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56 page Allergies Allergy Rhinitis ASTHMA PowerPoint Presentation on CD

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 All derivative (i.e. change in media; by compilation) work from this underlying U.S. Government public domain/public release data is COPYRIGHT © GOVPUBS

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Contains the following key public domain (not copyrighted) U.S. Government publication(s) on one CD-ROM in both Microsoft PowerPoint and Adobe Acrobat PDF file formats:

TITLE:

Asthma, 56 pages (slides)

SLIDE TOPICS, SUBTOPICS and CONTENTS:

ASTHMA
Rochelle M. Nolte, MDCDR USPHS
Family Medicine
Objectives
At the conclusion of the presentation, participants should be able to:
ID signs and symptoms consistent with asthma and allergic rhinitis
Differentiate the various severities of asthma
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
Persistant or intermediate
Graded relative to severity
Allergic Rhinitis
Affects 15%-50% of world-wide population
Affects 40 million people in the US
Prevalence increasing (increasing airborne pollutants, rising dust mite populations, poor ventilation in buildings, increased time indoors by people and pets, dietary factors, changes in gut indigenous microflora, increased abx use, increasingly sedentary lifestyle????????)
Allergic Rhinitis
Associated with asthma
95% of people with allergic asthma have rhinitis
30% of people with allergic rhinitis have asthma (compared to 3-5% of general population)
Family history of atopy seems associated with progression of either allergic rhinitis or asthma to allergic rhinitis + asthma
Treatment of allergic rhinitis reduces ER visits for asthma


Management of Allergic Rhinitis
Identification of allergens
Pollen
Molds/fungi
Dust mites
Animal dander
Cockroaches
Avoid or minimize exposure to allergens
Patient education
Management of Allergic Rhinitis
Pharmacotherapy
Intra-nasal corticosteroids
Antihistamines (non-sedating preferred)
Not recommended to use sedating qhs and non-sedating qAM
Decongestants
Antihistamine/decongestant combinations
Mast cell stabilizers
Leukotriene antagonists
Management of Allergic Rhinitis
Allergen Immunotherapy
Repeated, controlled administration of specific allergens to patients with IgE-mediated conditions
May impede progression of allergic rhinitis to asthma
May prevent multiple sensitizations and the need for prolonged/excessive use of pharmacotherapies
Consider when sx not controlled on medications

