simplebooklet thumbnail

test test test

Asthma and Allergy Center of Chicago SC www AsthmaAllergyChicago com www Research4Health com PERSPECTIVES IN ASTHMA CARE John MacTaggart DISCLAIMER 99 OF THIS DOCUMENT IS ORIGINAL TEXT SOME IMAGES HAVE BEEN HIJACKED OTHERS ARE PUBLIC DOMAIN THE INFORMATION CONTAINED HEREIN IS FOR GENERAL EDUCATION PURPOSES FOR PATIENTS OF THE ASTHMA AND ALLERGY CENTER OF CHICAGO AND NOT SPECIFIC RECOMMENDATIONS OR INSTRUCTIONS FOR INDIVIDUAL MEDICAL CARE Ver517
Asthma and Allergy Center of Chicago, SC www.AsthmaAllergyChicago.com www.Research4Health.com  PERSPECTIVES IN ASTHMA CARE...
ASTHMA WHAT S UP DOC Ok everyone agrees if it looks like a duck walks like a duck and sounds like a duck it must be a So far we can describe a lot about what asthma looks and sounds like but we are still at a loss to exactly define what is asthma We really don t have a good idea of how many people have some form of asthma but estimates range from 10 25 of the entire population You may be asking yourself why don t we know how many people have asthma In fact you re probably asking how do you even know that you have asthma Well keep reading Let s clear up a few things first All asthma is asthma Just stop confusing yourself by listening to people who use the terms such as wheezy asthma cough asthma allergic asthma non allergic asthma hyper reactive airway disease nocturnal asthma exercise asthma etc Doctors may use different words to associate a particular symptom or trigger some people may have with their asthma but in the end a duck is a duck For someone who has asthma it is more clinically useful to designate asthma as either Intermittent or Persistent Intermittent Asthma is characterized by 1 Normal lung function and no symptoms in the absence of exposure to a specific trigger say a cat or a cold 2 When asthma is triggered lung function worsens and symptoms may develop 3 With treatment intermittent asthma is completely reversible we ll talk about lung function tests later Persistent Asthma is characterized by 1 Abnormal lung function in the absence of ongoing asthma treatment whether or not they have symptoms 2 With treatment lung function may or may not normalize for people with persistent asthma 2
ASTHMA  WHAT   S UP.   DOC  Ok, everyone agrees, if it looks like a duck, walks like a duck, and sounds like a duck, it mu...
Asthma typically starts before the age of 35 If you are 50 years old and just developed your first ever breathing problems of your life you don t have asthma it s some other illness causing the problem Surprise asthma runs in families So do you want to know what are the chances of someone becoming asthmatic if one or both of their parents have asthma Let s quote population statistics 6 5 of families in which neither parent have asthma have a child with asthma 28 of families in which one parent has asthma have a child with asthma 63 of families in which both parents have asthma have at least one child with asthma In other words when surveys compare children in the population whose parents do not have asthma children with 1 parent who has asthma are 3 6 times more likely to develop the condition and children with 2 parents with asthma are 10 times more at risk than those without parents with asthma Wait a minute So just what is the actual risk for each of your children developing asthma Unfortunately no one can tell you the actual risk for your individual children We re talking population statistics here not individual prediction Some individuals inherit the potential to get asthma but then must be exposed to something else to express their full asthma potential What that something else may be for each individual and the risk for asthma remains unknown 3
Asthma typically starts before the age of   35. If you are 50 years old and just developed your first-ever breathing probl...
MORE BS basic science Asthma is commonly described as a chronic disease or a syndrome a group of diseases in which the small and medium sized tubes through which air and oxygen move in and out of your lungs show some degree of reversible blockage Asthma has 2 major components airway inflammation and airway constriction or bronchospasm Inflammation simply means that the lining of the lung tubes appear red and swollen Bronchospasm refers to tightening or constriction of the smooth muscle around the outside of the lung tubes 4
MORE BS  basic science  Asthma is commonly described as a chronic disease or a syndrome  a group of diseases  in which the...
