Respiratory Update Spring 2019 PDF

2/28/2019 1 Pulmonary Disease Management PATTI PARKER, PHD, RN Topics Covered 2  Common Complaints  Geriatric Specific Considerations  The Ma...

2/28/2019 1 Pulmonary Disease Management PATTI PARKER, PHD, RN Topics Covered 2  Common Complaints  Geriatric Specific Considerations  The Major Players  Asthma  COPD 1  2/28/2019 3 Common Complaints  Cough  Dyspnea  Hemoptysis  URIs  Acute and Chronic Bronchitis  Pneumonia  Single Pulmonary Nodule  Obstructive Sleep Apnea Cough 4  Differential Diagnoses  Begin with a thorough history  Prescription Drugs  When did it begin?  Cerumen impaction  When does it occur?  Post nasal drip  COPD  What stimulates it/aggravates it?  Asthma  What makes it better?  Postinfection—can cough up to 8 weeks  Describe the quality  GERD  Productive or nonproductive?  Occupational or environmental  Is it acute [60 years. 10  2/28/2019 21 Community Acquired Pneumonia [CAP]  Infection of the lung NOT  Treatment Guidelines from IDS/ATS acquired in the hospital, LTC or https://www.idsociety.org/practice- other recent contact with a guideline/community-acquired- health care system pneumonia-cap/  Management of Community Acquired Pneumonia in Older Adults from TAID  Evidence of consolidation on https://www.ncbi.nlm.nih.gov/pmc/articles/ CXR PMC4072047/pdf/10.1177_204993611351804 1.pdf  Community acquired pneumonia requiring hospitalization among US adults https://www.nejm.org/doi/pdf/10.1056/NEJ Moa1500245 22 Etiology  Healthy [age 60  Strep pneumoniae [30-35%]  Strep pneumoniae—including DRSP  Mycoplasma pneumoniae*  Mycoplasma pneumoniae  Chlamydophila pneumoniae*  Chlamydophila pneumoniae  Legionella*  H influenzae  Atypical PNA accounts for 37% of CAP  Nosocomial gram negatives—often seen in and 10% of those who are hospitalized elderly nursing home residents  Influenza viruses  Respiratory viruses  H. influenzae  Moraxella catarrhalis  Staph aureus  Anaerobes  Group A strep  Immunocompromised—CMV or PCP  M. catarrhalis 11  2/28/2019 23 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 24 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  May be clinically indistinguishable from pneumococcal pneumonia 12  2/28/2019 25 Differences in Presentation  Mycoplasma Pneumonia  Chlamydia Pneumonia  Sore throat, fever, dry hacking  Biphasic illness cough  Younger individuals  Complications—sinusitis, OM,  Severe pharyngitis and erythema multiforme or erythema laryngitis nodosum, intravascular hemolysis, meningoencephalitis, toxic  Fever psychosis, myocarditis or pericarditis  Cough  Persistent hacking cough for up to 6 weeks  Relapse occurs in 10 percent 26 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 13  2/28/2019 Diagnostic Testing 27  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 +  Sputum culture and gram stain  Blood cultures  Urinary antigen testing for Legionella and pneumococcus  ?CRP  Procalcitonin level may be indicated IF you suspect inadequate response from patient, even with appropriate therapy [usually not done if OP treatment is thought appropriate] 28 14  2/28/2019 29 CAP Ambulatory Treatment  Hydration  Respiratory hygiene  ASA or acetaminophen for fever & HA  Smoking Cessation  Prevention—pneumococcal & influenza vaccine CAP—Empiric Treatments 30 https://emedicine.medscape.com/article/2011819-overview#showall  Outpatient  Comorbidities present [alcoholism, chronic lung disease, IVDU, recent flu, asplenia, DM, CKD or liver  Healthy / No comorbidities [no risk for disease]: drug-resistant S pneumoniae]:  Azithromycin 500 mg PO one dose, then  Levofloxacin 750 mg PO q24h or 250 mg PO daily for 4 d or ER 2 g PO as a  Moxifloxacin 400 mg PO q24h or single dose or  Combination of a beta-lactam [amoxicillin 1 g  Clarithromycin 500 mg PO bid or PO q8h or amoxicillin-clavulanate 2 g PO extended-release 1000 mg PO q24h or q12h or ceftriaxone 1g IV/IM  Doxycycline 100 mg PO bid q24h or cefuroxime 500 mg PO BID] +  If received prior antibiotic within 3 macrolide [azithromycin or clarithromycin] months:  Treat for a minimum of 5 days, should be afebrile  Azithromycin or clarithromycin + for 48-72° or until afebrile for 3 days [longer amoxicillin 1 g PO q8h or amoxicillin- therapy may be needed if initial therapy not clavulanate 2 g PO q12h or active against identified bacteria or if patient has  Respiratory fluoroquinolone [levofloxacin complications of an extrapulmonary infection] 750 mg PO daily or moxifloxacin 400 mg PO daily) 15  2/28/2019 CAP—Empiric Treatments 31 https://emedicine.medscape.com/article/2011819-overview#showall  Inpatient, non-ICU  Levofloxacin 750 mg IV or PO q24h or  Moxifloxacin 400 mg IV or PO q24h or  Combination of a beta-lactam (ceftriaxone 1 g IV q24h or cefotaxime 1 g IV q8hor cefazoline 600 mg IV q12h) plus azithromycin 500 mg IV q24h  Duration of therapy—minimum 5 days, should be afebrile for 48-72°, stable BP, adequate oral intake, and room air O2 sat >90%; longer duration may be needed in some cases CAP—Empiric Treatments 32 https://emedicine.medscape.com/article/2011819-overview#showall  Inpatient, ICU  Combination of a beta-lactam (ceftriaxone 1 g IV q24h or cefotaxime 1 g IV q8hor ceftaroline 600 mg IV q12h) plus Azithromycin 500 mg IV q24h or Levofloxacin 750 mg IV or PO q24h or Moxifloxacin 400 mg IV or PO q24h or  If Pseudomonas suspected, due to alcoholism with necrotizing pneumoniae, chronic bronchiectasis/tracheobronchitis due to cystic fibrosis, mechanical ventilation, febrile neutropenia with pulmonary infiltrate, septic shock with organ failure:  Piperacillin-tazobactam 4.5 g IV q6h or 3.375 g IV q4h or 4-h infusion of 3.375 g q8h or Cefepime 2 g IV q12h or Imipenem/Cilastatin 500 mg IV q6h or meropenem 1 g IV q8h plus Levofloxacin 750 mg IV q24h or Moxifloxacin 400 mg IV or PO q24h or Azithromycin 500 mg IV q24h  Aminoglycoside [gentamicin 7 mg/kg/day IV or tobramycin 7 mg/kg/day IV] was included in older guidelines but is not included in newer guidelines for empiric therapy  Duration of therapy—10 to 14 days  If concomitant with or post influenza, add—Vancomycin 