1. Asthma: Causes, Monitoring and Treatment Presented by Cynthia Fouts, June, 2012

2. Learning Objectives After viewing this presentation, the learner will be able to: understand the two major classifications of asthma list ways to decrease the patient’s exposure to asthma triggers coach the patient in performing peak flow measurements write an asthma plan classify asthma severity choose correct management techniques based on severity.

3. Background: Asthma used to be viewed as a condition that a person gets, is treated, and suffers no lasting damage. Recent studies have shown that each asthma exacerbation leaves airway damage behind. In addition to physical damage, asthma exacerbations result in loss of productivity (both for adults at work and children in school). Asthma sufferers also report that asthma affects their activities and enjoyment of life

4. Asthma Types: There are two major types of asthma: Intrinsic – also known as nonallergic or nonatopic Extrinsic – also known as allergic or atopic

5. Intrinsic Etiology – elusive Usually occurs after 40 years of age Non-specific stimuli: Infections Cold Air Exposure Exercise Esophageal Reflux Emotional Stress Pollutants Food Additives, Food Preservatives

6. Extrinsic clearly associated with exposure to a specific antigenic agent Type I anaphylactic hypersensitivity reaction IgE-mediated allergic reaction Family related Usually appears in children Hypersensitivity immune response causes the disease by causing acute and chronic inflammation

7. Decreasing exposure to triggers: Tobacco smoke Quit if smoker Smoke-free environments (car & house) Dust mites Encase mattress in special dust-mite free cover Encase pillow in special dust-mite free cover or wash every week in hot water or cool water/bleach Reduce indoor humidity to <60% Do not sleep on cloth covered cushions or furniture Remove carpets from bedroom and from concrete Stuffed toys Keep out of the bed Wash weekly in hot water or cool water/bleach

8. Decreasing triggers, cont’d. Animal Dander Keep animal with fur out of the home Keep pet out of bedroom and keep door closed Remove carpet and cloth-covered furniture Cockroach Keep all food out of the bedroom Keep food and garbage in closed containers Use poison baits, traps and powders instead of sprays

9. Decreasing triggers, cont’d. Vacuum cleaning Try to get someone else to come in and do the vacuuming once or twice a week If do it yourself, use a mask, central vac system or vacuum with a HEPA filter Indoor mold Fix leaky faucets and pipes Clean moldy surfaces Dehumidify basements

10. Decreasing triggers, cont’d. Pollen and Outdoor Mold Keep windows closed during peak allergy seasons Stay inside during midday and afternoon Talk to doctor about anti-inflammatory meds before allergy season starts Smoke, Strong Odors and Sprays If possible do not use wood burning stove, kerosene heater, fireplace, or any unvented heater Stay away from new paint, new carpet, hair spray, perfumes

11. Decreasing triggers, cont’d. Exercise or Sports Check air quality index and avoid outside activity when air pollution or pollen levels high Warm up before exercising Should be able to be active without symptoms; if not talk to dr. about taking meds before activity to prevent symptoms Other triggers Avoid Sulfites in foods – beer or wine, shrimp, dried fruit, processed potatoes Cold air – cover mouth and nose with scarf Other meds – tell doctor about all meds you are taking

12. Daily monitoring All asthma patients should use a peak flow meter to monitor their daily symptoms. A peak flow meter is a small hand-held device which measures the speed which a patient can exhale. Measurement is in Liters/minute. Easy to use – even children who can follow simple directions can use it. Many times a peak flow meter will show a decrease in flow before the patient feels an increased shortness of breath.

13. Peak Flow Meters – different styles

14. How to Use a Peak Flow Meter Have patient in upright position Instruct to place mouthpiece into their mouth but do not obstruct the opening with their tongue Firmly seal lips around mouthpiece Take a big breath in BLAST out the breath – hard and fast!!! Note reading Reset meter to zero Repeat process twice more and record the best reading

15. Asthma Zone Management System This system is a process of daily monitoring using a peak flow meter, daily recording of results, and treatment based on those results.

16. Charting Peak Flow & Zones You will note on the preceeding example of a Peak Flow Chart that there were green, yellow, and red columns. These columns represent the 80- 100%, 50-80%, and <50% zones of the patient’s personal best. The personal best is the best of two weeks of measurements made during a time when the patient’s asthma is well controlled.

