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Educational Objectives Faculty Disclosure


									Volume 59, Issue 13                                                                                                    April 7, 2011

             From the Interstate Postgraduate Medical Association of North America’s 2010 Primary Care Update
Mark S. Regan, MD, Associate Professor of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
Asthma control: after initiating therapy, follow patients ev-        Management of patient on controller medication: reassess
  ery 2 to 6 wk; once stable, follow every 3 mo (consider             at each appointment; determine whether asthma well con-
  stepping down therapy); domains — 1) reducing impair-               trolled, not well controlled, or poorly controlled (assessed
  ment; prevent daily symptoms; reduce use of short-acting            via domains or validated questionnaires); patient can have
  -agonist; maintain lung function, normal activity levels,          well-controlled asthma and 0 to 1 exacerbations per year (if
  and patient satisfaction with care; 2) reducing risk for loss       >1/yr, classify as persistent asthma on initial evaluation, or
  of lung function and recurrence of exacerbations; minimize          asthma not well controlled or poorly controlled on follow-
  incidence of adverse effects; day-to-day function of patient        up); annual or biannual assessment for progressive loss of
  does not correlate well with risk for exacerbation                  lung function and treatment-related adverse effects recom-
Principles of management: anti-inflammatory controller                mended; frequent reassessment important for patients with
  medication best for inflammatory asthma; patient-clinician          asthma not well controlled or poorly controlled
  partnership essential; avoidance of allergens important in         Management of moderate persistent asthma: educate pa-
  atopic asthma; all patients must avoid irritants; control co-       tient about self-management of asthma; use action plan;
  morbid conditions (eg, obesity, obstructive sleep apnea,            add medium-dose IC for daily use, or low-dose IC with
  gastroesophageal reflux disease [GERD]); written action             LABA or leukotriene receptor antagonist; follow up in 4
  plan can be based on symptoms or peak flow; consider re-            wk; if nocturnal symptoms resolve, use of rescue inhaler
  ferral to asthma specialist                                         therapy decreases, and spirometry normal, continue current
2007 National Asthma Education and Prevention Pro-                    therapy and reassess in 3 mo
  gram guidelines: updates — separate recommendations in                  Chronic Obstructive Pulmonary Disease (COPD)
  place for patients 12 yr of age; recommendations about
                                                                     Initial clinical assessment: based on forced expiratory vol-
  initiating therapy separate from recommendations about
                                                                       ume in 1 sec (FEV1; does not correlate particularly well
  adjusting therapy; impairment based on quality of life
                                                                       with health-related QOL and functional capacity); tobacco
  (QOL) and functional capacity; response to medication                smokers with chronic productive cough require further
  may differ between domains of asthma control; in patients            evaluation; determine whether mild, moderate, severe, or
  not controlled with low-dose inhaled corticosteroid (IC),            very severe based on FEV1; severe asthma with CO2 reten-
  consider increasing dose or adding adjunctive treatment              tion classified as very severe
  (eg, long-acting -agonist [LABA]); omalizumab (anti-IgE           Patient education: stages I and II — educate about nature of
  antibody) available; management of special situations in-            COPD (eg, loss of lung function over time), use of inhalers,
  cludes response to therapy based on ethnicity                        recognizing acute exacerbations, and strategies for mini-
Initial assessment of patient not on controller therapy: deter-        mizing dyspnea; cessation of tobacco smoking shown to af-
  mine whether asthma intermittent (symptoms include night-            fect loss of lung function; stages III and IV — inform about
  time awakenings, use of -agonist, interference with normal          potential complications (eg, chronic respiratory failure, os-
  activity) or persistent (mild, moderate, or severe); patient who     teoporosis); discuss O2 therapy (check baseline arterial
  has nighttime awakenings 3 to 4 times per month but all other        blood gases [ABG] and assess for hypoxemia and CO2 re-
  symptoms within intermittent level of severity classified as         tention); for patients >65 yr of age, begin discussing ad-
  having mild persistent asthma; short-acting -agonist (as            vance directives and end-of-life decisions
  needed) preferred therapy for intermittent asthma; patients        Management of stable disease: use of continuous bronchodila-
  with persistent asthma require daily controller medication; IC       tion for airflow obstruction reasonable; LABAs or anticholin-
  basis of therapy; systemic corticosteroid not added until severe     ergics preferred over shorter-acting agents due to more
  persistent asthma or poor control on follow-up; use short burst      favorable side effect profile, more consistent bronchodilation
  of oral corticosteroid and consider omalizumab in atopic             over 24 hr, improved health status, and fewer exacerbations
  asthma; exacerbations — if 2/yr, classify as persistent asthma    Medications: LABAs — meta-analysis found patients treated
  (therapy based on symptoms and lung function)                        with salmeterol less likely to suffer moderate to severe exacer-

