Patient Care I Exam 3 - asthma

FEV1

forced expiratory volume in 1 second

FVC

forced vital capacity - amount of gas that can be forcibly and rapidly exhaled after a full inspiration

SMART/MART

(+/-Same) Maintenance And Reliever Therapy

Asthma

Characterized by variable and recurring respiratory symptoms, airflow obstruction, bronchial hyper-responsiveness, and underlying inflammation.

4 types of asthma

Allergic, aspirin-senstivie, neutrophilic, exercise-induced

T/F: Asthma is one of the most common chronic, noncommunicable diseases worldwide.

True

Asthma affects what population disproportionally?

Women, black/puerto rican, low household income.

T/F: Incidence of death is higher in white persons vs black/puerto rican persons.

False, it's the opposite.

Asthma-related mortality in US declined from 15.1 to 9.9 per million between 2001 and 2017.

Asthma triggers (that can worsen or cause asthma symptoms)

Allergens

Smoke

Viral respiratory infections

Irritants - perfume, gas, fumes, cold/hot air

Exercise

Medications - b-blockers, nsaids

Pathophysiology of asthma

1. Triggers cause immune activation (IL-4, IgE, mast cell degranulation)

2. Inflammatory mediators cause vasodilation and cellular infiltration

3. This causes an increase in the frequency and severity of smooth muscle contractions, bronchoconstrictions, airway swells & narrows, copious mucus production, decrease perfusion of alveolar capillaries, hyperinflation of alveoli, hypoxemia, increase RR.

4. Narrowing of breathing passage causes symptoms like wheezing, cough, SOB, and tightness in chest.

Clinical presentations of asthma

Coughing, wheezing, chest tightness, SOB

What is the purpose of the asthma action plan?

Helps make sense of peak expiratory flow by colors.

- compares to personal best PEF (L/min)

+ Green: 80-100%

+ Yellow: 50-80%

+ Red: <50%

Asthma action plan is a written plan for:

Maintenance, exercise, exacerbation, and emergency

- provides guidance like inhaler, # of puffs, frequency and oral corticosteroids.

Risk factors for exacerbation of asthma should be assessed every ___ years

1-2 years

Modifiable risk factors for asthma exacerbation

1. Medications

- SABA overuse (≥3 x 200-dose canisters/year)

- Inadequate ICS (not prescribed/poor adherence/wrong technq)

2. Comorbidities

- obesity, chronic sinusitis, GERD, pregnancy

3. Exposure (allergens, smoking, etc.)

4. Setting (psychological or socioeconomic problems)

5. Lung function (Low FEV1, esp <60% predicted, high bronchodilators responsiveness)

6. Type 2 Inflammatory Markers (High blood eosinophils)

7. Past Medical History (intubation/intensive care for asthma tx, ≥1 severe exacerbation in last year)

Asthma or COPD diagnosis

FEV1/Predicted FEV1 <70%

Pre-bronchodilator FEV1/FVC <70%

How many times should spirometry be repeated?

3 times for reproducibility and accuracy

Most frequent finding of asthma upon physical examination

Wheezing(could be subliminal) on auscultation

Reversibility in asthma

Post-bronchodilator FEV1 increases ≥12% and ≥200 mL

OR

Post bronchodilator PEF (peak-expiratory flow) increases ≥20%

Hx of variable respiratory symptoms

Frequency and intensity varies

Occurs or worsens at night

Exercise, laughter or allergens worsen it

Viral respiratory infection causes or worsens it.

Bronchodilator Reversibility Test

1. Forcefully exhale (pre-FEV1/FVC)

2. Use bronchodilator

3. Wait ~15 minutes

4. Forcefully exhale (post-FEV1/FVC)

Reversibility = FEV1 or FVC ≥12% or ≥200 mL

A 45 y.o pt presents with recurring cough and wheezing. His spirometry shows the following:

Pre-bronchodilator - FEV1 = 2.1L, FVC = 3.5L

Post-bronchodilator - FEV1 = 2.4L, FVC = 3.9L

Which of the following is the most accurate related to his spirometry results?

