Asthma V: Pharmacotherapy Strategies Flashcards

1
Q

changes to GINA 2019

A
  • For safety, GINA no longer recommends SABA-only treatment for Step 1
  • This decision was based on evidence that SABA-only treatment increases the risk of severe exacerbations, and that adding any ICS significantly reduces the risk
  • GINA now recommends that all adults and adolescents with asthma should receive ICS-containing controller treatment
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2
Q

what should you first assess before treatment? (4)

A
  • confirm diagnosis
  • symptom control and modifiable risk facotrs (lung func)
  • inhaler technique, adherence
  • child and parent preferences and goals
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3
Q

Children 6-11 steps for management

A
  1. As needed SABA
  2. Daily low dose ICS: symptoms 2 or more a month
  3. low dose ICS-LABA or medium dose ICS: symp most days, waking at night >/= once a wk
  4. medium dose ICS-LABA or refer for expert: symp most days, waking at night >/= once a wk, low lung func
    - short course OCS may be needed for pt with severe
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4
Q

adults and adolescents steps for management

ICS‐formoterol is the preferred reliever for
patients prescribed maintenance and reliever therapy. For other ICS‐LABAs, the reliever is SABA

A
  1. As needed low dose ICS-formoterol
  2. Daily low dose ICS or as needed low dose ICS-form: symptoms 2 or more a month
  3. low dose ICS-LABA (MART or maintenance only): symp most days, waking at night >/= once a wk
  4. medium dose ICS-LABA (MART or maintenance only): symp most days, waking at night >/= once a wk, low lung func
    - short course OCS may be needed for pt with severe
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5
Q

Management Considerations/Pearls

Read

A

Therapy can be increased or decreased based on level of asthma control
• If control is lost, therapy may be stepped-up
• If control has been maintained for a length of time (e.g., a year), then therapy may be stepped-down

Therapy may be increased / stepped-up if (for example):
• Seasonal allergies or colds trigger worsening of asthma symptomslead to nocturnal awakenings
• Reliever medication is required more frequently unscheduled physician visits or hospitalizations increase

Therapy may be decreased / stepped-down if (for example):
• While on controller medication, a patient has been symptom-free and has had no negative changes in pulmonary function
• If, upon monitoring, symptoms re-emerge, then therapy can be stepped back up

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6
Q

Management Considerations/Pearls

what to do f asthma is not controlled despite adherence to ICS therapy:
6-11
>/= 12 yrs?

A

6 – 11 years of age
• ICS should be increased to a medium dose
• Then LABA* or LTRA added as adjunct therapy*
• *This should be done after referral

> 12 years of age
• Add a LABA as adjunct therapy
• Then add LTRA or increase ICS to a medium dose*
• These are third-line options, and should also be
referred

A SABA is the preferred reliever in most asthma cases;
• Continue SABA prn when controller therapy added.
• SABA monotherapy is only appropriate in very mild asthma

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7
Q

Management Considerations/Pearls

If on more than one inhaler what should you remember

A

(1) consider using the same device for all medications; (2) use the bronchodilator first & the anti-inflammatory last;
(3) wait ~5 minutes between puffs of different medications

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8
Q

Asthma Action Plans

what are the key components?

A
  • This is a written document to help guide theself-management of worsening asthma in patients of all ages
  • Should be individualized for the patients’ medications, level of control, and health literacy

Key components

  • pt usual meds
  • When/how to increase reliever and controller or start OCS
  • When/how to access medical care if symptoms fail to respond
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9
Q

Asthma Action Plans

Green zone
what does it mean? PEF?
plan?

A

• Your asthma is under control
 No symptoms outside of asthma control criteria
 Individual can participate in regular activities
 PEF results 80-100% of your personal best
 More applicable to adolescent / adult patients, not young children

Current plan:
• Take your usual daily long-term control medicines (if you take any)
 This would be whatever maintenance therapy the individual requires for their asthma to be controlled

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10
Q

Asthma Action Plans

Yellow zone
what does it mean? PEF?
plan?