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
Most common chronic  condition in children
#1 cause of school absenteeism
Death rate up 50% from 1980 to 2000
Death rate up 80% in people under 19
Morbidity and mortality highly correlated with
Poverty, urban air quality, indoor allergens, lack of patient education, and inadequate medical care
About 5000 deaths annually
Asthma
Every day in the US, because of asthma:
40,000 people miss school or work
30,000 people have an asthma attack
5,000 people visit the emergency room
1,000 people are admitted to the hospital
 14 people die
(Asthma and Allergy Foundation of America)
Asthma
In 2000, 11 million reported having asthma attacks
>5% of kids <18 reported an asthma attack
In 1999, 2 million ER and 478,000 hospitalizations with asthma as the primary dx
Mortality in Black males 3X that of white
Mortality in Black females 2.5X that of white
Asthma
Usually associated with airflow obstruction of variable severity.
Airflow obstruction is usually reversible, either spontaneously, or with treatment
The inflammation associated with asthma causes an increase in the baseline bronchial hyperresponsiveness to a variety of stimuli
Clinical Diagnosis
Asthma Triggers
Allergens
Dust mites, mold spores, animal dander, cockroaches, pollen, indoor and outdoor pollutants, irritants (smoke, perfumes, cleaning agents)
Pharmacologic agents (ASA, beta-blockers)
Physical triggers (exercise, cold air)
Physiologic factors
Stress, GERD, viral and bacterial URI, rhinitis
Diagnostic Testing
Peak expiratory flow (PEF)
Inexpensive
Patients can use at home
May be helpful for patients with severe disease to monitor their change from baseline every day
Not recommended for all patients with mild or moderate disease to use every day at home
 Effort and technique dependent
Should not be used to make diagnosis of asthma
Diagnostic Testing
Spirometry
Recommended to do spirometry pre- and post- use of an albuterol MDI to establish reversibility of airflow obstruction
> 12% reversibility or an increase in FEV1 of 200cc is considered significant
Obstructive pattern:  reduced FEV1/FVC ratio
Restrictive pattern:  reduced FVC with a normal FEV1/FVC ratio
Diagnostic Testing
Spirometry
Can be used to identify reversible airway obstruction due to triggers
Can diagnose Exercise-induced asthma (EIA) or Exercise-induced bronchospasm (EIB) by measuring FEV1/FVC before exercise and immediately following exercise, then for 5-10 minute intervals over the next 20-30 minutes looking for post-exercise bronchoconstriction
Diagnostic Testing
Spirometry
National Asthma Education and Prevention Program (NAEPP) recommends spirometry:
For initial assessment
Evaluation of response to treatment
Assessment of airway function at least every 1-2 years
Diagnostic Testing
Methacholine challenge
Most common bronchoprovocative test in US
Patients breathe in increasing amounts of methacholine and perform spirometry after each dose
Increased airway hyperresponsiveness is established with a 20% or more decrease in FEV1 from baseline at a concentration < 8mg/dl
May miss some cases of exercise-induced asthma
Diagnostic testing
Diagnostic trial of anti-inflammatory medication (preferably corticosteroids) or an inhaled bronchodilator
Especially helpful in very young children unable to cooperate with other diagnostic testing
There is no one single test or measure that can definitively be used to diagnose asthma in every patient

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
Global Initiative for Asthma (GINA) 6-point plan
Educate patients to develop a partnership in asthma management
Assess and monitor asthma severity with symptom reports and measures of lung function as much as possible
Avoid exposure to risk factors
Establish medication plans for chronic management in children and adults
Establish individual plans for managing exacerbations
Provide regular follow-up care
Written Action Plans
Written action plans for patients to follow during exacerbations have been shown to:
(Cochrane review of 25 studies)
 Decrease emergency department visits
Decrease hospitalizations
Improve lung function
Decrease mortality in patients presenting with an acute asthma exacerbation
NAEPP recommends a written action plan*
Pharmacotherapy
Long-acting beta2-agonists (LABA)
Beta2-receptors are the predominant receptors in bronchial smooth muscle
Stimulate ATP-cAMP which leads to relaxation of bronchial smooth muscle and inhibition of release of mediators of immediate hypersensitivity
Inhibits release of mast cell mediators such as histamine, leukotrienes, and prostaglandin-D2
Beta1-receptors are predominant receptors in heart, but up to 10-50% can be beta2-receptors
Pharmacotherapy
Long-acting beta2-agonists (LABA)
Salmeterol (Serevent)
Salmeterol with fluticasone (Advair)
Should only be used as an additional treatment when patients are not adequately controlled with inhaled corticosteroids
Should not be used as rescue medication
Can be used age 4 and above with a DPI
Deaths associated with inappropriate use as only medication for asthma

