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Reference: National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for t

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Title: Reference: National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for t


1

Asthma
  • Reference National Asthma Education and
    Prevention Program. Expert Panel Report 2
    Guidelines for the Diagnosis and Management of
    Asthma. Bethesda, MD National Heart, Lung, and
    Blood Institute. National Institutes of Health
    April 1997. National Institute of Health
    Publication No. 97-4051.

2
Asthma Statistics
  • 14.6 million Americans have asthma
  • The centers for disease control and prevention
    reported a 61 increase in asthma rate between
    1982 and 1994
  • American lung association reports 5,600 people
    die annually in the US from asthma
  • Total estimated cost of asthma in 1993 was 12.6
    billion in direct and indirect expenditures

3
Missing the Mark U.S. Not Meeting
Asthma Goals
  • Asthma in America reveals that the united states
    is not meeting the goals for asthma management
    established last year by the national heart,
    lung, and blood institute (NHLBI). A
    point-by-point comparison

According to the NHLBIs Practical Guide for the
Diagnosis and Management of Asthma The goals of
asthma therapy provide the criteria that the
clinician and patient will use to evaluate the
patients response to therapy. Reference DATA
on file
4
National Goals Of Asthma Therapy
  • No sleep disruption
  • No missed school or work
  • No (or minimal) need for ER visits /
    hospitalizations
  • Maintain normal activity levels
  • Have normal or near normal lung function

5
Asthma In America Survey Findings
  • According to the NHLBIs practical guide for the
    diagnosis and management of asthma the goals of
    asthma therapy provide the criteria that the
    clinician and patient will use to evaluate the
    patients response to therapy.
  • Reference DATA on file.
  • 30 of asthma patients awakened by breathing
    problems at least once a week.
  • 49 of children with asthma - and 25 of adults
    with asthma - missed school or work because of
    asthma in past year.
  • 32 of children with asthma went to emergency
    room for asthma attacks in past year.
  • 41 of all people with asthma sought urgent care
    from the ER, clinic or hospital last year.

6
Asthma In America Survey Findings - Continued
  • 48 of patients limited in sports / recreation.
  • 36 limited in normal physical exertion.
  • 25 limited in their social activities.
  • Only 35 of patients report having had a
    lung-function test in past year.
  • Only 28 have peak flow meters to monitor their
    airflow 9 report using one at least a week.

7
Asthma Overview
  • Definition
  • Histopathology (what happens at the tissue level
  • Etiology/triggers (what causes asthma)
  • Pathogenesis (what does asthma do)
  • Treatment options
  • Pharmacist role

8
What is Asthma?
  • DEFINITION OF ASTHMA Asthma is a chronic
    inflammatory disorder of the airways…associated
    with variable airflow limitation
    bronchoconstriction and increased airway
    responsiveness. (1997 NIH Guidelines)

Reference National Asthma Education and
Prevention Program. Expert Panel Report 2
Guidelines for the Diagnosis and Management of
Asthma. Bethesda, MD National Heart, Lung, and
Blood Institute. National Institutes of Health
April 1997. National Institute of Health
publication No. 97-4051.
9
Asthma Definition
  • Chronic inflammatory disorder of the airways
  • Characterized by wheezing, coughing, chest
    tightness, difficult breathing/breathlessness
  • Bronchial hypersensitivity to stimuli
  • Airflow obstruction is reversible, either
    spontaneously or with treatment

10
Asthma Etiology
  • The etiology or cause of asthma is not well
    understood at this time
  • What is known
  • Asthma occurs in families
  • Is associated with atopy (atopic dermatitis)
  • Associated with allergen and chemical exposure
  • Increased risk with small birth size
  • Diet?

11
Asthma Airway Inflammation
  • Contributes to
  • Airway hyperresponsiveness
  • Airflow limitation
  • Respiratory symptoms
  • Disease chronicity

12
Asthma Airflow Limitation
  • Airflow limitation due to
  • Acute bronchoconstriction
  • Airway edema
  • Mucus plug formation
  • Airway remodeling

13
Asthma Histopathology
  • Denudation of the airway epithelium (change in
    the lining of the airway)
  • Collagen deposition beneath the basement membrane
    (hold on a diagram is coming)
  • Edema (swelling)
  • Mast cell activation (cells involved in allergic
    mediation)
  • Presence of other inflammatory cells

14
Michael W. Peterson, M.D., Associate Professor of
Medicine Department of Internal Medicine The
University of Iowa College of Medicine
http//www.vh.org/Providers/ClinGuide/AsthmaIM/Fig
ure2.html
15
Asthma Changes in Airway Morphology
16
Asthma Triggers
  • Allergen exposure
  • Respiratory infections
  • Vigorous exercise
  • Cold air
  • Dust
  • Strong emotion (laughing, crying)
  • Air pollution
  • Cigarette smoking
  • Drugs
  • Pets

17
Asthma Factors That Exacerbate (Intensify
Symptoms)
  • Allergens
  • Respiratory infections
  • Exercise and hyperventilation
  • Weather changes
  • Sulfur dioxide
  • Food, additives, drugs

