Advances in Asthma Management - Research Paper Example

Advances in Asthma Management of the Under the guidance of Word Count APA format Advances in Asthma Management PART-1: Exploration of the topic Introduction Reversible obstruction of the airways due to chronic inflammation and bronchial hyper-reactivity is known as asthma. Asthma is a common respiratory condition that affects people of all ages and sexes irrespective of region and race. This condition affects about 300 million people in the world including children (Bateman et al, 2008). It constitutes of approximately 2 percent of all emergency department visits (Morris, 2014). The condition is characterized by paroxysmal narrowing of the bronchial airways due to inflammation of the bronchi and also due to spasm of the bronchi due to contraction of the bronchial smooth muscle (Busse et al, 1993). Most of the patients develop symptoms in early childhood. 80-90 percent of them experience symptoms before 6 years of age (Morris, 2014). But, the clinical presentation can occur at any age. If left unattended and in the presence of severe symptoms, asthma can contribute to morbidity and mortality. Asthma is an incurable disease and individuals with this condition will need regular follow-up and monitoring of symptoms. In this essay, advances in asthma will be discussed with reference to a case scenario. Clinical presentation The most common symptoms of asthma in an adult are are wheezing, cough, nocturnal or exercise-induced cough, breathlessness, tightness of chest and sputum production (Morris, 2014). The symptoms may be perennial or seasonal, continuous or intermittent, or during the day or night. Some of the precipitating or aggravating factors include viral infections, intense emotions, environmental irritants, exercise, pets or carpets at home, drugs like aspirin, additive foods, weather changes, stress and certain diseases like gastrointestinal reflux, sinusitis and rhinitis (Morris, 2014; Hamilos, 1995). Many patients have a family history of asthma or other allergy conditions. Based on the history of frequency and the severity of acute exacerbation, asthma is classified into four types. They are mild intermittent asthma, mild persistent asthma, moderate persistent asthma and severe persistent asthma. It is important to ascertain the severity of asthma in a patient because; treatment of asthma is based on the severity and frequency of symptoms. In mild intermittent asthma, the symptoms occur less than twice a week. The flare-ups are brief and the intensity vary. Night symptoms occur less than 2 times a month and no symptoms occur in between flare-ups. FEV1 is atleast 80% of normal values. The variability of peak flow is less than 20 % (SIGN, 2009). In mild persistent asthma, the symptoms occurs usually between 3-6 times a week. The flare-ups affect activity level. Night time symptoms occur between 3-4 times a month. FEV1 is atleast 80 % of normal values. Peak flow variability is 20-30 percent (SIGN, 2009). In moderate persistent asthma, the symptoms occur daily and the flare-ups affect activity levels. Night time symptoms occur atleast 5 times a month. The FEV1 values are between 60% and 80% (SIGN, 2009). The peak flow variability is more than 30%. In severe persistent asthma, the symptoms are continual. Night time symptoms occur frequently. FEV1 is less than 60% and peak flow variability is more than 30% (SIGN, 2009). Methods of diagnosing asthma To arrive at a diagnosis of asthma, physicians must establish episodic airflow obstruction symptoms which are reversible and alternative diagnoses must be excluded (Morris, 2014). There are no specific tests to arrive at a diagnosis of asthma. Pulmonary function tests are useful to monitor response to treatment (Morris, 2014). Diagnosis of asthma in adults is based on the recognition of certain characteristic patterns of signs and symptoms and absence of alternative explanation for the clinical presentation (NAEPP, 2007). The diagnosis is mainly based on clinical presentation (NAEPP, 2007). Thus careful history taking is essential to establish the diagnosis. Clinical features which favor the diagnosis of asthma are presence of more than one of these symptoms: breathlessness, wheezing, cough and chest tightness, especially if the symptoms are worse in early mornings or nights, if the symptoms are exacerbated in response to exposure to allergens, cold air or following exercise, and if symptoms occur after taking medications like