15 mg/kg IV q12h or Linezolid 600 mg IV bid 16  2/28/2019 CURB-65—Mortality Prediction Tool for 33 Patients with CAP **urea—BUN of 20 mg/dL is equivalent to >7 mmol/L Follow-up 34  Telephone follow-up in 24°  Clinical Failures  Office visit 3-4 days  Poor compliance with  Reassure cough and fatigue medications may last 3-4 weeks  Resistant organisms  Repeat CXR  Unusual pathogen—TB, fungus,  Young adults 2 weeks viral  Smokers and older adults 4-6  Non-infectious cause—PE, CHF, weeks Cancer  Frail elderly 8 weeks 17  2/28/2019 35 Chronic Cough  Subacute Cough lasting 3-8 weeks  Chronic Persisting beyond 8 weeks  Most common causes—postnasal drip, GERD, Asthma 36 Differential Diagnoses  Cigarette smoking  COPD  Post nasal drip/allergies/chronic  Drugs—ACE inhibitors, beta sinusitis blockers, inhaled medications  Bronchospasm/asthma  GERD  CHF  Impacted cerumen/other foreign body  Bronchogenic/mediastinal tumors  Chronic aspiration  Chronic pulmonary infections—TB, bronchiectasis  Inflammation—sarcoid, alveolitis, BOOP [bronchiolitis obliterans  Hematological organizing pneumonia]  Psychogenic—rare cause 18  2/28/2019 37 Bronchiectasis  Chronic cough  Overproduction of secretions  Reduced clearance of secretions  These result in excess airway secretions Chronic Cough—Evaluation 38  History—development,  Physical Exam duration, character,  ENT precipitants  Lungs  Cardiac  Environmental exposures  Abdomen  Tobacco use  CXR  History of asthma or COPD  Excludes malignant disease,  Swallowing/throat clearing bronchiectasis, persistent pneumonia, sarcoidosis, TB  GI symptoms  Spirometry 19  2/28/2019 Diagnostics 39  CT chest with contrast  Spiral CT  Completed during single patient breath hold  Barium esophagography  Cardiac evaluation  Bronchoscopy  Of little benefit if CT chest normal  GI evaluation  Barium swallow and/or 24 hour pH esophageal monitoring  CT sinuses—ENT evaluation 40 Treatment  Stop offending meds  Treat underlying cause  Consider trial of H2 blockers or PPI  Anti-tussives as indicated  Dextromethorphan  Benzonatate  Codeine  Others  Stop smoking 20  2/28/2019 41 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  https://pubs.rsna.org/doi/full/10.1148/radiol.2017161659  If SPN >8mm refer specialist 42 21  2/28/2019 Diagnostic Approach 43  If possible—obtain old CTs  2 year stability usually means no further follow up is needed  If no previous images available—determine whether SPN is solid or subsolid  Subsolid—ground glass nodule—it could be a slow growing adenocarcinoma and it requires a different approach  Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017 [MacMahon, H et al https://pubs.rsna.org/doi/pdf/10.1148/radiol.2017161659 44 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 22  2/28/2019 45 Obstructive Sleep Apnea  One of the most under diagnosed and undertreated medical problems in adults in the United States  Costs billions of dollars every year in accidents  Subjective Assessment Tests  Stanford Sleepiness Score (SSS)  Epworth Sleepiness Scale (ESS)  Definitive Test—overnight polysomnogram  Multiple sleep latency test (MSLT)  Otolaryngology exam 46 Consequences  Pulmonary HTN  HTN with LV Dysfunction  Cardiac dysrhythmias  Psychomotor defects  Hypoxia and hypercapnia 23  2/28/2019 47 Management  General measures  Avoidance of alcohol, sedatives, hypnotics  Weight loss, O2 therapy, nasal dilators  Specific measures  Position therapy  Positive airway pressure (CPAP, bilevel systems, auto-CPAP)  Oral appliances  Surgical management 48 Geriatric Specific Considerations 24  2/28/2019 Age-Related Pulmonary Changes 49 Reduced airway size Shallow alveolar sacs Decline in chest wall compliance Intercostal muscle atrophy Reduction in diaphragmatic strength by 25% Difficulties in Recognizing Respiratory 50 Symptoms A common misperception is that older people tend to overestimate or exaggerate respiratory symptoms —the opposite is more often true Older people often have more than one cause of their problems  Dyspnea, cough, and wheezing may overlap  The causes may include a combination of diseases such as asthma or emphysema, obstructive sleep apnea, heart failure, and GERD 25  2/28/2019 Rhinosinusitis 51  Approaches to diagnosis, treatment do not differ with age Treat bacterial rhinosinusitis with analgesics, saline irrigation, and antibiotics if symptoms ≥7 days or worsen  But early antibiotics in mild disease can be harmful 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 Dyspnea 52 Common causes: COPD, cardiac disease, asthma, interstitial lung disease, deconditioning Does not necessarily correlate with oxygenation or pulmonary function tests but is the best predictor of QOL Thorough H & P can help tailor testing and empirical treatment choices Patient’s description can be revealing  “Heavy” may imply cardiac dysfunction or deconditioning  “Tight” may imply angina or asthma 26  2/28/2019 Chronic Cough 53 Usually has a benign cause in individuals without a history of chronic lung disease or smoking The most common causes are postnasal drip, asthma, and GERD A reasonable approach is empiric treatment for these conditions A combination of these conditions may contribute, so treatment for multiple causes may be warranted when single therapies are ineffective Consider possibility of silent aspiration, especially in those with frequent pneumonias, neurologic deficits, or residence in extended-care facilities Wheezing 54 Although asthma is a common cause of wheezing in all age groups, it is not the principal cause in older adults, particularly if the wheezing is not associated with cough or dyspnea. Common causes in older adults include:  COPD  Heart failure  Postnasal drip  Uncontrolled GERD “Cardiac asthma” refers to wheezing arising from heart failure 27  2/28/2019 Major Pulmonary Diseases in Older People 55 Asthma COPD Obstructive sleep apnea Idiopathic pulmonary fibrosis Venous thromboembolic disease Pneumonia Lung cancer OBSTRUCTIVE SLEEP APNEA 56 Consider diagnosis in patients with daytime somnolence or frequent napping, drowsiness while