Pharmacotherapy
Albuterol
Short-acting beta2-agonist
ATP to cAMP leads to relaxation of bronchial smooth muscle, inhibition of release of mediators of immediate hypersensitivity from cells, especially mast cells
Should be used prn not on a regular schedule
Prior to exercise or known exposure to triggers
Up to every 4 hours during acute exacerbation as part of a written action plan
Pharmacotherapy
Inhaled Corticosteroids
Anti-inflammatory (but precise MOA not known)
Act locally in lungs
Some systemic absorption
Risks of possible growth retardation thought to be outweighed by benefits of controlling asthma
Not intended to be used as rescue medication
Benefits may not be fully realized for 1-2 weeks
Preferred treatment in persistent asthma
Pharmacotherapy
Mast cell stabilizers (cromolyn/nedocromil)
Inhibits release of mediators from mast cells (degranulation) after exposure to specific antigens
Blocks Ca2+ ions from entering the mast cell
Safe for pediatrics (including infants)
Should be started 2-4 weeks before allergy season when symptoms are expected to be effective
Can be used before exercise (not as good as ICS)
Alternate med for persistent asthma
Pharmacotherapy
Leukotriene receptor antagonists
Leukotriene-mediated effects include:
Airway edema
Smooth muscle contraction
Altered cellular activity associated with the inflammatory process
Receptors have been found in airway smooth muscle cells and macrophages and on other pro-inflammatory cells (including eosinophils and certain myeloid stem cells) and nasal mucosa

Pharmacotherapy
Leukotriene receptor antagonists
No good long-term studies in pediatrics
Montelukast as young as 2; zarfirlukast age 7
Alternate, but not preferred medication in persistent asthma and as addition to ICS
Showed a statistically significant, but modest improvement when used as primary medication
Pharmacotherapy
Theophylline
Narrow therapeutic index/Maintain 5-20 mcg/mL
Variability in clearance leads to a range of doses that vary 4-fold in order to reach a therapeutic dose
Mechanism of action
Smooth muscle relaxation (bronchodilation)
Suppression of the response of the airways to stimuli
Increase force of contraction of diaphragmatic muscles
Interacts with many other drugs
Various severities of asthma
Step-wise pharmacotherapy treatment program for varying severities of asthma
Mild Intermittent (Step 1)
Mild Persistent (Step 2)
Moderate Persistent (Step 3)
Severe Persistent (Step 4)
Patient fits into the highest category that they meet one of the criteria for

Mild Intermittent Asthma
Day time symptoms < 2 times q week
Night time symptoms < 2 times q month
PEF or FEV1 > 80% of predicted
PEF variability < 20%
PEF  and FEV1 values are only for adults and for children over the age of 5

Mild Persistent Asthma
Day time symptoms > 2/week, but < 1/day
Night time symptoms < 1 night q week
PEF or FEV1 > 80% of predicted
PEF variability 20%-30%
Moderate Persistent Asthma
Day time symptoms q day
Night time symptoms > 1 night q week
PEF or FEV1 60%-80% of predicted
PEF variability >30%
Severe Persistent Asthma
Day time symptoms:  continual
Night time symptoms: frequent
PEF or FEV1 < 60% of predicted
PEF variability > 30%
Pharmacotherapy for Adults and Children Over the Age of 5 Years
Step 1 (Mild intermittent asthma)
No daily medication needed
PRN short-acting bronchodilator (albuterol) MDI
Severe exacerbations may require systemic corticosteroids
Although the overall diagnosis is “mild intermittent” the exacerbations themselves can still be severe

Pharmacotherapy for Adults and Children Over the Age of 5 Years
Step 2 (Mild persistent)
Preferred Treatment
Low-dose inhaled corticosteroid daily
Alternative Treatment (no particular order)
Cromolyn
Leukotriene receptor antagonist
Nedocromil
Sustained release theophylline to maintain a blood level of 5-15 mcg/mL
Pharmacotherapy for Adults and Children Over the Age of 5 Years
Step 3 (Moderate persistent)
Preferred Treatment
Low-to-medium dose inhaled corticosteroids
WITH long-acting inhaled beta2-agonist
Alternative Treatment
Increase inhaled corticosteroids within the medium dose range
Add leukotriene receptor antagonist or theophylline to the inhaled corticosteroid
Pharmacotherapy for Adults and Children Over the Age of 5 Years
Step 4 (Severe persistent)
Preferred Treatment
High-dose inhaled corticosteroids
AND long-acting inhaled beta2-agonists
AND (if needed) oral corticosteroids
Pharmacotherapy for Infants and Young Children (<5 years)
Step 1(mild intermittent)
No daily medication needed