A
• Caution, your asthma is getting worse
 This means intervention is necessary
 Reliever use >4x/week, nocturnal symptoms >1x/week
 Limitation of daily activities
 PEF results 60 – 79% of personal best
 goal return to the green zone

Plan:
• Add reliever medications
• Increase ICS or add OCS
• After self-management / resolution, should see MD for review

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11
Q

Recommended Step-Up Therapy for
the YELLOW Zone

For children aged 1-5

SEE TABLE

A
  • start maintenance therapy if not on
  • If on ICS, the old recommendation was to double controller therapy - no longer true
  • medical attention/starting OCS recommended
  • ICS/LABA is not recommended in preschool aged children, but for children 6-11 who are on this combination, medical attention / starting OCS is recommended

prednisone/prednisolone 1mg/kg qd x 3-5 days

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12
Q

Recommended Step-Up Therapy for
the YELLOW Zone

For those aged >/= 12 years

SEE TABLE’

For either age group, if these self-management changes don’t result in improved control in 2-4 days, patients should call their primary care provider.

A
  • start maintenance therapy if not on
  • If on ICS, the old recommendation was to double controller therapy - no longer true
  • 4x increase in ICS therapy for at 7-14 days (don’t exceed max dosing)
  • If on ICS/LABA combination like Symbicort® - Bud/Form:
  • Increase to max 4 puffs bid x 7-14 days OR use as controller/reliever to a total of max 8 puffs daily

▫ If on other ICS/LABA combination like Advair® - FP/Salm
 Increase to a 4-fold increase in ICS x 7-14 days
 Could use a higher strength ICS strength of the ICS/LABA combination, or add an extra ICS alone to do this

2nd choice: prednisone 30-50mg qd for at least 5 days

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13
Q

Asthma Action Plans

red zone
what does it mean? PEF?
plan?

A

You are having as asthma emergency – seek attention!
 emergency treatment is necessary
 Continuous daytime and/or nighttime symptoms that are worsening
 SABA relief does not last longer than 3-4 hours, or does not start working within 10 minutes after administration
 Wheezing upon rest, difficulty walking or talking
 Lips or fingernails or turning blue or grey
 PEF results <60% of personal best
 goal return to the green zone

Plan: call 911, emergency room, use reliever medication as you need on way to help

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14
Q

Asthma Worsening vs. Exacerbation

A

Asthma worsening refers to a single point in time where symptoms may worsen and become bothersome (i.e., affect sleep or daily functioning)
• It can be managed at home
• It requires an increase in SABA use

An acute exacerbation is different in that symptoms may become more severe (beyond just bothersome)
• It may include emergency management / hospitalization
• It may require initiation of oral corticosteroids
• “asthma flare-up” or “asthma attack”

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15
Q

Asthma Worsening/Chronic Ambulatory Asthma

signs/symptoms
read

A
  • May or may not have signs and symptoms:
  • Symptoms: Dyspnea, chest tightness, cough, wheeze
  • Signs: Expiratory wheeze on auscultation, dry hacking cough, atopy (allergic rhinitis, eczema)
  • Severity determined by, symptoms, awakenings, activity interference, lung function
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16
Q

Asthma Worsening/Chronic Ambulatory Asthma

lab
diagnostic tests

A

Labs
• Spirometry demonstrates obstruction (reduced
FEV1/FVC) with reversibility following inhaled SABA (>12% improvement

Other diagnostic tests:
• Fall in FEV1 of >15% following 6 min of maximal exercise
• Elevated eosinophils and IgE in blood

17
Q

Acute Severe Asthma Exacerbation/Flare Up

signs/symptoms
read

A

Can progress over hours or days:
• Symptoms: Anxious, in acute distress, severe SOB, chest tightness, only able to say a few words, unresponsive to usual measures (SABA).
• Signs: Tachypnea, tachycardia, cyanotic skin, expiratory & inspiratory wheezing, dry hacking cough, pallor, hyper inflated chest with intercostal & supraclavicular retractions. Breath sounds (BS) may be diminished with very severe obstruction.