driving, or snoring or witnessed apneas or hypopneas Life-threatening, yet potentially treatable Associated with:  Stroke  Myocardial infarction  3 increase in mortality  Significant cognitive impairment  Depression Often undiagnosed and therefore untreated 28  2/28/2019 TREATMENT OPTIONS FOR SLEEP APNEA 57 Weight loss Avoidance of alcohol and sedatives Sleeping on one’s side or upright Correction of metabolic disorders such as hypothyroidism Continuous positive airway pressure (CPAP) via a nasal mask IDIOPATHIC PULMONARY FIBROSIS 58 Relentlessly progressive: median survival 3–5 years Normal presentation: insidious dyspnea, nonproductive cough, with dry inspiratory rales on exam  Clubbing is often a prominent finding in IPF and not in emphysema In the past, commonly treated initially with OCS, but only 10%–20% of patients respond and adverse events are often prominent Early referral to a subspecialist is warranted if the patient wishes to consider further therapy. Lung transplant is only treatment. 29  2/28/2019 COPD and Comorbidities 59 COPD as part of multimorbidity ► An increasing number of people in any aging population will suffer from multi- morbidity, defined as the presence of two or more chronic conditions, and COPD is present in the majority of multi-morbid patients. ► Multi-morbid patients have symptoms from multiple diseases and thus symptoms and signs are complex and most often attributable to several causes in the chronic state as well as during acute events. ► There is no evidence that COPD should be treated differently when part of multi- morbidity; however, it should be kept in mind that most evidence comes from trials in patients with COPD as the only significant disease. ► Treatments should be kept simple in the light of the unbearable polypharmacy that these patients are often exposed to. © 2019 Global Initiative for Chronic Obstructive Lung Disease SUMMARY 60 With age, there is a decline in forced vital capacity, FEV1, and PaO2, while the A-a gradient increases Clinically significant dyspnea is often under-reported and unrecognized in older adults 5%–10% of people ≥65 years meet criteria for asthma COPD is the third leading cause of death in older adults; pharmacologic treatment chiefly consists of inhaled bronchodilators and steroids Smoking cessation will slow the decline in lung function at any age 30  2/28/2019 61 Asthma—Guidelines with most recent updates from GINA for 2018 GLOBAL INITIATIVE FOR ASTHMA G lobal INitiative for A sthma © Global Initiative for Asthma 31  2/28/2019 Burden of asthma 63  Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals  Prevalence is increasing in many countries, especially in children  Asthma is a major cause of school and work absence  Health care expenditure on asthma is very high  Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma.  Developing economies likely to face increased demand due to increasing prevalence of asthma  Poorly controlled asthma is expensive  However, investment in prevention medication is likely to yield cost savings in emergency care GINA 2017 GINA Program Objectives 64  To increase appreciation of asthma as a global public health problem  To present key recommendations for diagnosis and management of asthma  To provide strategies to adapt recommendations to varying health needs, services, and resources  To identify areas for future investigation of particular significance to the global community 32  2/28/2019 Global Strategy for Asthma Management & Prevention Evidence Sources of evidence category A  Well-designed RCTs or meta-analyses  Consistent pattern of findings in the population for which the recommendation is made  Substantial numbers of large studies B  Limited number of patients, post hoc or sub-group analyses of RCTs or meta-analyses  Few RCTs, or small in size, or differing population, or results somewhat inconsistent C  Uncontrolled or non-randomized studies  Observational studies D  Panel consensus based on clinical experience or knowledge GINA 2018 © Global Initiative for Asthma Key changes in GINA—Asthma-COPD overlap 66  The word ‘syndrome’ has been removed from the previous term ‘asthma- COPD overlap syndrome (ACOS)’ because:  This term was being commonly used in the respiratory community as if it was a single disease (‘the asthma-COPD overlap syndrome’)  This distracted from the key messages for clinicians and regulators  The aim is to focus attention back on the original issues  These patients are commonly seen in clinical practice  They are almost always excluded from the RCTs that provide the evidence base for treatment recommendations, and from studies of underlying mechanisms  Most current guidelines have opposite safety recommendations  Asthma: never use LABA without ICS  COPD: start treatment with LABA and/or LAMA, without ICS 33  2/28/2019 Key changes in GINA—Lung Function 67  Clarification about ‘periodical’ assessment of lung function  Most adults: lung function should be recorded at least every 1-2 yrs.  More frequently in higher risk patients  Lung function trajectories  Children with persistent asthma may have reduced growth in lung function, and some are at risk of accelerated decline in lung function in early adult life [McGeachie, NEJMed 2016]  Low resource areas  Poverty is commonly associated with spirometry restriction, so where possible, both FEV1 and FVC should be recorded Key changes in GINA—Fractional Exhaled Nitric Oxide [FENO] 68  Diagnosis of asthma  Additional factors that increase or decrease FENO are listed  FENO is not helpful in ruling in or ruling out asthma as defined by GINA  Assessment of future risk  Elevated FENO in allergic patients has been added to the list of independent predictors of exacerbations [Zeiger JACI 2011]  Single measurements  Results of FENO measurement at a single point in time should be interpreted with caution  Controller treatment  Given the lack of long-term safety studies, FENO cannot be recommended at present for deciding against treatment with ICS in patients with a diagnosis/suspected diagnosis of asthma.  