Pharmacotherapy for Infants and Young Children (<5 years)
Step 2 (mild persistent)
Preferred treatment
Low-dose inhaled corticosteroids
Alternative treatment
Cromolyn (nebulizer preferred)
OR leukotriene receptor antagonist

Pharmacotherapy for Infants and Young Children (<5 years)
Step 3 (moderate persistent)
Preferred treatment
Low-dose inhaled corticosteroids and long-acting beta2-agonist
OR Medium-dose inhaled corticosteroids
Alternative treatment
Low-dose inhaled corticosteroids with either:
Leukotriene receptor antagonist
OR theophylline
Pharmacotherapy for Infants and Young Children (<5 years)
Step 4 (severe persistent)
Preferred treatment
High-dose inhaled corticosteroids
AND long-acting inhaled beta2-agonist
AND (if needed) Oral corticosteroids
For young children, inhaled medications should be given by nebulizer, dry powder inhaler (DPI), or MDI with a chamber/spacer
Acute Exacerbations
Inhaled albuterol is the treatment of choice in absence of impending respiratory failure
MDI with spacer as effective as nebulizer with equivalent doses
Adding an antibiotic during an acute exacerbation is not recommended in the absence of evidence of an acute bacterial infection
Acute Exacerbations
Beneficial
Inhaled atrovent added to beta2-agonists
High-dose inhaled corticosteroids
MDI with spacer as effective as nebulizer
Oxygen
Systemic steroids
Likely to be beneficial
IV theophylline
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
Question
Which one of the following is true concerning control of mild persistent asthma in the pediatric population?
Cromolyn should not be used under age 5
Atrovent should be added if beta-agonists do not maintain control of asthma
LABA should be added if SABA is ineffective
SABA may be used q2h to maintain control
Initial treatment should be an inhaled anti-inflammatory such as ICS or cromolyn
Answer E
Initial medications for chronic asthma should include an anti-inflammatory such as ICS or cromolyn.  Cromolyn is safe for all pediatric age groups.  Atrovent is useful in COPD, but very limited use in asthma.  Albuterol should be used up to every 4 hours prn.  Overuse of inhaled beta-agonists has been associated with an increased mortality rate.
Question
It is estimated allergic rhinitis affects how may people in the US?
20 million
40 million
50 million
100 million
Answer:  B 40 million

Question
Which one of the following statements concerning the association between allergic rhinitis and asthma is false?
Almost all patients with allergic asthma also have symptoms of rhinitis
About 1/3 of patients with allergic rhinitis also have asthma
Pharmacologic treatment for allergic rhinitis will not improve the symptoms of asthma
Patients with allergic rhinitis and patients with asthma exhibit peripheral eosinophilia and basophilia.
Answer: C
Patients with asthma should have their allergic rhinitis treated
People with asthma and allergic rhinitis who are treated for their allergic rhinitis have a significantly lower risk of subsequent asthma-related events than those not treated for allergic rhinitis.
Question
Which one of the following findings on a nasal smear suggests a diagnosis of allergic rhinitis?
> 10% neutrophils
> 10% eosinophils
< 10% neutrophils
> 10% erythrocytes

Answer:  B  >10% eosinophils
Question
Which of the following statements is true?
An acceptable strategy for eliminating sedating effects of 1st-generation antihistamines and containing the cost of 2nd-generation is to use 2nd-generation in the AM and 1st-generation in the PM
In most states, patients taking 1st-generation are considered “under the influence of drugs.”
Mast cell stabilizers are becoming an excellent choice for children because of their ability to treat symptoms after they have started and their safety
Answer: B
Patients taking 1st-generation antihistamines are considered “under the influence of drugs.”  The sedating effects have been shown to carry over to the next day even when taken only at night and this type of chronic use is not recommended.
Mast cell stabilizers should be started before symptoms develop, not after.
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