Asthma

ASTHMA
By:Rochelle M. Nolte, MD
CDR USPHS, Family Medicine

Objectives
* At the conclusion of the presentation, participants should be able to:
o ID signs and symptoms consistent with asthma and allergic rhinitis
o Differentiate the various severities of asthma
o Summarize an appropriate treatment regimen for asthma of various severities

Allergic Rhinitis
* Symptoms: sneezing, itching, rhinorrhea, and congestion
* Nasal smear with >10% eosinophils suggestive
* Dx can be confirmed by allergen-specific Ig-E
* Classification
* Affects 15%-50% of world-wide population
* Affects 40 million people in the US
* Prevalence increasing
* Associated with asthma

Management of Allergic Rhinitis
* Identification of allergens
* Avoid or minimize exposure to allergens
* Patient education
* Pharmacotherapy
* Allergen Immunotherapy

Definition of Asthma
* Chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are associated with widespread but variable airflow obstruction that is reversible either spontaneously, or with treatment.

Asthma
Asthma Triggers
* Allergens
* Pharmacologic agents (ASA, beta-blockers)
* Physical triggers (exercise, cold air)
* Physiologic factors

Diagnostic Testing
* Peak expiratory flow (PEF)
* Spirometry
* Methacholine challenge
* Diagnostic trial of anti-inflammatory medication (preferably corticosteroids) or an inhaled bronchodilator

Goals of Asthma Treatment
* Control chronic and nocturnal symptoms
* Maintain normal activity, including exercise
* Prevent acute episodes of asthma
* Minimize ER visits and hospitalizations
* Minimize need for reliever medications
* Maintain near-normal pulmonary function
* Avoid adverse effects of asthma medications

Treatment of Asthma
Written Action Plans
* Written action plans for patients to follow during exacerbations have been shown to:
o (Cochrane review of 25 studies)
o Decrease emergency department visits
o Decrease hospitalizations
o Improve lung function
o Decrease mortality in patients presenting with an acute asthma exacerbation
o NAEPP recommends a written action plan*







Pharmacotherapy

* Long-acting beta2-agonists (LABA)
o Beta2-receptors are the predominant receptors in bronchial smooth muscle
o Stimulate ATP-cAMP which leads to relaxation of bronchial smooth muscle and inhibition of release of mediators of immediate hypersensitivity
o Inhibits release of mast cell mediators such as histamine, leukotrienes, and prostaglandin-D2
o Beta1-receptors are predominant receptors in heart, but up to 10-50% can be beta2-receptors

Pharmacotherapy
* Long-acting beta2-agonists (LABA)
* Albuterol
* Inhaled Corticosteroids
* Mast cell stabilizers (cromolyn/nedocromil)
* Leukotriene receptor antagonists
* Theophylline

Various severities of asthma
* Step-wise pharmacotherapy treatment program for varying severities of asthma
* Patient fits into the highest category that they meet one of the criteria for

Mild Intermittent Asthma
Moderate Persistent Asthma
Severe Persistent Asthma

Pharmacotherapy for Adults and Children Over the Age of 5 Years
* Step 1 to 4
Pharmacotherapy for Infants and Young Children (<5 years)
* Step 1to 4
Acute Exacerbations
* Beneficial
* Likely to be beneficial
Exercise-induced Bronchospasm
* Evaluate for underlying asthma and treat
* SABA are best pre-treatment
* Mast cell stabilizers less effective than SABA
* Anticholinergics less effective than mast cell stabilizers
* SABA + mast cell stabilizer not better than SABA alone

Questions &Answers

ASTHMA.ppt