Based on current evidence, GINA recommends treatment with low-dose ICS for most patients with asthma, even those with infrequent symptoms, to reduce the risk of serious exacerbations. 34  2/28/2019 Stepwise approach to control asthma symptoms and reduce risk 69 Diagnosis Symptom control & risk factors (including lung function) Inhaler technique & adherence Patient preference Symptoms Exacerbations Asthma medications Side-effects Non-pharmacological strategies Patient satisfaction Treat modifiable risk factors Lung function STEP 5 STEP 4 STEP 3 Refer for PREFERRED STEP 1 STEP 2 CONTROLLER add-on CHOICE treatment Med/high e.g. ICS/LABA tiotropium,* Low dose anti-IgE, ICS/LABA** anti-IL5* Low dose ICS Other Med/high dose ICS Add tiotropium*Add  low Consider low Leukotriene receptor antagonists (LTRA) controller dose ICS Low dose theophylline* Low dose ICS+LTRA High dose ICS dose options (or + theoph*) + LTRA OCS (or + theoph*) RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or low dose ICS/formoterol# Provide guided self-management education (self-monitoring + written action plan + regular review) REMEMBER TO... Treat modifiable risk factors and comorbidities, e.g. smoking, obesity, anxiety Advise about non-pharmacological therapies and strategies, e.g. physical activity, weight loss, avoidance of sensitizers where appropriate Consider stepping up if … uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler SLIT added technique and adherence first Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite as an option ICS treatment, provided FEV1 is >70% predicted Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations. Ceasing ICS is not advised. © Global Initiative for Asthma Key changes in GINA—Role of SLIT Provide guided self-management education REMEMBER Treat modifiable risk factors and comorbidities TO... Advise about non-pharmacological therapies and strategies Consider stepping up if … uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler technique and adherence first Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite ICS treatment, provided FEV1 is 70% predicted Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations. Ceasing ICS is not advised. SLIT: sublingual immunotherapy [sublingual tabs prescribed by allergists to desensitize against ragweed, northern pasture & dust mites] 70 © Global Initiative for Asthma 35  2/28/2019 Other Key Changes in GINA 71  Step 5 treatment for severe asthma  Anti-IL5: reslizumab (IV) [Cinqair] added to mepolizumab (SC) [Nucala] for ≥18 years  Step-down from low-dose ICS  Add-on LTRA may help  Insufficient evidence for step-down to as-needed ICS with SABA  Side-effects of oral corticosteroids  When prescribing short-term OCS, remember to advise patients about common side-effects— insomnia, increased appetite, reflux, mood changes  Vitamin D  To date, no good quality evidence that Vitamin D supplementation leads to improved asthma control or fewer exacerbations  Chronic sinonasal disease  Treatment with nasal corticosteroids improves sinonasal symptoms but not asthma outcomes 72 Definition and Diagnosis of Asthma—based on the latest GINA Guidelines 36  2/28/2019 What is known about asthma? 73  Asthma is a common and potentially serious chronic disease that can be controlled but not cured  Asthma causes symptoms such as wheezing, shortness of breath, chest tightness and cough that vary over time in their occurrence, frequency and intensity  Symptoms are associated with variable expiratory airflow, i.e. difficulty breathing air out of the lungs due to  Bronchoconstriction  Airway wall thickening  Increased mucus  Symptoms may be triggered or worsened by factors such as viral infections, allergens, tobacco smoke, exercise and stress What is known about asthma? 74  Asthma can be effectively treated  When asthma is well-controlled, patients can  Avoid troublesome symptoms during the day and night  Need little or no reliever medication  Have productive, physically active lives  Have normal or near-normal lung function  Avoid serious asthma flare-ups (also called exacerbations, or severe attacks) 37  2/28/2019 Definition of asthma 75 Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation. Types of Asthma 76 Phenotype Endotype Features Allergic [extrinsic] IgE mediated or mast cell May respond to specific Asthma mediated targeted therapies [anti- Type 2 inflammation IgE, anti-IL-5 and anti- IL4/IL-13] -Often responds to ICS Non-allergic [intrinsic] Eosinophilic or Neutrophilic May be ICS responsive or Asthma resistant Asthma with Fixed Lack of inflammation ICS resistant Airway Obstruction Defective repair mechanisms Airway smooth muscle abnormalities Asthma with Obesity Non-eosinophilic Obesity required ASA-sensitive asthma Type 2 inflammation Acute sensitivity to Leukotriene-mediated NSAIDs May respond to ICS, oral corticosteroids and LTRA may be effective 38  2/28/2019 77 Differential Diagnoses  Foreign body  Viral infections  Pulmonary infections  MVP  PE  CHF  COPD  Drugs—ACE inhibitors, Beta blockers, NSAIDS, ASA Diagnosis of asthma 78  The diagnosis of asthma should be based on:  A history of characteristic symptom patterns  Evidence of variable airflow limitation, from bronchodilator reversibility testing or other tests  Document evidence for the diagnosis in the patient’s notes, preferably before starting controller treatment  It is often more difficult to confirm the diagnosis after treatment has been started  Asthma is usually characterized by airway inflammation and airway hyperresponsiveness, but these are not necessary or sufficient to make the diagnosis of asthma. 