A. Pre-bronch. FEV1/FVC = 0.6; meets criteria for reversibility

B. Pre-bronch. FEV1/FVC = 0.75; does not meet criteria for reversibility

C. Post-bronch. FEV1/FVC = 0.67; meets criteria for revers.

D. Post-bronch. FEV1/FVC = 0.8; not meet

A. Pre-bronch. FEV1/FVC = 0.6; meets criteria for reversibility

Asthma guidelines

NAEPP (national asthma education and prevention program)

GINA (global initiative for asthma)

Key concepts of NAEPP's National Strategy for Asthma Management and Prevention

SMART

Asthma severity classifications (intermitt., mild, moderate, severe)

**Focuses on UNITED STATES

Key concepts of GINA

1. Terms - AIR, MART

2. Two treatment tracks

3. SMART

4. Various relief inhalers

Differences between the two guidelines for asthma

GINA

1. Annually updated

2. Pocket guide

3. Prioritizes symptoms presentations

NAEPP

1. Last updated 2020

2. Focuses on UNITED STATES.

Asthma treatment goals

1. Short and long-term control of symptoms

2. Prevent exacerbation

3. Prevent airway damage

4. Prevent medication s/e

Bronchodilators by class

SABA

ICS

ICS + LABA

LAMA

Leukotriene receptor antagonist

Singulair (montelukast)

Zyflo, Zyflo CR (Zileuton)

Antibiotic used in asthma

Zithromax, Z-pac (Azithromycin)

Biologics used in asthma

Omalizumab

Mepolizumab

Reslizumab

Benralizumab

Dupilumab

Tezepelumab

Systemic corticosteroids

prednisone,

prednisolone,

methylprednisolone

ProAir Digihaler

Albuterol 90 mcg

DPI “One of two FDA-approved DPI for rescue”

1 - 2 puffs q4-6 hours PRN

AE: tremors, tachycardia, tachphylaxis, increased airway responsiveness, decreased effectiveness w/ beta-blockers *use cardioselective*

Proair Respiclick

Albuterol 117 mcg

DPI “One of two FDA-approved DPI for rescue”

1 - 2 puffs q4-6 hours PRN

AE: tremors, tachycardia, tachphylaxis, increased airway responsiveness, decreased effectiveness w/ beta-blockers *use cardioselective*

Proventil HFA

Albuterol 120 mcg

MDI

1 - 2 puffs q4-6 hours PRN

AE: tremors, tachycardia, tachphylaxis, increased airway responsiveness, decreased effectiveness w/ beta-blockers use cardioselective

Ventolin HFA

Albuterol 90 mcg

MDI

1 - 2 puffs q4-6 hours PRN

AE: tremors, tachycardia, tachphylaxis, increased airway responsiveness, decreased effectiveness w/ beta-blockers use cardioselective

Albuterol nebulizer (no brand)

2.5 mg/3mL (0.083%)

5 mg/mL (0.5%)

1 unit 3-4 times daily PRN

AE: tremors, tachycardia, tachphylaxis, increased airway responsiveness, decreased effectiveness w/ beta-blockers use cardioselective

Xopenex HFA

Levalbuterol 45 mcg

MDI

1-2 puffs q4-6 hrs PRN

AE: tremors, tachycardia, tachphylaxis, increased airway responsiveness, decreased effectiveness w/ beta-blockers use cardioselective

Levalbuterol nebulizer (no brand)

0.63 mg/3mL (0.021%)

1.25 mg/3mL (0.042%)

1 unit q6-8 hrs PRN

AE: tremors, tachycardia, tachphylaxis, increased airway responsiveness, decreased effectiveness w/ beta-blockers use cardioselective

SABA MOA

Relaxes bronchial smooth muscles (duration 4-6 hrs)

For quick relief of symptoms and acute bronchospasms; pre-tx for exercise.

**Use lowest dose and frequency as needed.

ICS MOA

Suppresses multiple inflammatory process characteristic of asthma w/i airways

Always include in asthma regimens;

decreases airway responsiveness and symptoms;

increases lung function

Inhaled and systemic adverse effects of corticosteroids

Inhaled:

- oral candidiasis (rinse and spit)

- dysphonia (hoarse voice)

Systemic:

- osteoporosis (takes a long time, ICS is localized therefore lessened in inhaled)

- cataracts, glaucoma

Reliever (as needed) combination

ICS + SABA

ICS + Formoterol

Maintenance (daily) combination/monotherapy

ICS

ICS + LABA

ICS + LABA + LAMA

Advair Diskus

Wixela Inhub (generic)

Fluticasone Propionate + Salmeterol

ICS + LABA

DPI

A/E: tachycardia, h/a, decreased effectiveness w/ b-blockers use cardioselective

AirDuo Respiclick

Fluticasone + Salmeterol (ICS + LABA)

MDI

A/E: tachycardia, h/a, decreased effectiveness w/ b-blockers use cardioselective

Advair HFA

fluticasone propionate + salmeterol xinfoate (ICS+LABA)

MDI

A/E: tachycardia, h/a, decreased effectiveness w/ b-blockers *use cardioselective*

