Asthma V: Pharmacotherapy Strategies Flashcards
changes to GINA 2019
- 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
what should you first assess before treatment? (4)
- confirm diagnosis
- symptom control and modifiable risk facotrs (lung func)
- inhaler technique, adherence
- child and parent preferences and goals
Children 6-11 steps for management
- As needed SABA
- Daily low dose ICS: symptoms 2 or more a month
- low dose ICS-LABA or medium dose ICS: symp most days, waking at night >/= once a wk
- 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
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
- As needed low dose ICS-formoterol
- Daily low dose ICS or as needed low dose ICS-form: symptoms 2 or more a month
- low dose ICS-LABA (MART or maintenance only): symp most days, waking at night >/= once a wk
- 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
Management Considerations/Pearls
Read
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
Management Considerations/Pearls
what to do f asthma is not controlled despite adherence to ICS therapy:
6-11
>/= 12 yrs?
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
Management Considerations/Pearls
If on more than one inhaler what should you remember
(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
Asthma Action Plans
what are the key components?
- 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
Asthma Action Plans
Green zone
what does it mean? PEF?
plan?
• 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
Asthma Action Plans
Yellow zone
what does it mean? PEF?
plan?
• 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
Recommended Step-Up Therapy for
the YELLOW Zone
For children aged 1-5
SEE TABLE
- 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
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.
- 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
Asthma Action Plans
red zone
what does it mean? PEF?
plan?
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
Asthma Worsening vs. Exacerbation
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”
Asthma Worsening/Chronic Ambulatory Asthma
signs/symptoms
read
- 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
Asthma Worsening/Chronic Ambulatory Asthma
lab
diagnostic tests
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
Acute Severe Asthma Exacerbation/Flare Up
signs/symptoms
read
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.
Acute Severe Asthma Exacerbation/Flare Up
lab
diagnostic tests
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
Acute Exacerbations – Presentation
READ
• 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
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
Mild: Dyspnea only with activity (assess tachypnea in young children)
Moderate: Dyspnea interferes with or limits usual activity
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
Severe: Dyspnea at rest; interferes with conversation
Life threatening: Too dyspneic to speak; Perspiring
Risk Factors for Acute Exacerbations
- 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
Emergency Management of Acute Exacerbation
Initial assessment
- O2 saturation measurement
- Lung function baseline
- Compare current situation to this data if available
Emergency Management of Acute Exacerbation
Therapy
• 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
Emergency Management of Acute Exacerbation
If more intervention needed
- Magnesium sulfate (a bronchodilator)
- Heliox (a mixture of helium and oxygen)
- IV salbutamol
- Theophyilline
Then intubation to avoid cardiac arrest
Discharge Plans Post-Asthma Exacerbation
- 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
Asthma Monitoring and Follow-up
• 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
Monitoring and Follow-up After and
Exacerbation
- 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