39  2/28/2019 Patient with respiratory symptoms Are the symptoms typical of asthma? NO YES Detailed history/examination for asthma History/examination supports asthma diagnosis? Further history and tests for NO alternative diagnoses Clinical urgency, and YES Alternative diagnosis confirmed? other diagnoses unlikely Perform spirometry/PEF with reversibility test Results support asthma diagnosis? Repeat on another NO occasion or arrange NO YES other tests Confirms asthma diagnosis? Empiric treatment with YES NO YES ICS and prn SABA Review response Consider trial of treatment for Diagnostic testing most likely diagnosis, or refer within 1-3 months for further investigations Treat for ASTHMA Treat for alternative diagnosis GINA , Box 1-1 (4/4) © Global Initiative for©Asthma Global Initiative for Asthma Diagnosis of asthma – symptoms 80  Increased probability that symptoms are due to asthma if:  More than one type of symptom (wheeze, shortness of breath, cough, chest tightness)  Symptoms often worse at night or in the early morning  Symptoms vary over time and in intensity  Symptoms are triggered by viral infections, exercise, allergen exposure, changes in weather, laughter, irritants such as car exhaust fumes, smoke, or strong smells  Decreased probability that symptoms are due to asthma if:  Isolated cough with no other respiratory symptoms  Chronic production of sputum  Shortness of breath associated with dizziness, light-headedness or peripheral tingling  Chest pain  Exercise-induced dyspnea with noisy inspiration (stridor) 40  2/28/2019 Diagnosis of asthma – variable 81 airflow limitation  Confirm presence of airflow limitation  Document that FEV1/FVC is reduced (at least once, when FEV1 is low)  FEV1/ FVC ratio is normally >0.75 – 0.80 in healthy adults  Confirm variation in lung function is greater than in healthy individuals  The greater the variation, or the more times variation is seen, the greater probability that the diagnosis is asthma  Excessive bronchodilator reversibility (adults: increase in FEV1 >12% and >200mL; children: increase >12% predicted)  Excessive diurnal variability from 1-2 weeks’ twice-daily PEF monitoring (daily amplitude x 100/daily mean, averaged)  Significant increase in FEV1 or PEF after 4 weeks of controller treatment  If initial testing is negative:  Repeat when patient is symptomatic, or after withholding bronchodilators  Refer for additional tests (especially children ≤5 years, or the elderly) Typical spirometric tracings Volume Flow Normal FEV1 Asthma (after BD) Normal Asthma (before BD) Asthma (after BD) Asthma (before BD) 1 2 3 4 5 6 Volume Time (seconds) Note: Each FEV1 represents the highest of three reproducible measurements GINA 2018 © Global Initiative for Asthma 41  2/28/2019 Diagnosis of asthma – physical 83 examination  Physical examination in people with asthma  Often normal  The most frequent finding is wheezing on auscultation, especially on forced expiration  Wheezing is also found in other conditions, for example:  Respiratory infections  COPD  Upper airway dysfunction  Endobronchial obstruction  Inhaled foreign body  Wheezing may be absent during severe asthma exacerbations (‘silent chest’) 84 Assessment of Asthma 42  2/28/2019 Assessment of asthma 85 1. Asthma control - two domains  Assess symptom control over the last 4 weeks  Assess risk factors for poor outcomes, including low lung function 2. Treatment issues  Check inhaler technique and adherence  Ask about side-effects  Does the patient have a written asthma action plan?  What are the patient’s attitudes and goals for their asthma? 3. Comorbidities  Think of rhinosinusitis, GERD, obesity, obstructive sleep apnea, depression, anxiety  These may contribute to symptoms and poor quality of life GINA assessment of symptom control A. Symptom control Level of asthma symptom control Well- Partly Uncontrolled In the past 4 weeks, has the patient had: controlled controlled Daytime asthma symptoms more than twice a week? Yes No Any night waking due to asthma? Yes No None of 1-2 of 3-4 of Reliever needed for symptoms* these these these more than twice a week? Yes No Any activity limitation due to asthma? Yes No *Excludes reliever taken before exercise, because many people take this routinely GINA , Box 2-2A © Global Initiative for Asthma 43  2/28/2019 GINA assessment of asthma control A. Symptom control Level of asthma symptom control Well- Partly Uncontrolled In the past 4 weeks, has the patient had: controlled controlled Daytime asthma symptoms more than twice a week? Yes No Any night waking due to asthma? Yes No None of 1-2 of 3-4 of Reliever needed for symptoms* these these these more than twice a week? Yes No Any activity limitation due to asthma? Yes No B. Risk factors for poor asthma outcomes Assess risk factors at diagnosis and periodically Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patient’s personal best, then periodically for ongoing risk assessment ASSESS PATIENT’S RISKS FOR: Exacerbations Fixed airflow limitation Medication side-effects GINA, Box 2-2B (1/4) © Global Initiative for Asthma Assessment of risk factors for poor asthma outcomes Risk factors for Independent* risk exacerbations factors for exacerbations include: include: Ever intubated for asthma Uncontrolled asthma symptoms Having ≥1 exacerbation in last 12 months Low FEV1 (measure lung function at start of treatment, at 3-6 months to assess personal best, and periodically thereafter) Incorrect inhaler technique and/or poor adherence UPDATED Smoking 2017 Obesity, pregnancy, Elevated FeNO in adults bloodwith eosinophilia allergic asthma Obesity, pregnancy, blood eosinophilia * Independent of the level of symptom control GINA , Box 2-2B (2/4) © Global Initiative for Asthma 44  2/28/2019 Assessment of risk factors for poor asthma outcomes Risk factors for exacerbations include: Ever intubated for asthma Uncontrolled asthma symptoms Having ≥1 exacerbation in last 12 months Low FEV1 (measure lung function at start of treatment, at 3-6 months to assess personal best, and periodically thereafter) Incorrect inhaler technique and/or poor adherence Smoking Elevated FeNO in adults with allergic asthma Obesity, pregnancy, blood eosinophilia Risk factors for fixed airflow limitation include: No ICS treatment, smoking, occupational exposure, mucus hypersecretion, blood eosinophilia GINA , Box 2-2B (3/4) © Global Initiative for Asthma Assessment of risk factors for poor asthma outcomes Risk factors for exacerbations include: Ever intubated for asthma Uncontrolled