Breo Ellipta

Fluticasone + Vilanterol (ICS + LABA)

SMI

A/E: tachycardia, h/a, decreased effectiveness w/ b-blockers use cardioselective

Symbicort

Breyna (generic)

budesonide/formoterol (ICS/LABA)

MDI

A/E: tachycardia, h/a, decreased effectiveness w/ b-blockers use cardioselective

Dulera

Mometasone + formoterol (ICS + LABA)

MDI

A/E: tachycardia, h/a, decreased effectiveness w/ b-blockers use cardioselective

BBW with long-acting beta agonist

Increased risk of asthma related deaths in LABA monotherapy

*reason why they are not used by themselves

LABA MOA, place in therapy

Relaxes bronchial smooth muscles (duration ~12-24 hrs)

Combination w/ ICS -> ICS+LABA

Common asthma maintenance regimen, never used alone.

Qvar Redihaler

Beclomethasone dipropionate (ICS)

MDI

Medium dose: >200-400

High dose: >400

Pulmicort Flexhaler (DPI)

Pulmicort Respules (Neb)

Budesonide (ICS)

Medium dose: >400-800

High dose: >800

Alvesco HFA

Ciclesonide (ICS)

MDI

Medium dose: >160-320

High dose: >320

Arnuity Ellipta

fluticasone furoate (ICS)

SMI

Low-Medium dose: 100

High dose: 200

ArmonAir Respiclick

fluticasone propionate (ICS) - inhalation powder

Medium dose: >250-500

High dose: >500

Asmanex HFA

Mometasone Furoate (ICS)

MDI

Low-Medium dose: 200-400

High dose: 400

Asmanex Twisthaler

Mometasone Furoate (ICS)

DPI

Medium dose: >220-440

High dose: >440

Triple therapy (ICS-LABA-LAMA)

Trelegy Ellipta (fluticasone/vilanterol/umeclidinium)

Breztri Aeriosphere (budesonide glycopyrrolate formoterol fumarate)

*breztri not indicated for asthma

AIR (anti-inflammatory reliever)

Treatment that contains ICS and quick relief medications (ICS-SABA)

* quick relief of asthma due to bronchoconstriction (wheezing, cough, SOB)

* reduce risk of future episodes by controlling inflammation

* use as needed for symptoms

SMART or MART (single maintenance and reliever therapy OR maintenance and reliever therapy)

ICS + formoterol combined into one inhaler

- formoterol is fast-acting and long-lasting

- prescribed for moderate to severe persistent asthma as daily controller and/or tx rapid onset of symptoms (quick relief)

Counseling points for SMART

* less complicated

* used for tx of symptoms and daily maintenance(low-dose)

* rinse and spit

LAMA

Blocks acetylcholine bronchoconstrictor effect on airway smooth muscles

STEP 5 (severe) - LAMA + ICS +/- LABA (triple combo or dual)

Modest lung function improvement, but not asthma symptoms

Spiriva Respimat

Tiotropium (LAMA) 1.25 mcg

SMI

2 puffs daily

A/e: dry mouth, urinary retention (mad as a hatter, dry as a bone, etc.)

Trelegy Ellipta

fluticasone/umeclidinium/vilanterol (ICS/LAMA/LABA)

200/62.5/25 mcg

100/62.5/25 mcg

SMI

1 puff daily

Singulair

Montelukast (LTRA)

10 mg PO once every evening

FDA warning Montelukast: Serious neuropsychiatric events such as suicidal thoughts or action have been reported

Zyflo

Zileuton (Leukotriene Inhibitor)

600 mg CR PO BID w/i 1 hr of meals

A/e: elevated LFTs

Leukotriene Receptor Antagonists

Blocks effects of leukotrienes (inflamm cascade factor)

Place in therapy: Add-on alternative in maintenance therapy, useful in allergic rhinitis

** Steroid sparing

Azithromycin (Zithromax)

Limits mucus airway secretions

500 mg PO TIW ≥6 months

Last line of therapy only for severe asthma after referral from specialist in persistent symptoms despite ICS-LABA

A/e: n/v/d, abdominal pain, elev. LFTs, tinnitus (long-term use)

**concern for Ab resistence

Prior to Zithromax, what screening must be conducted?

Baseline hearing (tinnitus)

QTc prolongation

Major drug-drug interaction - for all drugs so not a new thing

Fasenra

Benralizumab (IL-5 antagonist)

30 mg SC monthly

Indication - Severe Eosinophilic asthma

A/e - injection site reaction

Cinqair

Reslizumab (IL-5 antagonist)

3 mg/kg IV monthly

Indication: severe eosinophilic asthma

!!BBW for anaphylaxis!!