Whether or not you have symptoms untreated asthmatic lungs have some ongoing inflammation and bronchospasm During asthma attacks these processes worsen symptoms appear and activity limitation occurs ultimately in the worst case scenario leading to as they say on television death Cells involved in asthma inflammation 5
Whether or not you have symptoms, untreated asthmatic lungs have some ongoing inflammation and bronchospasm. During asthma...
DIAGNOSIS How do you know if you have asthma This is not some great philosophical question Let s see if you can get the point by using some analogies Can a doctor tell you what your blood pressure is by listening to your heart or feeling your pulse How about a doctor knowing your temperature by feeling your forehead Obviously then a doctor can know your level of lung function by listening to your lungs or asking you how you re breathing ridiculous So how do you know if you actually have asthma You have to use the right tool to measure lung function a simple office test called spirometry This test should be available in every single doctor s office that treats people with asthma Spirometry should be undertaken in all patients with Asthma It remains THE STANDARD for diagnosing and monitoring Asthma All physicians who care for Asthma patients should have access to spirometry for routine care of their patients World Health Organization National Heart Lung and Blood Institute American Thoracic Society American Academy of Asthma Allergy Immunology American Academy of Family Physicians American Board of Internal Medicine American Academy of Pediatrics 6
DIAGNOSIS How do you know if you have asthma  This is not some great philosophical question. Let   s see if you can get th...
Spirometry assessment of pulmonary function is NECESSARY for the diagnosis of asthma because medical history and physical examinations are not reliable means of excluding other diagnoses or of characterizing the status of lung impairment NHBLI Expert Panel 2 Guidelines for the Diagnosis and Management of Asthma YOU CANNOT ACCURATELY DIAGNOSE ASTHMA WITHOUT DOING SPIROMETRY Spirometry can and should be done on every single person to clearly establish the diagnosis of asthma then repeated regularly to determine response to therapy and the course of the disease It is a very simple test that can usually be performed even on young children typically after the age where they are coordinated enough to blow up a balloon Peak flow meters see below are not accurate enough to be used to diagnose asthma Repeat After Me Doctors must do spirometry to diagnose me with asthma and regularly thereafter to determine my response to treatment In infants and younger children in whom it is not possible to do lung function tests we currently do not have any other widely available simple tests to help in diagnosis and treatment For these young children the diagnosis of asthma relies upon a history that shows repeated or persistent breathing problems that respond to specific medications without evidence of other underlying respiratory disease It is important to realize that children can have active asthma and have few symptoms Any repeated respiratory symptom cough shortness of breath etc which may occur with routine activity laughing crying colds or exercise may actually be signs of asthma Doctors must take an accurate clinical history to determine if you have asthma and whether there is evidence for other commonly associated diseases such as allergies eczema or nasal sinus polyps It is important to determine if you may have other 7
   Spirometry assessment of pulmonary function is NECESSARY for the diagnosis of asthma because medical history and physic...
conditions that could give you asthma like symptoms such as acid reflux GERD sinus disease chest wall inflammation costochondritis or other non asthma lung disease Records of any previous treatment may be of benefit in determining current and future therapy If you have any other active medical conditions such as heart disease high blood pressure skin disease or allergies it is important to inform your doctor All medications have potential side effects and your doctor needs to know all of your current medications including over the counter in order to limit adverse drug interactions and side effects from asthma therapy If you haven t had a chest x ray one should be done at sometime in your asthma evaluation to look at the anatomy underlying your lung function Other blood tests including a CBC thyroid liver vision glaucoma and bone density tests may be part of your assessment Your doctor may order Allergy testing if your clinical history and exam indicate potential allergy triggers for your airway disease Finally you ll need a complete physical examination The airways start with your nose and mouth Your doctor needs to determine if there are signs of inflammation in these areas let s not forget your eyes and skin too As anyone with asthma knows upper airway problems always lead to problems with asthma Although there is nothing specific on physical examination that can differentiate allergic from non allergic tissue inflammation the absence of findings is important Not all inflammation of the airways is allergic infections irritants drugs pregnancy hypothyroidism acid reflux and nasal polyps are some of the other non allergic conditions that may be associated with symptoms and physical findings similar to those caused by allergies ASTHMA TRIGGERS For each individual there are a variety of things that may cause acute asthma worsening The common cold seasonal or animal allergies are the most frequent asthma triggers among asthmatics Non allergic triggers such as cigarette smoke 8
conditions that could give you asthma-like symptoms such as acid reflux  GERD , sinus disease, chest wall inflammation  co...