beta blockers or aspirin (SIGN, 2009). Other clinical features which favor the diagnosis of asthma are history of atopy, family history of atopy or asthma, wide spread rhonchi of chest auscultation and otherwise unexplained aspects like raised peripheral blood eosinophils, low PEF and low FEV1 (SIGN, 2009). Certain clinical features indicate low probability of asthma and these are presence of light headedness, dizziness, peripheral tingling, chronic productive cause without wheezing or breathlessness, normal auscultatory findings of the chest when symptomatic, disturbances in voice, presence of symptoms only following colds, chronic history of cigarette smoking, presence of cardiac disease and recording of normal spirometry when symptomatic (SIGN, 2009). The initial diagnosis should be based on careful assessments of the clinical symptomatology and measurement of obstruction of the airflow. In those with high probability of asthma, trial of treatment should be initiated immediately. Further testing must be reserved only for those with poor response to trial of treatment (SIGN, 2009). However, in patients with low probability of asthma, treatment must be initiated only after investigation and ruling out of alternative diagnosis. In patients with intermediate probability of asthma, simultaneous investigation and trial of treatment must be executed. The most preferred initial test is spirometry which helps to assess the presence and severity of obstruction of the airflow. Other investigations which may be useful include tests of lung volumes, peak expiratory flow variability, gas transfer, airway inflammation and airway hyperresponsiveness (SIGN, 2009). Monitoring of asthma In most of the patients with asthma, symptom-based monitoring is adequate and those who achieve control of symptoms with adequate treatment are at decreased risk of exacerbations. During review of patients with asthma on treatment, certain factors need to be monitored. The most important aspect is symptomatic asthma control which is best assessed by administering asthma control questionnaire rather than non-specific broad questions (Williams et al, 2003). Another aspect which needs to be monitored during review is lung function by means of peak expiratory flow measurement or spirometry. Decrease in lung function compared to previous values is suggestive of broncho-constriction at the time of testing or decrease in lung function over long term. Such a decline is an indication for prompt and detailed assessment. In case of acute exacerbations, the patient must be administered oral corticosteroids and must be advised to take rest. Other aspects which need to be monitored during review are technique of inhaler use, compliance to treatment and preventive measures, reliance on bronchodilators and efficient use of self-management plan. Approach to asthma management Treatment depends on the staging of asthma which again depends on the frequency and severity of symptoms. The main drugs for treatment are bronchodilators and steroids. These drugs can be given either oral, through metered dose inhalers or through nebulisations (Morris, 2014). Education of the patients is very important in the management of asthma (Expert Panel Report 3, 2007). Parents, patients, partners, friends, relative and caregivers need to learn to identify symptoms and signs of asthma, what medications to given at home and when to bring the patient to the hospital. Any environmental factors which trigger attacks of asthma must be avoided (Morris, 2014). Management strategies which aim to control eosinophilic airway inflammation or hyper-responsiveness of the airways have better control of exacerbations than those which aim at controlling immediate clinical symptoms. Non-pharmacological management: It is important to address non-pharmacological management strategies while discussing management of asthma with patient so that concerns about environmental triggers can be discussed and concordance with pharmacotherapies is achieved (Bateman et al, 2008). The main prophylactic measure is aeroallergen avoidance. The patient must be advised to avoid dust mite exposure and also avoid close contact with pets like cats and dogs. Other allergens which must be avoided include sensitization foods like eggs and other food allergens and environmental allergens like smoking and air pollutants (SIGN, 2009). Pharmacological management: The aim of treatment in asthma is control of symptoms which is defined as absence of