asthma symptoms Having ≥1 exacerbation in last 12 months Low FEV1 (measure lung function at start of treatment, at 3-6 months to assess personal best, and periodically thereafter) Incorrect inhaler technique and/or poor adherence Smoking Elevated FeNO in adults with allergic asthma Obesity, pregnancy, blood eosinophilia Risk factors for fixed airflow limitation include: No ICS treatment, smoking, occupational exposure, mucus hypersecretion, blood eosinophilia Risk factors for medication side-effects include: Frequent oral steroids, high dose/potent ICS, P450 inhibitors GINA , Box 2-2B (4/4) © Global Initiative for Asthma 45  2/28/2019 The role of lung function in asthma 91  Diagnosis  Demonstrate variable expiratory airflow limitation  Reconsider diagnosis if symptoms and lung function are discordant  Frequent symptoms but normal FEV1: cardiac disease; lack of fitness? UPDATED 2017  Few symptoms but low FEV1: poor perception; restriction of lifestyle?  Risk assessment  Low FEV1 is an independent predictor of exacerbation risk  Measure lung function to monitor progress  At diagnosis and 3-6 months after starting treatment (to identify personal best)  Periodically thereafter, at least every 1-2 years for most adults; more often for high risk patients and for children, depending on age and asthma severity  Consider long-term PEF monitoring for patients with severe asthma or impaired perception of airflow limitation  Adjusting treatment?  Utility of lung function for adjusting treatment is limited by between-visit variability of FEV1 (15% year-to-year) Assessing asthma severity 92  How?  Asthma severity is assessed retrospectively from the level of treatment required to control symptoms and exacerbations  When?  Assess asthma severity after patient has been on controller treatment for several months  Severity is not static – it may change over months or years, or as different treatments become available  Categories of asthma severity  Mild asthma: well-controlled with Steps 1 or 2 (as-needed SABA or low dose ICS)  Moderate asthma: well-controlled with Step 3 (low-dose ICS/LABA)  Severe asthma: requires Step 4/5 (moderate or high dose ICS/LABA ± add-on), or remains uncontrolled despite this treatment 46  2/28/2019 How to Distinguish between Uncontrolled and Severe Asthma 93 Watch patient using their Compare inhaler technique with a device- specific checklist, and correct errors; inhaler. Discuss adherence recheck frequently. Have an empathic and barriers to use discussion about barriers to adherence. If lung function normal during symptoms, Confirm the diagnosis consider halving ICS dose and repeating of asthma lung function after 2–3 weeks. Remove potential Check for risk factors or inducers such as smoking, beta-blockers, NSAIDs, allergen risk factors. Assess and exposure. Check for comorbidities such as manage comorbidities rhinitis, obesity, GERD, depression/anxiety. Consider step up to next treatment level. Consider treatment Use shared decision-making, and balance step-up potential benefits and risks. If asthma still uncontrolled after 3–6 months Refer to a specialist or on Step 4 treatment, refer for expert advice. severe asthma clinic Refer earlier if asthma symptoms severe, or doubts about diagnosis. GINA, Box 2-4 (5/5) © Global Initiative for Asthma 94 Treating Asthma to Control Symptoms and Minimize Risk 47  2/28/2019 Goals of asthma management 95  The long-term goals of asthma management are 1. Symptom control: to achieve good control of symptoms and maintain normal activity levels 2. Risk reduction: to minimize future risk of exacerbations, fixed airflow limitation and medication side-effects  Achieving these goals requires a partnership between patient and their health care providers  Ask the patient about their own goals regarding their asthma  Good communication strategies are essential  Consider the health care system, medication availability, cultural and personal preferences and health literacy Reducing the impact of impaired 96 health literacy  Health literacy affects health outcomes, including in asthma  ‘The degree to which individuals have the capacity to obtain, process and understand basic health information and services to make appropriate health decisions’ (Rosas-Salazar, JACI 2012)  Strategies for reducing the impact of impaired health literacy  Prioritize information (most important to least important)  Speak slowly, avoid medical language, simplify numeric concepts  Use anecdotes, drawings, pictures, tables and graphs  Use the ‘teach-back’ method – ask patients to repeat instructions  Ask a second person to repeat the main messages  Pay attention to non-verbal communication 48  2/28/2019 Treating to control symptoms and minimize risk 97  Establish a patient-provider partnership  Manage asthma in a continuous cycle:  Assess  Adjust treatment (pharmacological and non-pharmacological)  Review the response  Teach and reinforce essential skills  Inhaler skills  Adherence  Guided self-management education  Written asthma action plan  Self-monitoring  Regular medical review The control-based asthma 98 management cycle Diagnosis Symptom control & risk factors (including lung function) Inhaler technique & adherence Patient preference Symptoms Exacerbations Side-effects Patient satisfaction Lung function Asthma medications Non-pharmacological strategies Treat modifiable risk factors 49  2/28/2019 The Rules of Two… 99  If the patient has….  Symptoms more that 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 more than TWO cannisters of a rescue medication in a year  Then the patient needs to be on an ICS as a controller Choosing between controller options – population-level decisions Choosing between treatment options at a population level e.g. national formularies, health maintenance organisations, national guidelines The ‘preferred treatment’ at each step is based on:  Efficacy based on group mean data for symptoms,  Effectiveness exacerbations and lung function (from RCTs, pragmatic studies and observational data)  Safety  Availability and cost at the population level GINA , Box 3-3 (1/2) © Global Initiative for Asthma 50  2/28/2019 Choosing between controller options – individual patient decisions Decisions for individual patients Use shared decision-making with the patient/parent/carer to discuss the following: 1. Preferred treatment for symptom control and for risk reduction 2. Patient characteristics (phenotype) Does the patient have any known predictors of risk or response? (e.g. smoker, history of exacerbations, blood eosinophilia) 3. Patient preference What are the patient’s goals and concerns for their asthma? 