Asthma Treatment and Management

Initiating Asthma Treatment

• May be initiated by a patient with a written asthma action plan
• Day-to-day adjustment for patients prescribed low-dose ICS/formoterol maintenance and reliever regimen

Stepping Down Asthma Treatment

• Consider stepping down after good control maintained for 3 months
• Aim to find each patient's minimum effective dose that controls symptoms and exacerbations
• Stepping down ICS doses by 25-50% at 3-month intervals is feasible and safe for most patients
• Stopping ICS is not recommended in adults with asthma due to the risk of exacerbations

General Principles for Stepping Down

• Aim to find the lowest dose that controls symptoms and exacerbations, and minimizes the risk of side-effects
• Consider stepping down when symptoms have been well controlled and lung function stable for ≥3 months
• Prepare for step-down by recording symptom control, considering risk factors, and booking a follow-up visit

Treating Modifiable Risk Factors

• Provide skills and support for guided asthma self-management
• Prescribe medications or regimens that minimize exacerbations, such as ICS-containing controller medications
• Encourage avoidance of tobacco smoke and provide smoking cessation advice and resources
• For patients with severe asthma, refer to a specialist center for consideration of add-on medications and/or sputum-guided treatment
• For patients with confirmed food allergy, ensure appropriate food avoidance and availability of injectable epinephrine for anaphylaxis

Non-pharmacological Interventions

• Avoidance of tobacco smoke exposure is crucial, provide advice and resources at every visit
• Encourage physical activity due to its general health benefits

Stepwise Approach to Control Asthma Symptoms and Reduce Risk

• Diagnosis, symptom control, and risk factors should be considered
• Inhaler technique and adherence, patient preference, and lung function should be evaluated
• Non-pharmacological strategies and treatment of modifiable risk factors are essential
• Referral for add-on treatment and consideration of stepping up or down should be considered based on patient response

Pulmonary Disease Management

• Pulmonary disease management involves understanding common complaints, geriatric specific considerations, and the major players in the disease.

Common Complaints

• Cough is a common complaint, with differential diagnoses including prescription drugs, cerumen impaction, post nasal drip, COPD, asthma, postinfection, GERD, and occupational or environmental factors.
• Dyspnea is a common complaint, with underlying causes to be identified.
• Hemoptysis is a common complaint, with underlying causes to be identified.

Cough

• A thorough history is necessary to diagnose the cause of a cough, including:
  • When did it begin?
  • When does it occur?
  • What stimulates it/aggravates it?
  • What makes it better?
  • Describe the quality (productive or nonproductive?)
• Cough can be a symptom of various conditions, including URIs, acute and chronic bronchitis, pneumonia, single pulmonary nodule, and obstructive sleep apnea.

The Major Players

• Asthma is a major player in pulmonary disease management.

• COPD is a major player in pulmonary disease management.### Pneumonia

• Common causes of pneumonia: Influenzae, Moraxella catarrhalis, Staph aureus, Anaerobes, Group A strep, Immunocompromised—CMV or PCP, M.catarrhalis

• Pneumococcal pneumonia: S pneumoniae (gram +), abrupt onset, productive cough with rusty colored sputum, fever, chills, pleuritic chest pain, more subtle in older patients

• Atypical pneumonia: Mycoplasma pneumoniae, headache, sore throat, myalgia, dry hacking cough, most common in persons under 40, may be clinically indistinguishable from pneumococcal pneumonia

Differences in Presentation

• Mycoplasma pneumonia: sore throat, fever, dry hacking cough, complications include sinusitis, OM, erythema multiforme, intravascular hemolysis, meningoencephalitis, toxic psychosis, myocarditis or pericarditis
• Chlamydia pneumonia: biphasic illness, younger individuals, severe pharyngitis and laryngitis, fever, cough

Physical Exam

• No specific signs can confirm pneumonia
• PE cannot reliably distinguish type of pneumonia
• Tachypnea is more common in older adults
• Pulse oximetry screening should be performed if suspect CAP
• Fever, increased tactile fremitus, dullness to percussion, egophony, crackles (rales), bronchial breath sounds

Diagnostic Testing

• CXR required to differentiate
• Normal CXR does not exclude diagnosis
• Pulse ox, CBC with diff, electrolytes, rapid test for influenza may be helpful
• Additional testing is indicated in those severely ill, those immunosuppressed, and those HIV+

CAP Ambulatory Treatment

• Hydration, respiratory hygiene, ASA or acetaminophen for fever & HA, smoking cessation, prevention—pneumococcal & influenza vaccine
• Empiric treatments: azithromycin, clarithromycin, doxycycline, levofloxacin, moxifloxacin, beta-lactam, combination of beta-lactam and macrolide

CAP Inpatient Treatment

• Combination of beta-lactam and macrolide, or fluoroquinolone
• ICU: combination of beta-lactam and macrolide or fluoroquinolone
• Duration of therapy: minimum 5 days, should be afebrile for 48-72 hours, stable BP, adequate oral intake, and room air O2 sat >90%