Nucala

Mepolizumab (IL-5 antagonist)

100 mg SC monthly

Indication: Severe Eosinophilic Asthma

a/e: injection site reaction

Dupixent

Dupilumab (IL-3/4 antagonist)

300 mg SC every 2 weeks

Indication: Severe Eosinophlic asthma, OC-Dependent asthma

A/e: injection site reactions

Xolair

Omalizumab (anti-IgE)

75-375 mg SC q2-4 weeks

Indication: Severe allergic asthma

!!BBW for anaphylaxis!!

Tezspire

Tezepelumab (blocks thymic stromal lymphopoietin-reducing inflammatory cytokines)

210 mg SC monthly

Indication: Severe Asthma

A/e: injection site reaction

1. Prelone

2. Omnipred, Orapred

1. Prednisone

2. Prednisolone

45 - 50 mg PO x 5-7 days

For mild-moderate exacerbation (outpatient)

A/e:

Short-term: Insomnia, Hyperglycemia, Mood changes

Maintenance: Cataracts, Glaucoma, HTN, T2DM, Adrenal Suppression, Osteoporosis

Drug-drug interactions: Ritonavir, ketoconazole, itraconazole

Solumedrol

methylprednisolone sodium succinate

Medrol dose pack - 24 mg on first dose then decreases every day - pulse dosing

1-2 mg/kg IV daily or divided in 2 doses (severe exacerbation)

Hospital setting

A/e:

Short-term: Insomnia, Hyperglycemia, Mood changes

Maintenance: Cataracts, Glaucoma, HTN, T2DM, Adrenal Suppression, Osteoporosis

Drug-drug interactions: Ritonavir, ketoconazole, itraconazole

What bronchodilators are no longer recommended in asthma?

Aminophylline and theophylline

* these have life-threatening effects at high doses

General principles for asthma treatment

1. Avoid SABA and LABA monotherapy

2. Always include ICS

3. Relief inhaler options (ICS-formoterol/-SABA/+SABA)

T/F Dulera has been approved by NAEPP/GINA to be used as a SMART alternative to Symbicort in the USA.

False, it has not been studied or approved

GINA track 1

Preferred controller + reliever (ICS-Formoterol)

GINA track 2

Alternative controller and reliever

* must check if patient is likely to adhere to daily controller treatment before starting this track

GINA track 1 steps 1-2

as needed only low dose ICS-formoterol

GINA track 1 step 3

low dose maintenance ICS-formoterol

GINA track 1 step 4

medium dose maintenance ICS-formoterol

GINA track 1 step 5

Add-on LAMA and refer for assessment of phenotype

Consider high dose maintenance ICS-formoterol, biologics

Reliever for track 1 and track 2

Track 1: low-dose ICS-formoterol as needed

Track 2: ICS-SABA as needed or SABA as needed

GINA track 2 step 1

take ICS whenever SABA taken

GINA track 2 step 2

low dose maintenance ICS

GINA track 2 step 3

low dose maintenance ICS-LABA

GINA track 2 step 4

medium/high dose maintenance ICS-LABA

GINA track 2 step 5

Add-on LAMA, refer for phenotype assessment

Consider high-dose maintenance ICS-LABA, biologics

A patient is having infrequent asthma symptoms (3 times a month or <1-2 days/wk), what is the preferred and alternative initial treatment?

Preferred: GINA track 1 step 1

Alternative: GINA track 2 step 1

A patient is has asthma symptoms less than 3-5 days/week, with normal or mildly reduced lung function. What is the preferred and alternative initial treatment?

Preferred: GINA track 1 step 2

Alternative GINA track 2 step 2

A patient has asthma symptoms most days, waking due to asthma once a week or more, or low lung function. What is the preferred and alternative initial treatment?

Preferred: GINA track 1 step 3

Alternative GINA track 2 step 3

A patient has daily asthma symptoms, waking at night with asthma once a week or more, with a low lung function, or current smoker. What is the preferred and alternative initial treatment?

Preferred: GINA track 1 step 4

Alternative: GINA track 2 step 4

Assessing symptom control

Review symptoms every visit or 1-3 months

Uncontrolled if 3-4 of these, and warrants further investigation:

In the past 4 weeks, the patient had:

1. Daytime symptoms more than twice/week

2. Any night waking due to asthma

3. SABA reliever needed more than twice/week

4. Any activity limitation due to asthma

When should we step up in GINA?

When symptoms are uncontrolled and after further investigation