4. Practical issues Inhaler technique - can the patient use the device correctly after training? Adherence: how often is the patient likely to take the medication? Cost: can the patient afford the medication? GINA , Box 3-3 (2/2) © Global Initiative for Asthma Initial controller treatment 102  Before starting initial controller treatment  Record evidence for diagnosis of asthma, if possible  Record symptom control and risk factors, including lung function  Consider factors affecting choice of treatment for this patient  Ensure that the patient can use the inhaler correctly  Schedule an appointment for a follow-up visit  After starting initial controller treatment  Review response after 2-3 months, or according to clinical urgency  Adjust treatment (including non-pharmacological treatments)  Consider stepping down when asthma has been well-controlled for 3 months 51  2/28/2019 Stepwise approach to control asthma symptoms and reduce risk 103 Diagnosis Symptom control & risk factors (including lung function) Inhaler technique & adherence Patient preference Symptoms UPDATED Exacerbations 2017 Asthma medications Side-effects Non-pharmacological strategies Patient satisfaction Treat modifiable risk factors Lung function STEP 5 STEP 4 STEP 3 Refer for PREFERRED STEP 1 STEP 2 CONTROLLER add-on CHOICE treatment Med/high e.g. ICS/LABA tiotropium,* Low dose anti-IgE, ICS/LABA** anti-IL5* Low dose ICS Other Med/high dose ICS Add tiotropium*Add  low Consider low Leukotriene receptor antagonists (LTRA) controller dose ICS Low dose theophylline* Low dose ICS+LTRA High dose ICS dose options (or + theoph*) + LTRA OCS (or + theoph*) RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or low dose ICS/formoterol# Provide guided self-management education (self-monitoring + written action plan + regular review) REMEMBER TO... Treat modifiable risk factors and comorbidities, e.g. smoking, obesity, anxiety Advise about non-pharmacological therapies and strategies, e.g. physical activity, weight loss, avoidance of sensitizers where appropriate Consider stepping up if … uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler technique and adherence first Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite ICS treatment, provided FEV1 is >70% predicted Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations. Ceasing ICS is not advised. GINA , Box 3-5 (1/8) © Global Initiative for Asthma Stepwise management—Pharmacotherapy 104 Diagnosis Symptom control & risk factors (including lung function) UPDATED Inhaler technique & adherence 2017 Patient preference Symptoms Exacerbations Side-effects Asthma medications Patient satisfaction Non-pharmacological strategies Lung function Treat modifiable risk factors STEP 5 STEP 4 STEP 3 Refer for *Not for children 800 Ciclesonide (HFA) 80–160 >160–320 >320 Fluticasone furoate (DPI) 100 n.a. 200 Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500 Mometasone furoate 110–220 >220–440 >440 Triamcinolone acetonide 400–1000 >1000–2000 >2000  This is not a table of equivalence, but of estimated clinical comparability  Most of the clinical benefit from ICS is seen at low doses  High doses are arbitrary, but for most ICS are those that, with prolonged use, are associated with increased risk of systemic side-effects Reviewing response and adjusting 118 treatment  How often should asthma be reviewed?  1-3 months after treatment started, then every 3-12 months  During pregnancy, every 4-6 weeks  After an exacerbation, within 1 week  Stepping up asthma treatment  Sustained step-up, for at least 2-3 months if asthma poorly controlled  Important: first check for common causes (symptoms not due to asthma, incorrect inhaler technique, poor adherence)  Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen  May be initiated by patient with written asthma action plan  Day-to-day adjustment  For patients prescribed low-dose ICS/formoterol maintenance and reliever regimen*  Stepping down asthma treatment  Consider step-down after good control maintained for 3 months  Find each patient’s minimum effective dose, that controls both symptoms and exacerbations *Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol 59  2/28/2019 General principles for stepping down controller treatment 119  Aim  To find the lowest dose that controls symptoms and exacerbations, and minimizes the risk of side-effects  When to consider stepping down  When symptoms have been well controlled and lung function stable for ≥3 months  No respiratory infection, patient not travelling, not pregnant  Prepare for step-down  Record the level of symptom control and consider risk factors  Make sure the patient has a written asthma action plan  Book a follow-up visit in 1-3 months  Step down through available formulations  Stepping down ICS doses by 25–50% at 3 month intervals is feasible and safe for most patients (Hagan et al, Allergy 2014)  Stopping ICS is not recommended in adults with asthma because of risk of exacerbations (Rank et al, JACI 2013) Treating modifiable risk factors 120  Provide skills and support for guided asthma self-management  This comprises self-monitoring of symptoms and/or PEF, a written asthma action plan and regular medical review  Prescribe medications or regimen that minimize exacerbations  ICS-containing controller medications reduce risk of exacerbations  For patients with ≥1 exacerbations in previous year, consider low-dose ICS/formoterol maintenance and reliever regimen*  Encourage avoidance of tobacco smoke (active