Mortality Prediction Tool

• CURB-65: confusion, urea, respiratory rate, blood pressure, age > 65

Follow-up

• Telephone follow-up in 24 hours
• Office visit in 3-4 days
• Reassure cough and fatigue may last 3-4 weeks
• Repeat CXR in 2 weeks for young adults, 4-6 weeks for smokers and older adults, 8 weeks for frail elderly

Chronic Cough

• Subacute cough: lasting 3-8 weeks
• Chronic cough: persisting beyond 8 weeks
• Most common causes: postnasal drip, GERD, asthma
• Differential diagnoses: cigarette smoking, postnasal drip, allergies, chronic sinusitis, bronchospasm, CHF, impacted cerumen or other foreign body, bronchogenic tumors, chronic pulmonary infections, hematological, inflammation, psychogenic

Bronchiectasis

• Chronic cough, overproduction of secretions, reduced clearance of secretions
• Excess airway secretions, chronic pulmonary infections, bronchogenic tumors, chronic aspiration

Sleep Apnea

• Pause in breathing for 10-90 seconds
• Central apneas: absent airflow and respiratory efforts, neurological diseases
• Obstructive apneas: tongue and soft palate fall backward, mixed apneas
• Consequences: pulmonary HTN, HTN with LV dysfunction, cardiac dysrhythmias, psychomotor defects, hypoxia and hypercapnia

Management

• General measures: avoidance of alcohol, sedatives, hypnotics, weight loss, O2 therapy, nasal dilators
• Specific measures: position therapy, positive airway pressure, oral appliances, surgical management

Geriatric Specific Considerations

• Age-related pulmonary changes: reduced airway size, shallow alveolar sacs, decline in chest wall compliance, intercostal muscle atrophy, reduction in diaphragmatic strength
• Difficulties in recognizing respiratory symptoms: older people tend to underreport or underestimate respiratory symptoms
• Multiple causes of respiratory problems: asthma, COPD, heart failure, GERD
• Rhinosinusitis: treat bacterial rhinosinusitis with analgesics, saline irrigation, and antibiotics, treat chronic rhinosinusitis with topical nasal steroids and saline irrigation
• Dyspnea: common causes include COPD, cardiac disease, asthma, interstitial lung disease, deconditioning
• Wheezing: most common causes are asthma, COPD, heart failure### Indicators for ICS as a Controller
• Symptoms more than twice a day
• Night time symptoms more than twice a month
• Severe asthma requiring emergency treatment or oral steroids more than twice a year
• Use of more than two cannisters of rescue medication in a year

Choosing Controller Options

Population-Level Decisions

• Based on efficacy, effectiveness, safety, availability, and cost at the population level
• Considerations include:
  • Group mean data for symptoms
  • Exacerbations and lung function (from RCTs, pragmatic studies, and observational data)

Individual Patient Decisions

• Use shared decision-making with the patient/parent/carer to discuss:
  • Preferred treatment for symptom control and risk reduction
  • Patient characteristics (phenotype)
  • Patient preference
  • Medication options, considering factors such as arthritis, patient skills, and cost
• Consider using a spacer for ICS by pMDI and avoiding multiple different inhaler types if possible

Inhaler Technique

• Check technique at every opportunity
• Identify errors with a device-specific checklist
• Correct technique with a physical demonstration and re-check up to 2-3 times
• Re-check inhaler technique frequently, as errors often recur within 4-6 weeks
• Confirm correct technique for prescribed inhalers

Adherence to Asthma Medications

• Poor adherence is very common (estimated 50% of adults and children)
• Contributes to uncontrolled asthma symptoms and risk of exacerbations and asthma-related death
• Contributory factors include:
  • Unintentional (e.g. forgetfulness, cost, confusion)
  • Intentional (e.g. no perceived need, fear of side-effects, cultural issues, cost)
• Identify patients with low adherence by asking empathic questions

Pulmonary Disease Management

• Pulmonary disease management is a critical aspect of healthcare, particularly in geriatric populations.

Common Complaints

• Cough
• Dyspnea
• Hemoptysis
• URIs
• Acute and Chronic Bronchitis
• Pneumonia
• Single Pulmonary Nodule
• Obstructive Sleep Apnea

Cough

• Begin with a thorough history
• Important factors to consider:
  • When did it begin?
  • When does it occur?
  • What stimulates it/aggravates it?
  • What makes it better?
  • Describe the quality
  • Productive or nonproductive?