poor air quality hairspray paints fumes and other irritants may cause some individuals asthma to worsen Normal activities such as exercise laughing crying or sleep should not cause acute asthma problems If your asthma worsens with these activities it indicates that your asthma is not properly controlled TREATMENT Asthma Medication or Device Asthma care shouldn t be all that difficult but then neither should doing your taxes Basically there are two primary classes of asthma medications anti inflammatory and anti bronchospasm and some other treatments we ll mention later Within each of the medication classes all the medicines have essentially the same benefit The great majority of asthma patients should have complete control using an anti inflammatory therapy once or twice daily and occasional use of an antibronchospasm agent Is that you your child why not Well here s the problem The best asthma treatments today are given via inhalers or for very young children via nebulizers In reality doctors don t actually prescribe asthma medications for their patients they prescribe devices inhalers or nebulizers that have medicine in them The real problem is that most doctors don t understand how to effectively deliver medications from inhaler or nebulizer devices into their patients lungs or how to properly instruct patients how to use the devices how embarrassing 9
poor air quality, hairspray, paints, fumes, and other irritants may cause some individuals asthma to worsen. Normal activi...
It sounds silly but consider this if you put gasoline into the back seat of a car does it work as well as if you put it in the gas tank Asthma medications in inhalers need to get into the lungs to work effectively There are distinct advantages and disadvantages for different asthma inhalation devices Inhaler devices should be matched to each individual to obtain the best results There are a variety of different inhalers and inhaler accessory devices on the market Below are just a few examples INHALER EXAMPLES EXAMPLES OF ADD ON DEVICES FOR INHALER USE Now let s get on to a discussion of some of the different asthma medications currently available 10
It sounds silly but consider this  if you put gasoline into the back seat of a car does it work as well as if you put it i...
MEDICATIONS The most effective asthma medications for control of persistent asthma are those that act long term to reduce the underlying airway reactivity Reduction in the airway reactivity leads to improvements in lung function fewer symptoms and the ability to perform normal daily activities Discuss all prescribed medications with your doctor the risks of therapy should not outweigh the potential benefits 1 Short Acting Beta 2 Agonists SABAs Rescue Inhalers or Nebulizers These are the medications with which most asthma patients are most familiar They are the inhaler or pump that people pick up for immediate symptom relief These medications are available in liquid pill inhaler and nebulizer forms If you use a short acting beta 2 agonist more than twice weekly it indicates that your asthma is not under control Proper dosing and use of inhaled corticosteroid ICS or combination inhaled corticosteroid long acting beta 2 agonist therapy ICS LABA should virtually eliminate the need for the use of rescue short acting beta 2 agonist medication in all virtually all asthmatics Some brand names include Albuterol HFA Proventil HFA ProAir HFA Xopenex HFA and Maxair 2 Inhaled Corticosteroids ICS Considered to be the most effective preventive anti inflammatory long term therapy for all levels of persistent asthma There are no real differences in benefit among the different medications but actual results seem to vary due to the use of different inhalation devices for the different medications The majority of asthma patients can be well controlled with once or twice daily use of the appropriately inhaled medication These medications are generally well tolerated and safe Simple mouth rinsing after use can prevent white fungus patches in the mouth Some brand names include Flovent HFA Flovent Diskus Pulmicort Asmanex QVAR Alvesco AerobidHFA 3 Inhaled Long Acting Beta 2 Agonists LABAs These agents exert an anti bronchospasm effect for anywhere from 8 24 hours There is some concern regarding use of these agents with and without the use of an inhaled corticosteroid Some patients using these agents alone 11
MEDICATIONS The most effective asthma medications for control of persistent asthma are those that act long-term to reduce ...