daytime symptoms, absence of awakening in night time due to asthma, absent need for administration of rescue medication, absence of exacerbations, absence of limitations in activities like exercise and normal lung function (SIGN, 2009). All these aspects must be achieved with minimal side effects of the drugs administered to gain control of asthma. The management of asthma is based on step-wise strategy. Step-1: This step is employed in mild intermittent asthma. Inhaled short-acting beta-2 agonists, inhaled ipraatropium bromide, beta-2 agonists tablets or syrup and theophyllines are suitable as short-acting bronchodilators. Of these, short-acting inhaled beta-2 agonists act more quickly and have fewer side effects when compared to others alternatives (SIGN, 2009; Rowe et al, 2004). Hence, these drugs must be prescribed as short-term reliever therapy for all patients with symptomatic bronchial asthma. Step-2 : In this step, introduction of inhalational steroids is done. Some of the commonly used inhalational steroids are beclometasone, budesonide, fluticasone, monetasone and ciclesonide. The purpose of inhalational steroids are for prevention and for achieving overall treatment goals. This step is considered in patients with exacerbations of asthma in the last 2 years, in those who have used inhaled beta-2 agonists for control of symptoms for a minimum of 3 times a week, in those who have has symptoms of asthma for atleast 3 times a week and those who have awakened in nights for atleast once in a week. Initially start steroids with 400mcgs of budesonide per day and reduce to 200mcg (OByrne and Parameswaran, 2006 and SIGN, 2009). Other preventive therapies which may be instituted are chromones like sodium chromoglycate and montelukast (SIGN, 2009; Nayak, 2004). Step-3: This should be initiated only after checking compliance, inhaler technique and elimination of triggering factors. In this step, the dose of inhalational steroids is increased to as much as budesonide of 800mcg per day. Other drugs like slow-release theophylline and beta agonists may be started but are associated with complications. Currently, use of inhalational steroids as rescue medication instead of beta-2 agonists has also been recommended. Step-4: Despite step-3, if the control is inadequate, then the need for step-4 becomes essential. In this step, steroids are increased to as much as 2000mcg per day of budesonide. Other drugs like leukotriene receptor antagonists, theophyllines, slow-release beta-2 agonists may also be used (SIGN, 2009). Step-5: For those who are unresponsive to step-4 regimens, low dose oral steroids may need to be given for long term. While on these steroids, blood pressure, blood sugar, cholesterol, bone mineral density and cataract development must be monitored. Anti Ig E monoclonal antibody may need to be considered in this stage. Monoclonal antibodies also may be tried in those who are eosinophilic prednisolone dependent patients (Nair et al, 2009) Recognition of acute asthma Acute asthma is recognized by wide variation in PEF, raised respiratory rate, increased heart rate, inability to complete full sentences in one breath, fall in PEF to less than 50% of best predicted and extreme fatiguibility. Moderate asthma exacerbation is when the symptoms are increasing and the PEF is more than 50% of best predicted. When PEF falls to less than 50% of best predicted and is associated with increased respiratory rate, increased heart rate and inability to complete full sentences in one breath, it is known as acute severe asthma. Life threatening asthma is the term used to such an exacerbation of asthma when the patient has altered conscious level, arrhythmias, exhaustion, hypotension, cyanosis, silent chest and poor respiratory effort. The PEF is less than 33% of the best predicted value, saturations in room air are less than 92 percent. However, PaCO2 is in the normal range. When PaCO2 is raised, then the exacerbation is "near fatal asthma". Patients in acute asthma must be referred if there is no response to treatment. Also, social circumstances and presence of any concomitant disease warrants referral (SIGN, 2009). Part-2: Case Study 50 year old Maria presented to the emergency department with complaints of cough and breathlessness since 2days. She had no history of fever, cold, rash, vomiting, loose stools, chest pain or vertigo. On admission, her heart rate was 87 per min, respiratory rate was 32 per minute, temperature was normal and blood