                   Educational Objectives                                                Faculty Disclosure
  The goal of this program is to improve management of airway        In adherence to ACCME Standards for Commercial Support,
  disorders and chronic cough. After hearing and assimilating        Audio-Digest requires all faculty and members of the planning
  this program, the clinician will be better able to:                committee to disclose relevant financial relationships within
      1. Initiate therapy for asthma based on severity.              the past 12 months that might create any personal conflicts of
      2. Monitor and adjust asthma therapy based on control of       interest. Any identified conflicts were resolved to ensure that
          symptoms and/or peak flow variation.                       this educational activity promotes quality in health care and
      3. Select appropriate agents for the treatment of chronic      not a proprietary business or commercial interest. For this pro-
          obstructive pulmonary disease.                             gram, Dr. Regan and the planning committee reported nothing
                                                                     to disclose.
      4. Use directed testing and empiric therapy to identify
          causes of chronic cough.
      5. Optimize therapy before ruling out possible contribu-
          tors to chronic cough.
                                         AUDIO-DIGEST FAMILY PRACTICE 59:13

 bations, compared to patients treated with placebo (absolute            chronic productive cough usually associated with tobacco
 difference, 5%); ICs — not well established for use in stage I          smoking; determine whether patient meets criteria for
 or stage II COPD; not shown to alter decline in FEV1 or natu-           chronic bronchitis (eg, productive cough lasting 3 mo for 2
 ral history of disease; effective in reducing rate of exacerba-         consecutive years); assess for COPD; cough usually re-
 tions in patients with more severe disease; appear to be                solves in 4 wk after smoking cessation; in travelers, con-
 associated with fewer hospitalizations and lower mortality;             sider parenchymal disease due to tuberculosis (TB) or
 larger trials suggest risk for pneumonia, but that patients with        endobronchial TB (rare); systemic symptoms uncommon
 very severe disease and frequent (2/yr) exacerbations may be         Initial management: chest x-ray; patient history and physical
 candidates for use; tiotropium — causes prolonged blockade              examination typically unremarkable; 40% of patients have
 of M3 muscarinic receptors; half-life 3 days; clinical trials          multiple causes; combination of directed testing and empiric
 consistently show improvements in clinically relevant patient-          approach to treatment most efficient and cost-effective; if pa-
 centered outcomes, relative to placebo; “fares well” against            tient has no symptoms other than cough, begin empiric ther-
 salmeterol, but differences in clinically relevant outcomes un-         apy for upper airway cough syndrome (UACS; eg, chronic
 clear; theophylline — may be helpful to patients who do not             nasopharyngitis, chronic sinusitis, chronic postnasal drip); if
 respond to LABAs and ICs (ie, patients with severe disease);            no response to treatment of UACS in 2 to 4 wk, evaluate for
 target level low (<10 mg/dL); interacts with corticosteroids at         cough variant asthma with baseline spirometry (usually nor-
 gene transcription level; in subset of patients, small changes          mal), bronchodilator reversibility (if evidence of obstruction),
 seen in dyspnea rating, exercise capacity, lung mechanics, and          and/or bronchial provocation challenge testing; if options not
 respiratory muscle strength; concern for potential drug interac-        readily available, empiric treatment with bronchodilator and
 tions with, eg, macrolide antibiotics                                   IC reasonable; consider nonasthmatic eosinophilic bronchitis
Current guidelines: mild symptomatic COPD — acceptable                   (NAEB; eosinophil infiltration; not manifested by symptoms
 to use short-acting -agonist as needed; moderate or severe             other than cough; bronchial challenge testing negative); diag-
 COPD — add long-acting bronchodilator (based on symp-                   nose specifically rather than by empiric treatment (look for
 toms); use IC in patients with severe or very severe disease            sputum eosinophils); GERD requires longest duration (8 wk)
 who have 2 exacerbations per year; consider long-term O2               of empiric therapy before identification as cause of cough
 therapy in all patients with severe or very severe disease            Initial treatments: UACS — diagnostic trial of first-genera-
 (based on ABG); consider lung volume reduction surgery                  tion antihistamine with or without decongestant (older pa-