18
Asthma Pathogenesis (What Happens)
  • Due to the end result of inflammation and airway
    remodeling the lung becomes less efficient in
    exchanging oxygen
  • The amount of air that can be exhaled per unit
    time is decreased

19
Factors in Making Diagnosis
  • History
  • Wheeze, cough, shortness of breath
  • Other causes
  • If not infection or other disease process
  • Consider GERD
  • Document airway obstruction
  • PEFR or spirometry
  • Demonstrate reversibility of obstruction/symptoms

20
Asthma FEV1 Decreased
21
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22
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23
Goals of Therapy
  • Prevent chronic symptoms
  • Maintain normal pulmonary function
  • Prevent exacerbations
  • Meet patients and families expectations of and
    satisfaction with asthma care

24
Goals of Therapy
  • Minimal (ideally no) need for quick relief
    beta2-agonist therapy
  • No emergency visits to doctors or hospitals
  • Maintain normal activity levels, including
    exercise
  • Minimal or no adverse effects of medicine

25
Major New Revisions
  • Medications now classified as long-term control
    and quick relief
  • Continued emphasis that most effective control
    for long-term control are those with
    anti-inflammatory effect
  • New medications available
  • Long-acting inhaled beta-agonists
  • Leukotriene modifiers
  • Nedocromil

26
Major New Revisions (Continued)
  • Address issues regarding safety of medications
  • Stepwise approach emphasizes initiating therapy
    at a higher level and then stepping down
  • Recommendations on estimated clinical
    comparability of inhaled corticosteroids

27
Key Points Inhaled Corticosteroids
  • According to the NIH Inhaled Steroids are the
    Most Effective Long-Term Control Medication for
    Persistent Asthma
  • The daily use of inhaled steroids can help
  • Diminish asthma symptoms. Improvement will
    continue gradually
  • Reduce occurrence of severe exacerbations
  • Decrease use of quick-relief medication
  • Improve lung function significantly, as measured
    by peak flow, FEV1, and airway
    hyperresponsiveness

Asthma symptoms may return if patients stop
taking inhaled steroids. Children usually
begin with a trial of cromolyn or nedocromil.
Reference National Asthma Education and
Prevention Program. Expert Panel Report 2
Guidelines for the Diagnosis and Management of
Asthma. Bethesda, MD National Heart, Lung, and
Blood Institute. National Institutes of Health
April 1997. National Institute of Health
publication No. 97-4051.
28
Improvement in PEF After Initiation of ICS
Therapy in Patients With Different Duration of
Asthma Symptoms
40
30
Mean Improvement in PEF
20
10
0
0
3 mo
1 yr
2 yr
Time
Reference Selroos et al. Chest.
1995108(5)1228-1234.
29
Classification System
Based on Pre-treatment Symptoms.
  • PEF or FEV1 Long Term
    Control
  • Days w/ Sxs Noc w/ sxs PEF
    variability Daily Medications
  • STEP 4
  • Severe
  • Persistent
  • STEP 3
  • Moderate
  • Persistent
  • STEP 2
  • Mild
  • Persistent
  • STEP 1
  • Mild
  • Intermittent

30
Role of the Pharmacist
  • 1. Educate patients about asthma medications.
  • 2. Instruct patients about the proper techniques
    for inhaling medications.
  • 3. Monitor medication use and refill intervals to
    help identify patients with poorly controlled
    asthma.

31
Role of the Pharmacist
  • 4. Encourage patients purchasing OTC asthma
    inhalers or tablets to seek medical care.
  • 5. Help patients use peak flow meters
    appropriately.
  • 6. Help patients discharged from the hospital
    understand their asthma management plan.

32
Overview of Asthma Medications
  • Long-term control
  • Corticosteroids
  • Cromolyn
  • /Nedocromil
  • Long-acting beta2-agonists
  • Menthylxanthines
  • Leukotriene modifiers
  • Quick relief
  • Short-acting inhaled beta2-agonists
  • Anticholinergics
  • Systemic corticosteroids

33
Step 1
34
Classification of Severity Step 2
35
Step 2 Interventions
36
Step 3
37
Step 4
38
Step Down
39
Medications of Interest Serevet (Salmeterol)
  • Available in MDI and DPI
  • Long acting bronchodilator for long term control
  • Not to be used in place of anti-inflammatory
  • Used with inhaled steroid in step 3
  • May use one nightly dose for nocturnal symptoms
  • Duration of bronchodilation 12 hours
  • Not to be used for symptom relief or for
    exacerbations

40
Medications of Interest Flovent Fluticasone
  • Inhaled steroids are most effective
    anti-inflammatory currently available.
  • Twice daily dosing for improved compliance.
  • Multiple strengths available.
  • As with all steroids it is important to rinse
    mouth after use and spacers are helpful.

41
Daily Inhaled Steroids Decrease Symptomatic Days
in Asthmatics
42
Summary
  • Asthma is a significant cause of illness and
    death in the United States
  • Asthma is a chronic disease and requires
    continuous surveillance
  • Appropriate use of long term control medications
    can improve quality of life for people with
    asthma

43
The End
  • Questions?
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