Community Acquired Pneumonia (CAP)

• Infection of the lung not acquired in the hospital, LTC, or other recent contact with a healthcare system
• Evidence of consolidation on CXR
• Treatment Guidelines from IDS/ATS
• Management of CAP in older adults from TAID

Etiology

• Healthy: Strep pneumoniae, Mycoplasma pneumoniae, Chlamydophila pneumoniae, H influenzae, etc.
• Elderly nursing home residents: Nosocomial gram negatives
• Immunocompromised: CMV or PCP

Pneumococcal Pneumonia Clinical Features

• S pneumoniae (gram +)
• Abrupt onset
• Productive cough—rusty colored sputum
• Fever, chills
• Pleuritic chest pain
• More subtle in older patients—could present with altered mental status or weakness

Atypical Pneumonia Clinical Features

• Mycoplasma pneumoniae main organism
• Headache, sore throat
• Myalgia
• Dry hacking cough
• Pathogens “atypical” as will not gram stain due to no cell wall
• Most common in persons under aged 40

Differences in Presentation

• Mycoplasma Pneumonia: Sore throat, fever, dry hacking cough
• Complications: Sinusitis, OM, erythema multiforme or erythema nodosum, intravascular hemolysis, meningoencephalitis, toxic psychosis, myocarditis or pericarditis
• Persistent hacking cough for up to 6 weeks
• Relapse occurs in 10 percent
• Chlamydia Pneumonia: Biphasic illness
• Younger individuals
• Severe pharyngitis and laryngitis
• Fever
• Cough

Physical Exam

• No specific signs can confirm pneumonia
• PE cannot reliably distinguish type of pneumonia
• Tachypnea—more common in older adults
• Pulse oximetry screening should be performed if suspect CAP
• Fever
• Increased tactile fremitus, dullness to percussion, egophony
• Crackles (rales)
• Bronchial breath sounds

Diagnostic Testing

• CXR required to differentiate
• Normal CXR does not exclude diagnosis
• Pulse Ox
• CBC with diff
• Electrolytes
• Rapid test for influenza may be helpful
• Additional testing is indicated in those severely ill, those immunosuppressed, and those HIV+

CAP Ambulatory Treatment

• Hydration
• Respiratory hygiene
• ASA or acetaminophen for fever & HA
• Smoking Cessation
• Prevention—pneumococcal & influenza vaccine

CAP—Empiric Treatments

• Outpatient: Azithromycin, Clarithromycin, Doxycycline
• Inpatient, non-ICU: Levofloxacin, Moxifloxacin, Combination of a beta-lactam + macrolide
• Inpatient, ICU: Combination of a beta-lactam + macrolide, Levofloxacin, Moxifloxacin

CURB-65—Mortality Prediction Tool for Patients with CAP

• Confusion
• Urea >7 mmol/L
• Respiratory rate ≥30/min
• Blood pressure ≤90 mmHg
• Age ≥65 years

Chronic Cough

• Lasting beyond 8 weeks
• Most common causes: postnasal drip, GERD, Asthma
• Differential diagnoses: Cigarette smoking, postnasal drip/allergies/chronic sinusitis, Bronchospasm/asthma, CHF, Bronchogenic/mediastinal tumors, Chronic pulmonary infections, etc.

Bronchiectasis

• Chronic cough
• Overproduction of secretions
• Reduced clearance of secretions
• These result in excess airway secretions

Chronic Cough—Evaluation

• History: development, duration, character, precipitants
• Environmental exposures
• Tobacco use
• History of asthma or COPD
• Swallowing/throat clearing
• GI symptoms
• Physical Exam: ENT, Lungs, Cardiac, Abdomen
• CXR: excludes malignant disease, bronchiectasis, persistent pneumonia, sarcoidosis, TB
• Spirometry

Diagnostics

• CT chest with contrast
• Spiral CT
• Barium esophagography
• Cardiac evaluation
• Bronchoscopy
• GI evaluation
• Barium swallow and/or 24-hour pH esophageal monitoring
• CT sinuses—ENT evaluation

Treatment

• Stop offending meds
• Treat underlying cause
• Consider trial of H2 blockers or PPI
• Anti-tussives as indicated
• Stop smoking

Single Pulmonary Nodule

• Common incidental finding on CT
• Review with new algorithms for evaluation and management
• Pure subsolid SPN < 5mm require no follow-up
• If SPN < 8mm follow Fleischner Society guidelines on intervals for repeat CT
• If SPN >8mm refer specialist

Obstructive Sleep Apnea

• Pause in breathing for 10–90 seconds
• Central apneas: absent airflow and respiratory efforts
• Neurological diseases
• Obstructive apneas (OSA): Tongue and soft palate fall backward
• Mixed apneas

Consequences

• Pulmonary HTN
• HTN with LV Dysfunction
• Cardiac dysrhythmias
• Psychomotor defects
• Hypoxia and hypercapnia

Management

• General measures: Avoidance of alcohol, sedatives, hypnotics
• Specific measures: Position therapy, Positive airway pressure (CPAP, bilevel systems, auto-CPAP), Oral appliances, Surgical management

Geriatric Specific Considerations

• Age-related pulmonary changes: Reduced airway size, Shallow alveolar sacs, Decline in chest wall compliance, Intercostal muscle atrophy, Reduction in diaphragmatic strength by 25%

Rhinosinusitis

• Approaches to diagnosis, treatment do not differ with age
• Treat bacterial rhinosinusitis with analgesics, saline irrigation, and antibiotics if symptoms ≥7 days or worsen
• Treat chronic rhinosinusitis with topical nasal steroids and saline irrigation
• Treat allergic rhinosinusitis by recommending avoidance of inciting allergens and/or with topical nasal steroids and anti-allergy medications