 or lung transplantation in patients with very severe disease            tients may have difficulty tolerating due to somnolence);
Acute exacerbations: symptoms — increased shortness of                   consider using intranasal steroid preceded by saline rinse
 breath; increased sputum volume and purulence; acute con-               and first-generation antihistamine; cough variant asthma —
 fusion; diagnosis — chest x-ray in patients who present to              IC or bronchodilator (short- or long-acting); leukotriene re-
 emergency department or hospital (20% have abnormali-                  ceptor antagonist (eg, montelukast [Singulair] or zafirlukast
 ties that alter management); spirometry not recommended;                [Accolate]) can be added if response slow or partial; when
 ABG assessment; sputum samples have limited value; em-                  response partial, consider giving short burst of systemic
 piric therapy effective; purulent sputum suggests need for              steroid; NAEB — ICs; consider giving short burst of sys-
 antibiotic therapy (obtain samples from patients requiring              temic steroids when specific diagnostic tests unavailable;
 hospitalization); check brain natriuretic peptide (patients             GERD — moderate dosing of proton pump inhibitor (PPI;
 often have cardiac comorbidities)                                       eg, 40 mg of omeprazole once daily) combined with diet
Outpatient steroid use: data about use of systemic steroids lim-         and lifestyle changes (eg, elevation of head of bed by 30º);
 ited, but more rapid improvement in lung function and hypox-            nonacidic reflux can perpetuate cough
 emia and decrease in relapse and treatment failure suggested;         Further work-up: current guidelines suggest empiric approach
 patients with dyspnea (particularly those with severe or very se-       based on sensitivity and specificity of 24-hr esophageal pH
 vere disease) candidates for prednisone (burst and taper); 30 to        monitoring; consider swallow evaluation (particularly in older
 40 mg/day for 7 to 10 days adequate; consider risks of frequent         population); assess for esophageal dysmotility with barium
 short courses (eg, osteoporosis); role of ICs not well defined in       esophagraphy or esophageal manometry; multichannel intralu-
 acute exacerbations; use same dosing and duration of therapy            minal impedance testing helps tease out nonacidic GERD; in
 for hospitalized patients (14 days); all hospitalized patients         patients with partial response to treatment of UACS, consider
 need prednisone (burst and taper)                                       imaging of sinuses (unclear whether computed tomography
Antibiotics: 80% of exacerbations due to infections (50% due           [CT)] better than plain imaging); additional investigations—
 to bacterial infection); important in patients with severe exacer-      high-resolution CT to look for interstitial lung disease or airway
 bations who have more severe underlying disease; treatment              disease not apparent on plain chest imaging; bronchoscopy to
 based on development of purulent sputum; color of sputum sen-           evaluate for endobronchial lesion that may not be apparent on
 sitive indicator of bacterial infection, but relatively nonspecific     chest imaging or high-resolution CT; echocardiography (rarely,
                                                                         pericardial disease can cause cough); complete otolaryngologic
                         Chronic Cough
                                                                         examination to rule out otic disease; assess environmental expo-
Classification: acute — duration <3 wk; subacute — 3 to 8                sure to allergens
  wk; chronic — >8 wk; often multiple causes; characteristics          General considerations: optimize therapy for each diagnosis
  (eg, productive, nonproductive) and medical history often              before ruling out as contributing etiology; check compliance
  not helpful in identifying etiology                                    with therapy; due to possibility of multiple etiologies, main-
Patient history: 15% of patients with history of angioten-              tain all partially effective therapies
  sin-converting enzyme (ACE) inhibitor use have problems              Management: UACS — intranasal antihistamines or anticholin-
  with chronic nonproductive cough; onset of cough usually               ergics; expect improvement in cough within short time
  early but can be delayed; ACE inhibitor should be stopped              (marked improvement or resolution may take longer); cough
  or patient should be switched to other agent (eg, angioten-            variant asthma — spirometry typically normal with no acute
  sin-receptor blocker); median duration of cough, 26 days;              bronchodilator response; negative predictive value of bron-
                                                 AUDIO-DIGEST FAMILY PRACTICE 59:13