pressure was 130/76mmHg. Examination of the respiratory system revealed equal bilateral air entry with diffuse wheeze and occasional crepitations. Saturations were 90% in room air. Other systems examination was unremarkable. On further enquiry, she revealed that she had repeated episodes of this kind in the past and she was diagnosed to have bronchial asthma. She was put on some inhalers which she did not continue for long. Her husband is a smoker. They have carpets at home and do not vacuum clean regularly. She had no history of admissions in the past. Regular peak flow volume was not checked. In the emergency room, her peak flow volume was 55 percent. Maria was immediately started on nebulisation with levo-salbutamol. Her distress settled in 10 to 15 minutes after which she was discharged home on round the clock levolin inhaler for 3 days. She was then educated about preventive measures for asthma and self-management. Education of the patient and the family members is very essential in asthma. Patient must be educated about compliance with treatment, monitoring of response to treatment, identification of danger signs of asthma, self administration of inhalation therapy and nebulisation, proper use of therapy devices, prevention of environmental triggering factors and indications to rush to the hospital (Ignacio-Garcia and Gonzalez-Santos, 1995). Patient must be educated to initiate inhalation bronchodilator therapy at home before shifting to hospital. Patients must also be informed about the importance of regular follow-up with physician and review. The adult patient who has missed her review sessions must be educated the need for regular follow-up. Her husband will need counseling to stop smoking because passive smoking is an important environmental triggering factor for asthma. The patient must be asked to maintain a diary of her symptoms and treatment strategies she has adopted. Part 3: Summary/Conclusion Asthma is a chronic respiratory disease characterized by reversible airflow obstruction. The condition can develop at any age. Though it incurable, it is controllable. For effective control of asthma, it is essential for the patient to be well-educated about various aspects of asthma including self-management and avoidance of environmental factors. Regular follow-up and review is essential to ascertain response to treatment and review the step of treatment. References Bateman, E.D., Hurd, S.S., Barnes, P.J., Bousquet, J., Drazen, J.M., FitzGerald, M., et al. (2008). Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J., 31(1),143-78. Busse, W.W., Calhoun, W.F., Sedgwick, J.D. (1993) Mechanism of airway inflammation in asthma. American Review Respiratory Diseases, 147(6 Pt 2), S20-4. Expert Panel Report 3 (EPR-3) (2007): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol., 120(5 Suppl):S94-138 Hamilos, D.L. (1995) Gastroesophageal reflux and sinusitis in asthma. Clinics of Chest Medicine, 16(4), 683-97. Ignacio-Garcia, J.M., Gonzalez-Santos, P. (1995) Asthma self-management education program by home monitoring of peak expiratory flow. American Journal Respiratory and Critical Care Medicine, 151(2 Pt 1), 353-9. Morris, M.J. (2014). Asthma. Medscape. Retrieved on 27th April, 2014 from http://emedicine.medscape.com/article/296301-overview National Asthma Education and Prevention Program or NAEPP. (2007) Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. NIH Publication No. 07-4051. Nair, P., Pizzichini, M.M., Kjarsgaard, M., et al. (2009) Mepolizumab for prednisone-dependent asthma with sputum eosinophilia. New England Journal of Medicine, 360(10), 985-93. Nayak, A. (2004) A review of montelukast in the treatment of asthma and allergic rhinitis. Expert Opinion in Pharmacotherapy, 5(3), 679-86. OByrne, P.M., Parameswaran, K. (2006) Pharmacological management of mild or moderate persistent asthma. Lancet, 368(9537), 794-803 Rowe, B.H., Edmonds, M.L., Spooner, C.H., Diner, B., Camargo, C.A. Jr. (2004) Corticosteroid therapy for acute asthma. Respiratory Medicine, 98(4), 275-84. Scottish Intercollegiate Guidelines Network. (SIGN). (2009) British Guideline on the Management of Asthma. Retrieved on 26th April, 2014 www.sign.ac.uk/guidelines/fulltext/101/index.html Williams, S.G., Schmidt, D.K., Redd, S.C., Storms, W. (2003) Key clinical activities for quality asthma care. Recommendations of the National Asthma Education and Prevention Program. Morbidity and Mortality Weekly Report Recommendations and Reports, 52, 1-8. Read More