18
Q

Acute Severe Asthma Exacerbation/Flare Up

lab
diagnostic tests

A

Labs:
• PEF and/or FEV1 less than 40% (50%*) predicted.
• Decreased PaO2, decreased O2 sats by pulse oximetry (<90% on room air = severe).
• Decreased arterial or capillary CO2, if mild but in the normal range or increased in mod/sever obstruction

Other diagnostic tests:
• Arterial Blood Gasses to assess for metabolic acidosis in severe obstruction
• CBC if signs of infection
• Serum electrolytes (B2-agonist + steroids lower K+, Mg, Po4 and increase glucose

19
Q

Acute Exacerbations – Presentation

READ

A

• Breathlessness (difficulty speaking)
• Increased respiratory rate (double the normal rate)
• Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute, child (6-12) 18-30 breaths per minute.
• Nasal flaring
• Use of accessory muscles / intercostal and subcostal indrawing
• In young children: feeding difficulty, fatigue/lethargy,
anxiety/restlessness.
• With younger age, symptoms may be more severe and present more quickly.
• In older children and adults: tracheal tug, prolonged expiration and inspiration, wheeze

20
Q

Severity of Acute Asthma Exacerbations
what severity is this?

  • PEF > 50%
  • O2 sats> 90% RA
  • HR 100-120
  • Talks in phrases, prefers sitting to lying
  • Not agitated
A

Mild: Dyspnea only with activity (assess tachypnea in young children)

Moderate: Dyspnea interferes with or limits usual activity

21
Q

Severity of Acute Asthma Exacerbations
what severity is this?

  • PEF <50
  • O2 sats< 90% RA
  • Heart rate >120
  • Talks in words, sits hunched forward, agitated
  • Life threatening: Drowsy, confused or silent chest
A

Severe: Dyspnea at rest; interferes with conversation

Life threatening: Too dyspneic to speak; Perspiring

22
Q

Risk Factors for Acute Exacerbations

A
  • Previous admissions to the ICU for asthma
  • Multiple recent hospital admissions or ER visits
  • Excessive use of bronchodilators
  • Current oral corticosteroid use
  • Poor adherence to maintenance therapy
  • viral inf, env triggers
  • URTIs precede for children
23
Q

Emergency Management of Acute Exacerbation

Initial assessment

A
  • O2 saturation measurement
  • Lung function baseline
  • Compare current situation to this data if available
24
Q

Emergency Management of Acute Exacerbation

Therapy

A

• Supplemental O2 to maintain 92% saturation
• Inhaled bronchodilators
- SABA treatment administered every 20-30 minutes
- Systemic corticosteroids in those with moderate-severe symptoms
• This may also be initiated in those who do not respond to SABA therapy.
• Steroids are recommended because they help resolve airflow obstruction and reduce rates of relapse once the patient has been discharged from the ER

25
Q

Emergency Management of Acute Exacerbation

If more intervention needed

A
  • Magnesium sulfate (a bronchodilator)
  • Heliox (a mixture of helium and oxygen)
  • IV salbutamol
  • Theophyilline

Then intubation to avoid cardiac arrest

26
Q

Discharge Plans Post-Asthma Exacerbation

A
  • Short-course oral corticosteroids
  • Introduction of or continued use of inhaled corticosteroids
  • Follow-up with a primary care provider
  • Level of control to be reviewed in 4-8 weeks
  • Referral to as asthma educator or asthma specialist
27
Q

Asthma Monitoring and Follow-up

A

• Depending on the patient, this could be done at every pick-up (1-3 months) or after ~1 week for those starting new therapy or changing therapy

Based on fill-history
• E.g., you notice a patient consistently filling their reliever, but not their controller medications – is there a good reason? Why? May need patient education

28
Q

Monitoring and Follow-up After and

Exacerbation

A
  • Arrange for an early follow-up
  • 2-7 days for adults
  • 1-2 days for children
  • Reassess need for systemic corticosteroid
  • Reduce reliever to as needed.
  • Continue controller at higher doses for short term (1-2 weeks)
  • Check and correct action plan