of PEFR?
How does PEFR compare to FEV1?
- PEFR = Flow velocity/s
- FEV1 = Volume of air/s
- Use is similar
How do you use a PEFR?
- Indicator at bottom
- Breathe deeply as can
- Exhale as fast as can
- 3x= highest = best
What is PEFR used for?
- Detect subtle changes early in Exacerbation
- Monitor therapy
- Use zones to choose therapy
When should youEstablish Personal best with a PEFR?
Day when asthma is well controlled
What is PEFR Green zone?
>80% = Fine
What is PEFR Yellow zone?
50-80% = Treat exacerbation early
What is a PEFR Red zone?
<50% = Get ED help
After using a rescue inhaler, what improvement should you expect in PEFR?
Should improve with treatment = 15% or greater increase (if not see PCP)
What is a Component of Control rating of “Well controlled”?
- Same as Mild persistent:
- Symptoms > 2D/wk, Night wakening 3-4x/mo, SABA use > 2D/wk, Minor interference ADL, FEV1 >80% during attacks, FEV1/FVC = Normal, 0-1 exacerbations/year
What is a Component of Control rating of “Not Well controlled”?
- Same as Moderate persistent:
- Symptoms QD, Night wakening > 1x/wk, SABA use QD, Some interference ADL, FEV1 60-80% during attacks, FEV1/FVC = Reduced by 5%, > 2 exacerbations/year
What is a Component of Control rating of “Very Poorly Controlled”?
- Same as Severe persistent:
- Symptoms multiple x day, Night wakening > 7D/wk, SABA use multiple x day, Extreme interference ADL, FEV1 <60% during attacks, FEV1/FVC = Reduced by 5%, > 2 exacerbations/year
How should you treat a patient with a Component of control rating of “Well controlled”?
no step ∆, Check up 1-6mo, Controlled for 3mo = step down
How should you treat a patient with a Component of control rating of “Not Well controlled”?
step up 1, Check up 2-6 wks, consider alt Tx for SE
How should you treat a patient with a Component of control rating of “Very Poorly controlled”?
Short course oral steroids (use pulse dosing), step up 1-2, check up 2 wks, consider alternate treatments
After stepping up an asthma treatment, what should you do?
- Step back whenever possible = target fewest/least intense med possible
- Don’t step down if change in environment (moved, etc.)
If a patient needs to be stepped up, what questions should you ask that are not on the components of control chart?
Ask open ended questions about compliance
What would you like to do?
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