or ETS)  Provide smoking cessation advice and resources at every visit  For patients with severe asthma  Refer to a specialist center, if available, for consideration of add-on medications and/or sputum-guided treatment  For patients with confirmed food allergy:  Appropriate food avoidance  Ensure availability of injectable epinephrine for anaphylaxis *Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol 60  2/28/2019 Non-pharmacological interventions 121  Avoidance of tobacco smoke exposure  Provide advice and resources at every visit; advise against exposure of children to environmental tobacco smoke (house, car)  Physical activity  Encouraged because of its general health benefits. Provide advice about exercise-induced bronchoconstriction  Occupational asthma  Ask patients with adult-onset asthma about work history. Remove sensitizers as soon as possible. Refer for expert advice, if available  Avoid medications that may worsen asthma  Always ask about asthma before prescribing NSAIDs or beta-blockers  Remediation of dampness or mold in homes  Reduces asthma symptoms and medication use in adults  Sublingual immunotherapy (SLIT)  Consider as add-on therapy in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite ICS treatment, provided FEV1 is 70% predicted This slide shows examples of interventions with high quality evidence Indications for considering referral 122  Difficulty confirming the diagnosis of asthma  Symptoms suggesting chronic infection, cardiac disease etc  Diagnosis unclear even after a trial of treatment  Features of both asthma and COPD, if in doubt about treatment  Suspected occupational asthma  Refer for confirmatory testing, identification of sensitizing agent, advice about eliminating exposure, pharmacological treatment  Persistent uncontrolled asthma or frequent exacerbations  Uncontrolled symptoms or ongoing exacerbations or low FEV1 despite correct inhaler technique and good adherence with Step 4  Frequent asthma-related health care visits  Risk factors for asthma-related death  Near-fatal exacerbation in past  Anaphylaxis or confirmed food allergy with asthma 61  2/28/2019 Indications for considering referral 123  Significant side-effects (or risk of side-effects)  Significant systemic side-effects  Need for oral corticosteroids long-term or as frequent courses  Symptoms suggesting complications or sub-types of asthma  Nasal polyposis and reactions to NSAIDS (may be aspirin exacerbated respiratory disease)  Chronic sputum production, fleeting shadows on CXR (may be allergic bronchopulmonary aspergillosis) Patient Considerations that 124 Clinicians Must Consider…  If the family/patient thinks asthma is not serious, they are less likely to follow the treatment plan  If the family/patient overestimates the seriousness of asthma, they may follow the plan, but avoid taking part in normal physical activities  Fears about Medications  39% believe medicines are addictive  36% believe medicines are not safe to take over a long period  58% believe regular use will reduce effectiveness 62  2/28/2019 Guided asthma self-management and 125 skills training Essential components are:  Skills training to use inhaler devices correctly  Encouraging adherence with medications, appointments  Asthma information  Guided self-management support  Self-monitoring of symptoms and/or Peak Expiratory Flows  Written asthma action plan  Regular review by a health care provider Provide hands-on inhaler skills training Choose Choose an appropriate device before prescribing. Consider medication options, arthritis, patient skills and cost. For ICS by pMDI, prescribe a spacer Avoid multiple different inhaler types if possible Check Check technique at every opportunity – “Can you show me how you use your inhaler at present?” Identify errors with a device-specific checklist Correct Give a physical demonstration to show how to use the inhaler correctly Check again (up to 2-3 times) Re-check inhaler technique frequently, as errors often recur within 4-6 weeks Confirm Can you demonstrate correct technique for the inhalers you prescribe? Brief inhaler technique training improves asthma control GINA , Box 3-11 (4/4) © Global Initiative for Asthma 63  2/28/2019 Check adherence with asthma 127 medications  Poor adherence:  Is very common: it is estimated that 50% of adults and children do not take controller medications as prescribed  Contributes to uncontrolled asthma symptoms and risk of exacerbations and asthma-related death  Contributory factors  Unintentional (e.g. forgetfulness, cost, confusion) and/or  Intentional (e.g. no perceived need, fear of side-effects, cultural issues, cost)  How to identify patients with low adherence:  Ask an empathic question, e.g. “Do you find it easier to remember your medication in the morning or the evening?”, or “Would you say you are taking it 3 days a week, or less, or more?”  Check prescription date, label date and dose counter  Ask patient about their beliefs and concerns about the medication Strategies to improve adherence in asthma 128  Only a few interventions have been studied closely in asthma and found to be effective for improving adherence  Shared decision-making  Comprehensive asthma education with nurse home visits  Inhaler reminders for missed doses  Reviewing patients’ detailed dispensing records 64  2/28/2019 129 “Guided self-management education”  Highly effective in improving asthma outcomes  Reduced hospitalizations, ED visits, symptoms, night waking, time off work, improved lung function and quality of life  Three essential components  Self-monitoring of symptoms and/or PEF  Written asthma action plan  Describe how to recognize and respond to worsening asthma  Individualize the plan for the patient’s health literacy and autonomy  Provide advice about a change in ICS and how/when to add OCS  If using PEF, base action plan on personal best rather than predicted  Regular medical review 130 Investigations in those with severe asthma  Confirm the diagnosis of asthma  Consider alternative diagnoses or contributors to symptoms, e.g. up