  chial provocation challenge testing 100% (positive predic-                       of long-term therapy (dose- and duration-dependent) include
  tive value 60%-85%); patient can have persistent bronchial                        increased risk for community-acquired pneumonia, calcium
  hyperreactivity with subacute cough and post-viral upper re-                      malabsorption and risk for hip fracture, vitamin B12 malab-
  spiratory infection or lower respiratory infection; if test posi-                 sorption, community-acquired Clostridium difficile infection,
  tive, begin trial of IC and long-acting bronchodilator; consider                  and atrophic gastritis
  adding leukotriene receptor antagonist if response slow or in-                   Unexplained cough: after high-resolution CT and no response
  complete; short course of prednisone to rule out diagnosis of                     to treatment, consider bronchoscopy; possible causes include
  cough variant asthma or NEAB reasonable (rarely required);                        nonacid reflux disease, swallowing disorder (particularly in
  NAEB — can be ruled out by absence of sputum eosinophils;                         older patients), congestive heart failure, otic disease, or
  response to IC expected within 4 wk; natural history vari-                       “habit” or psychogenic cough (rare); etiology identified in
  able; 33% of patients asymptomatic at 1 yr; 10% to 15% de-                        92% of patients
  velop other symptoms that characterize asthma within 1 yr;                       Questions and answers: normal pre- and postbronchodilator
  other subset remains stable with only cough; GERD — if no                         spirometry — does not rule out asthma; additional testing (ie,
  improvement after 2 mo of empirical treatment with moderate                       bronchial challenge testing) to evaluate for asthma, or empiric
  doses of PPI and lifestyle modifications, consider 24-hr                          therapeutic trial required; man 40 yr of age with cough for 1
  esophageal pH monitoring; with partial response, consider                         yr and globus sensation with intermittent hoarse voice —
  adding prokinetic agent (risk for side effects high, particularly                 associated symptoms suggest UACS or GERD; treat patient
  in older population); if no response to addition of prokinetic                    empirically for UACS, then work up as needed
  agent, proceed to esophageal pH monitoring; adverse effects

Dr. Regan spoke in Tampa, FL, at 2010 Primary Care Update: Improving Patient Care, presented October 24-26, 2010, by Interstate Post-
graduate Medical Association. For information about next year’s meeting, visit The Audio-Digest Founda-
tion thanks Dr. Regan and the Interstate Postgraduate Medical Association for their cooperation in the production of this program.