as regular preventive therapy may be at increased risk of side effects including death As this issue still remains the FDA does not approve the use LABAs for asthma as single therapy but does approve the use in combination with inhaled steroids Some brand names include Serevent Foradil Arcapta Vilanterol Striverdi 4 Inhaled Combination Corticosteroid Long Acting Beta 2Agonists ICS LABA The addition of long acting anti bronchospasm agents beta 2 agonists is beneficial in those patients who in spite of adequate inhaled corticosteroid use continue to have activity interference symptoms and a need for rescue asthma inhalers Many patients are needlessly prescribed combination therapy due to failure to adequately deliver inhaled steroids most often due to poor inhaler technique Some brand names include Advair Symbicort Breo Dulera 5 Other Stuff a Anticholinergics Inhaled medications primarily used to treat COPD although may be beneficial for many asthmatics Short acting anticholinergics are not FDA approved for asthma but are clearly useful instead of short acting beta 2agonists for people who cannot take usual SABA rescue medication Some brand names for short acting agents include Atrovent Atrovent HFA Robinul Combivent a combination of Atrovent with Albuterol Spiriva a long acting anticholinergic agent LAMA is FDA approved for use in patients uncontrolled on ICS LABA therapy Some brand names of other LAMAs include Spiriva Turdoza Seebri Incruse b Inhaled Cromolyn Basically extremely poor medications compared to inhaled steroids for long term preventive control These agents work best when used immediately prior to allergen animal exposure to prevent allergen animal induced asthma attacks They may also have a limited role as additional agents to beta 2 agonists for prevention of exercise induced asthma Available only for nebulizer use in the US the only brand name is Intal c Methylxanthines Basically after 50 years of use a class of medications still looking for a reason to be prescribed Once a mainstay of therapy the use of these medications has fallen into disfavor due to a high level of side effects and inadequate benefit Due to widespread misuse these medications should only be prescribed by a specialist familiar with the risks Some brand names include Theophylline Slobid Theodur Theo24 and Uniphyl 12
as regular preventive therapy may be at increased risk of side effects, including death. As this issue still remains, the ...
d Leukotriene Modifiers These medications act as poor anti bronchospasm agents but are marketed to doctors as anti inflammatory like treatments They do not offer the benefits of inhaled corticosteroid therapy and add nothing to asthma control for those patients properly dosed with inhaled corticosteroids Studies demonstrate that people using these agents have poorer asthma control compared to those using inhaled corticosteroids Two brand names currently marketed include Singulair and Zileuton Note many asthma specialists consider Zileuton to be a potentially dangerous drug due to risk of liver toxicity Singulair is also marketed for the treatment of allergies in reality it provides little benefit for the treatment of allergies e Immunomodulators i Omalizumab Xolair Indicated for allergic asthma 6 and older ii Mepolizumab Nucala Indicated for severe asthma 12 and older with eosinophilic phenotype iii Reslizumab Cinqair Indicated for severe asthma 12 and older with eosinophilic phenotype By altering underlying cellular signals immunomodulators may shut down the series of events associated with asthma inflammation If you re thinking these forms of therapy are be expensive you re right and likely why big pharma is so excited in their prospects Immunomodulators are considered add on therapy added to patients uncontrolled with ICS LABA treatment Let s put it this way if you are a candidate for one of these treatments you should have really really bad asthma e Allergy Vaccine Therapy Allergy Shots Allergy shots actually the oldest immunomodulators are not considered a primary therapy for asthma In properly selected allergic patients allergy vaccine therapy may reduce airway inflammation No additional benefit improvement in lung function and reduction in concomitant therapies has been clearly demonstrated in patients on inhaled corticosteroid therapy with moderate or severe persistent asthma f Systemic Corticosteroids The use of systemic steroid therapy has dramatically fallen since the introduction of inhaled corticosteroids Risks of systemic steroids high blood pressure cataracts avascular necrosis skin thinning fractures muscle wasting etc tend to generally outweigh their benefit for longterm preventive use Systemic steroids are generally reserved for shortterm burst therapy for treatment of severe asthma attacks in and out of the hospital The long term side effects are not commonly associated 13
d. Leukotriene Modifiers These medications act as poor anti-bronchospasm agents but are marketed to doctors as anti-inflam...