17. Written Action Plan Written asthma action plans include two important elements: Daily management Recognition and handling worsening symptoms

18. Daily Management Monitoring with a peak flow meter Recording of peak flow measurement What medications to take every day; when and how to take them

19. Recognition and Handling Worsening Symptoms What symptoms and PF measurements indicate worsening asthma (yellow zone) What medications to take in response to these signs and symptoms What symptoms and PEF measurements indicate the need for urgent medical attention (red zone) Emergency telephone numbers for the physician, ED, and person or service to transport the patient rapidly for medical care

20. Classification of Asthma Severity – Mild Intermittent SymptomsNocturnal Symptoms Daily Meds for Long Term Control Medication for Quick Relief Symptoms no more frequent than twice a week. Asymptomatic and with normal PF between exacerbations. Exacerbations brief (hours to days). Intensity of Exacerbations varies. No more frequent than twice monthly No daily medications Short-acting inhaled β 2 -agonist Use more than twice weekly may indicate the need to initiate long- term therapy

21. Classification of Asthma Severity – Mild Persistent SymptomsNocturnal Symptoms Daily Meds for Long Term Control Medication for Quick Relief Symptoms more frequent than twice weekly but less than once per day. Exacerbation may affect activity. More frequent than twice monthly Once-daily medication: Antiinflammatory agent (low-dose corticosteroid, cromolyn) or Sustained-release theophylline NOTE: Leukotriene modifiers may be considered for pts at least 12 yr old. Short-acting inhaled β 2 -agonist Daily use or increasing use may indicate the need to additional long-term therapy

22. Classification of Asthma Severity – Moderate Persistent SymptomsNocturnal Symptoms Daily Meds for Long Term Control Medication for Quick Relief Daily Symptoms Daily use of inhaled, short-acting β 2 -agonist Exacerbations affect activity. Exacerbations at least twice weekly and may last for days. More frequent than once weekly. One or two daily med: Antiinflammatory agent (medium- dose inhaled glucocorticoid) and/or Medium-dose inhaled glucocorticoid plus long-acting bronchodilator Short-acting inhaled β 2 -agonist Daily use or increased use indicates need for additional long- term therapy

23. Classification of Asthma Severity – Severe Persistent SymptomsNocturnal Symptoms Daily Meds for Long Term Control Medication for Quick Relief Continual symptoms. Limited physical activity. Frequent exacerbations. FrequentTwo daily medications: Antiinflammatory agent (high-dose inhaled glucocorticoid) and Long-acting bronchodilator (inhaled or oral β 2 -agonist or theophylline) Short-acting inhaled β 2 -agonist Daily use or increased use indicates need for additional long- term therapy

24. Treatment Regimen Note that the medications ordered for a patient are associated with the severity rating of their asthma. It is important to educate the patient on the correct administration of MDI’s and DPI’s to ensure adequate intake of the medications. It is possible to control almost all asthma with medication and avoidance of triggers.

25. Bibliography Des Jardins, T. and Burton, G. (2006). Clinical Manifestations and Assessment of Respiratory Disease. St. Louis, Mo: Mosby Elsevier. pg. 197-206. Guidelines for the Diagnosis and Management of Asthma (EPR-3). (2007) National Heart Lung and Blood Institute. Retrieved from http://www.nhlbi.nih.gov/guidelines/asthma/index.htm http://www.nhlbi.nih.gov/guidelines/asthma/index.htm Measuring Your Peak Flow Rate. (2012) American Lung Association. Retrieved from http://www.lung.org/lung-disease/asthma/living-with- asthma/take-control-of-your-asthma/measuring-your-peak-flow- rate.htmlhttp://www.lung.org/lung-disease/asthma/living-with- asthma/take-control-of-your-asthma/measuring-your-peak-flow- rate.html National Asthma Control Initiative. (2008) National Heart Lung and Blood Institute. Retrieved from http://www.nhlbi.nih.gov/health/prof/lung/asthma/naci/index.htm http://www.nhlbi.nih.gov/health/prof/lung/asthma/naci/index.htm