                        Suggested Reading                                          intranasal antihistamines in the treatment of allergic rhinitis. Ann
                                                                                   Allergy Asthma Immunol. 2011 Feb;106(2 Suppl):S6-S11; Na-
Birring SS: Controversies in the evaluation and management of
                                                                                   tional Asthma Education and Prevention Program: Expert
chronic cough. Am J Respir Crit Care Med. 2010 Dec 10. [Epub
                                                                                   Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Man-
ahead of print]; Bousquet J et al: Persistency of response to                      agement of Asthma–Summary Report 2007. J Allergy Clin Im-
omalizumab therapy in severe allergic (IgE-mediated) asthma.                       munol. 2007 Nov;120(5 Suppl):S94-138; Pratter MR et al: An
Allergy. 2011 Jan 21. [Epub ahead of print]; Brightling CE:                        empiric integrative approach to the management of cough:
Chronic cough due to nonasthmatic eosinophilic bronchitis:                         ACCP evidence-based clinical practice guidelines. Chest. 2006
ACCP evidence-based clinical practice guidelines. Chest. 2006                      Jan;129(1 Suppl):222S-231S; Pratter MR: Unexplained (idio-
Jan;129(1 Suppl):116S-121S; Brown KK: Chronic cough due to                         pathic) cough: ACCP evidence-based clinical practice guide-
chronic interstitial pulmonary diseases: ACCP evidence-based                       lines. Chest. 2006 Jan;129(1 Suppl):220S-221S; Pratter MR:
clinical practice guidelines. Chest. 2006 Jan;129(1 Suppl):180S-                   Overview of common causes of chronic cough: ACCP evidence-
185S; D'Urzo A, Jugovic P: Chronic cough. Three most com-                          based clinical practice guidelines. Chest. 2006 Jan;129(1
mon causes. Can Fam Physician. 2002 Aug;48:1311-6; Dono-                           Suppl):59S-62S; Sethi S, Cote C: Bronchodilator Combination
hue JF, Jones PW: Changing patterns in long-acting                                 Therapy for COPD. Curr Clin Pharmacol. 2011 Jan 11. [Epub
bronchodilator trials in chronic obstructive pulmonary disease.                    ahead of print]; Wechsler ME: Managing asthma in primary
Int J Chron Obstruct Pulmon Dis. 2011 Jan 7;6:35-45; Irwin                         care: putting new guideline recommendations into context. Mayo
RS: Chronic cough due to gastroesophageal reflux disease:                          Clin Proc. 2009 Aug;84(8):707-17.
ACCP evidence-based clinical practice guidelines. Chest. 2006
Jan;129(1 Suppl):80S-94S; Kaliner MA et al: The efficacy of

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                                        AUDIO-DIGEST FAMILY PRACTICE 59:13

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   1. Which of the following is the preferred therapy for intermittent asthma?
       (A) Systemic corticosteroid                              (C) Omalizumab
       (B) Short-acting -agonist as needed                     (D) Long-acting bronchodilator
   2. Which of the following is(are) recommended for the management of moderate persistent asthma?
       (A) Educating patient about self-management
       (B) Medium-dose inhaled corticosteroid (IC) for daily use
       (C) Low-dose IC with long-acting -agonist (LABA)
       (D) All the above
   3. In early stages of chronic obstructive pulmonary disease (COPD), which of the following has been shown to affect loss
      of lung function?
         (A) Weight loss
         (B) Increased physical activity
         (C) Smoking cessation
         (D) Controlling gastroesophageal reflux disease (GERD)
   4. ICs are effective in:
        (A) Altering decline in forced expiratory volume in 1 sec
        (B) Reducing rate of exacerbations in patients with more severe COPD
        (C) Reducing risk for pneumonia
        (D) Stages I and II COPD only
   5. Choose the correct statement about tiotropium.
        (A) Causes prolonged blockade of M3 muscarinic receptors
        (B) Has half-life of 7 days
        (C) Side effect profile significantly better than salmeterol
        (D) Contraindicated in patients on macrolide antibiotics
   6. Theophylline may be most helpful in which of the following groups of COPD patients?
        (A) Patients who do not respond to LABAs and ICs (C) Patients on macrolide antibiotics
        (B) Patients with mild COPD                          (D) Older patients
   7. What is the initial treatment of upper airway cough syndrome when it is the suspected etiology of chronic cough?
       (A) IC
       (B) Bronchodilator
       (C) Leukotriene receptor antagonist
       (D) First-generation antihistamine with or without decongestant
For Questions 8 to 10, match the etiology of chronic cough in Column I with its description in Column II.
                         Column I                                                       Column II
    8. Cough variant asthma                                    (A) Requires 8 wk of empiric therapy to be identified as
                                                                   cause of chronic cough; patients should be advised
                                                                   about lifestyle modifications
    9. Nonasthmatic eosinophilic bronchitis                    (B) Not manifested by symptoms other than cough;
                                                                   bronchial challenge testing negative; response to IC
                                                                   expected within 4 wk
  10. GERD
                                                               (C) Evaluated by baseline spirometry or bronchial
                                                                   challenge testing; initially treated with IC or
                                                               (D) Most often diagnosed by bronchoscopy; cause of
                                                                   chronic cough in 50% of patients

Answers to Audio-Digest Family Practice Volume 59, Issue 11: 1-D, 2-D, 3-B, 4-A, 5-B, 6-C, 7-B, 8-B, 9-A, 10-C

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