with short term use Some drug names include Medrol Prednisone and Prelone Prednisolone MYTHS and some truths 1 I can feel when my asthma is worsening Ugh The longer you have asthma the less you are actually able to sense what s going on with your asthma Your body learns to adjust to not breathing properly and you loose the ability to actually sense your asthma worsening that s why checking lung function home peak flows and office spirometry is so important to controlling asthma How many problems do you need to have with your asthma before you learn the message 2 My doctor says that I don t need to have regular breathing tests Your doctor likely doesn t understand how to manage asthma You need to insist that you get the care you deserve for asthma that means regular breathing tests spirometry as a measure to assess your asthma control 3 Allergy shots can cure asthma The truth There are no current cures for asthma Allergy shots may be indicated in a few select patients to control or reduce hayfever or animal allergies that may trigger asthma but allergy shots are not a primary treatment for asthma Furthermore there is little evidence to support the rumor that allergy shots can prevent asthma from developing in people with hayfever 14
with short-term use. Some drug names include  Medrol, Prednisone, and Prelone Prednisolone.  MYTHS   and some truths  1. I...
4 Inhaled corticosteroid medications will stunt my child s growth Listen closely Poorly controlled asthma can delay growth in young children before puberty What about the effects of inhaled corticosteroid on height prior to puberty The best studies done to date indicate that a population of children treated with inhaled steroids may be at risk for on average about 1 cm less than an inch difference in height early in asthma treatment Ok now let s see uncontrolled asthma can affect a child s height and interfere with them playing sports sleep attending school and doing things kids normally do OR use inhaled corticosteroid asthma therapy your child does the normal things kids do without problems or causing you to miss work and sleep and potentially have an inch difference in height prior to puberty Clearly the message should be to use inhaled corticosteroids under proper supervision from your doctor 5 If I get pregnant I can t still use my regular asthma medications First the short easy answer then read on In pregnancy the preferred inhaled corticosteroid is budesonide Pulmicort and the preferred short acting beta 2agonist is albuterol but keep reading If you have asthma and it is not properly controlled during your pregnancy you may increase the risks of preeclampsia pre term birth low birth weight in your infant and the potential for perinatal mortality According to the NAEPP 2005 expert report on managing asthma during pregnancy It is safer for pregnant women who have asthma to be treated with asthma medications than to have asthma symptoms and exacerbations With regard to other inhaled corticosteroid medication use the report states that although budesonide brand named Pulmicort and Rhinocort Aqua is the preferred inhaled corticosteroid it is important to note that no data indicate that the other preparations are unsafe during pregnancy Discuss monthly monitoring of your asthma with your doctor to prevent asthma worsening and to monitor for medication side effects If you have allergies ask your doctor to prescribe allergy medications that are generally recommended as safe GRAS during your pregnancy 15
4. Inhaled corticosteroid medications will stunt my child   s growth. Listen closely...Poorly controlled asthma can delay ...
6 If untreated asthma will become increasingly severe over time First regardless of asthma severity anyone with asthma may be at risk of having a life threatening attack if asthma is not properly treated Second there is little evidence showing that asthma treated or untreated actually progresses from mild to more severe overtime What Third the terms mild moderate and severe asthma really have little meaning in routine asthma care These terms are mainly derived from clinical asthma drug studies where it is useful to divide asthmatics into different groups in order to study the effects of different drug treatments Wait this is getting way too complicated Basically the terms mild moderate and severe asthma more accurately reflect current asthma treatment and the quality or lack of quality of medical care rather than some intrinsic characteristic of the disease ASTHMA MANAGEMENT THE PRIMARY GOALS OF ASTHMA TREATMENT ARE 1 ALLOW EVERYDAY ACTIVITIES WITHOUT INTERFERENCE FROM BREATHING PROBLEMS 2 NORMALIZE LUNG FUNCTION AND PREVENT FUTURE WORSENING 3 MINIMIZE MEDICATION SIDE EFFECTS It s easy to treat asthma the problem is treating people who have asthma People tend to get in their own way Effective control of asthma does not just happen you must actively participate in your care If your doctor prescribes a specific inhaler and a specific device to use with the inhaler follow the directions Do not accept any medication substitutions or 16
6. If untreated, asthma will become increasingly severe over time First, regardless of asthma severity, anyone with asthma...
