Docstoc

Asthma

Document Sample
Asthma Powered By Docstoc
					Core Clinical Topics – MDFMR – 2009
                 Cheryl Seymour, MD
Why are we here?
 Most common chronic pediatric disease
 5 million US children
 Despite better treatment, morbidity is not
  decreasing
 Our care locally is not meeting national
  standards
Why asthma is hard for me
 Guidelines just got a lot more complicated
 Assessment is based on history primarily
 No lab tests to follow
 Treatments are not pills, but inhalers
 Education is key
 Parent and child to communicate with
Chart audits
What did you find?

 13 questions – 9 are about history-taking


 “Assessment of current control”??
Today
 Lecture – Guideline Review, EMR tips
 Small Groups
      Asthma Education at the FMI
      CAM Approaches
      Talking to Patients about Asthma
 Large Group – Cases
 Jeopardy
PACE as inspiration
 Physician Asthma Care Education
 University of Michigan
 Two 2.5 hour sessions
 Patients of physician participants had fewer
   days with symptoms, fewer ER visits, fewer
   hospitalizations compared to controls.
Cabana et al. PEDIATRICS Vol. 117 No. 6 June 2006, pp. 2149-2157
Benchmarks of good control
 No coughing or wheezing
 No shortness of breath or rapid breathing
 No waking up at night
 Normal physical activities
 No school absences due to asthma
 No missed time from work for parent or
 caregiver
Case
19 yo female presents with chronic cough.
Given albuterol and Prednisone in the ER
  yesterday– gives relief – is currently using
  MDI for symptoms about 2 times per day.
  Also uses before exercise, daily.
She wakes up at night coughing about once a
  week. Works as waitress without symptoms
Asthma Guidelines – EMR3
 First visit assess – SEVERITY
    Current impairment
    Risk of future exacerbations

    Pick a categorized diagnosis

 Subsequent visits assess – CONTROL
      Current impairment
      Risk of future exacerbations
Severity - Impairment
Assess:
 Frequency of symptoms
 Nightime awakenings
 Frequency of albuterol use for sxs
 Interference with normal activity
 Lung function (spirometry)
Severity - Risk
 Determined by the frequency of
 exacerbations requiring oral corticosteroids
 in the past 6 months or year
Severity – Your Choices
 Intermittent
 Persistent – Mild
 Persistent – Moderate
 Persistent – Severe


Use the tables! – EPR3 Pocket Guide
Case – Visit 1
19 yo female presents with chronic cough.
Given albuterol and Prednisone in the ER 5
  days ago– gave relief. Is currently using MDI
  for symptoms about 2 times per day. Also
  uses before exercise, daily.
She wakes up at night coughing about twice a
  week. Works as waitress without symptoms
Case – Visit 1
 What is your assessment of her severity?



 What would you use for treatment?
Initial treatment
 Stepwise approach
 Emphasis on aggressive treatment at the
  outset with plan to step down
 Inhaled short-acting beta agonist
     “quick reliever” for everyone
 Education at EVERY visit
Case – Visit 1
 What is your assessment of her severity?



 What would you use for treatment?
Management – Besides meds
 Spacers for everyone!
 When should she follow-up?
 Patient education
    Your role
    Team-based approach to management
    Diaries, asthma action plans
    Written education materials
Asthma Guidelines – EMR3
 First visit assess – SEVERITY
    Current impairment
    Risk of future exacerbations

    Pick a categorized diagnosis

 Subsequent visits assess – CONTROL
      Current impairment
      Risk of future exacerbations
Control - Impairment
Assess:
 Frequency of symptoms
 Nightime awakenings
 Frequency of albuterol use for sxs
 Interference with normal activity
Control - Impairment

 Use of daily diaries, standardized control
  questionnaires
 Assessment of symptoms has equal benefit
  to daily peak flows
 Peak flows may be more useful if moderate
  or severe disease
Control – Future Risk
 Frequency of exacerbations requiring oral
  corticosteroids
 Objective change in lung function over time
 Treatment related adverse events
 Anticipated changes in environment or
  other triggers
Control – Your choices
 Controlled
 Not well controlled
 Very poorly controlled


Use the tables! – EPR3 Pocket Guide
Case – Visit 2
19 yo female presents in follow-up.
She is using her albuterol before exercise and
  once or twice a week for symptoms. She is
  no longer waking up at night with cough.
Has a hard time remembering her controller
  at night. She is about to move in with her
  boyfriend who smokes.
Case – Visit 2
 What is your assessment of her control?



 What would you do for treatment?
Follow-up treatment
 Before changing therapy, assess:
   Medication adherence
   Spacer and MDI proper use
   Environmental control / triggers
 Step up one or two steps if uncontrolled
 Patient education at every visit
Case – Visit 2
 What is your assessment of her severity?



 What would you use for treatment?
Ongoing care
 Can step down if well controlled for more
  than 3 months = No exacerbations!
 Scheduled follow-up – NOT prn
 Education of family, school, coaches, etc.
 Flu and H1N1 for all
 Consider allergy evaluation
EMR tips and tricks
 Asthma action plans
 Asthma flowsheet
 Chronic care section of office note
Chronic care in note
PACE – Key points
1. The key elements of assessment and monitoring
   are severity, control, and responsiveness to
   treatment.
2. Appropriate asthma management requires the
   proper use of long term control and quick relief
   medications.
3. Because asthma symptoms are variable, families
   need to recognize symptoms and adjust
   medications at home according to the clinician’s
   assessment of control and his/her written action
   plan for the patient.
Please go to your small groups!

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:16
posted:10/10/2011
language:English
pages:31