different devices from your insurance or pharmacy unless your doctor has previously agreed to the change At each visit you should tell your doctor 1 Whether you are experiencing any limitations or interference with your activities due to breathing problems 2 How often you are using rescue medication and 3 Whether you are experiencing any possible medication side effects Peak Flow Meters PEAK FLOW METERS WHAT AND WHY A peak flow meter can be a very useful tool for most asthma patients to achieve and maintain asthma control Peak flow meters allow you to measure how fast you can expel air from your lungs When asthma worsens the peak flow reading may decline hours or days before symptoms develop Peak flow meters cannot and should not be used to diagnose asthma only spirometry should be used to diagnose asthma Symptoms do NOT accurately indicate how well asthma is controlled nor when an asthma attack occurs how severe the attack might be In fact some asthma patients start to feel better during a severe asthma attack even though their lung function is getting worse Having a peak flow meter knowing when to use it and what the readings mean about your asthma are critical to your long term asthma control Furthermore your doctor should provide you with a written Asthma Action Plan The Plan is a written set of instructions on how to change asthma medications to prevent and reverse attacks based upon changes in the peak flow readings 17
different devices from your insurance or pharmacy unless your doctor has previously agreed to the change. At each visit yo...
Is there a downside to checking peak flows As a monitoring tool peak flows can actually be misleading in 25 of asthmatics Spirometry can determine the accuracy and reliability of peak flow measurements for each asthmatic and whether a peak flow meter can be beneficial in asthma home monitoring ROUTINE OFFICE CHECK UPS Regular re assessment of your lung function using Spirometry in the doctor s office is essential to determine whether your medications are working properly to monitor for possible medication side effects and for the doctor to explain how to safely make changes in your treatment It is also an opportunity to have your peak flow meter checked to determine if it is working properly Over time peak flow meters lose their accuracy resulting in false and misleading readings 18
Is there a downside to checking peak flows  As a monitoring tool, peak flows can actually be misleading in   25  of asthma...
YOU KNOW THAT YOUR ASTHMA IS WELL CONTROLLED WHEN 1 YOUR PEAK FLOWS ARE AT OR ABOVE YOUR BEST BASELINE 2 YOU RARELY USE ANY RESCUE MEDICATION LESS THAN TWICE WEEKLY 3 YOU CAN RUN BIKE LAUGH CRY PLAY SLEEP KICK THE DOG JUST KIDDING AND JUST DO ALL THE NORMAL STUFF THAT PEOPLE DO AT YOUR AGE WITHOUT ANY BREATHING PROBLEMS 4 THE HORSE IS OFF THE COUCH 19
YOU KNOW THAT YOUR ASTHMA IS WELL CONTROLLED WHEN  1.  YOUR PEAK FLOWS ARE AT OR ABOVE YOUR BEST BASELINE  2.  YOU RARELY ...
R E ME MB E R NEVER EVER 1 Allow your asthma to get out of control for even 1 hour 2 Exercise if your peak flows are not normal or your asthma is out of control 3 Go to bed having problems with your asthma it will always get worse over the period of sleep 4 Skip doses of your daily preventive medicine because you feel good it s always harder to remember to take medicine when you feel good 5 Forget to post your asthma action plan where you can always see it take a pic on your cellphone 6 Forget to carry your rescue medication with you at all times 20
R E ME MB E R NEVER   EVER   1.  Allow your asthma to get out of control for even 1 hour  2.  Exercise if your peak flows ...