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Management of Acute Asthma in Adults

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Management of Acute Asthma in Adults Powered By Docstoc
					    Update on
   Acute Asthma

Carlos Camargo, MD, DrPH

Emergency Medicine, MGH
Channing Laboratory, BWH
 Harvard Medical School

                  www.emnet-usa.org
Outline of Presentation

• Background

• NAEPP guidelines

• Novel therapies

• Preventive interventions

• Summary

                             www.emnet-usa.org
    Definition of Asthma

    • Chronic lung disease characterized by:
        – Airway narrowing that is reversible (± completely) either
          spontaneously or with treatment
        – Airway inflammation
        – Airway hyper-responsiveness to a variety of stimuli.

    • Episodic dyspnea with associated wheezing

    • Heterogeneous group with:
        – Shortness of breath
        – Wheezing
        – Cough

ATS. ARRD 1987                                            www.emnet-usa.org
NAEPP Guidelines, 1997

• National Asthma Education and Prevention
  Program (NAEPP)

• Classification of chronic asthma:
   – Mild intermittent asthma
   – Mild persistent asthma (>2 days/wk, >2 nights/mo)
   – Moderate persistent asthma
   – Severe persistent asthma

• Inhaled corticosteroids (ICS) are “preferred
  treatment” for all patients with persistent asthma

                                           www.emnet-usa.org
Epidemiology

• 17 - 27 million Americans (6-10% prevalence)

• 10 million office visits + 2 million ED visits +
  500,000 hospitalizations + 5,000 deaths

• Major cause of school and work absences

• At least $12 billion per year

• Increasing burden for years ... but now flat (or  )

                                            www.emnet-usa.org
Asthma Prevalence, 1980-2001
                            NHIS
                            2001

                            * 11.3


                           * 7.3

                           * 4.3




                        www.emnet-usa.org
Asthma Prevalence, 1980-2001
                             NHIS
                             2001

                             * 11.3


                             * 7.3

                             * 4.3




                        www.emnet-usa.org
    Asthma Mortality, 1980-1999

                             Asthma Mortality Rates Per 1,000,000
                                      By Year -- USA

                     25

                     20
Rate per 1,000,000




                     15

                     10

                     5

                     0
                          1980     1985       1990      1995        1999
                                              Year


                                                                       www.emnet-usa.org
    Visits in thousands   ED Visits for Asthma, 1992-2000


                           2400



                           2200



                           2000



                           1800



                           1600



                           1400



                           1200



                           1000
                                  1992-93   1994-95   1996-97    1998-99     2000
                                                      Year (s)




NHAMCS Database                                                            www.emnet-usa.org
MARC

– Founded 1996

– Goal: To improve care of acute
 asthma & other airway disorders

– Funded by NIH, industry,
 foundations

– Emergency Medicine Network

– www.emnet-usa.org


                                   www.emnet-usa.org
EMNet (153 US and 32 International sites = 185 sites)




                                                        12/1/05
Potential for Improving Asthma

• ED is often used for asthma care
   – 2 million ED visits per year
   – Most asthma hospitalizations begin in the ED


• Among ED patients (MARC data):
   – 74% adults (63% children) use ED for all “problem” asthma care
   – 45% adults (31% children) receive all asthma Rx from ED
   – With PCP: 63 + 61% for problem care; 24 + 25% for all Rx


• High-risk population

                                                     www.emnet-usa.org
ED Patients with Acute Asthma

                                1996     1997-98     1999-01
                               (n=770)   (n=4,920)   (n=1,248)



Ever admitted for asthma (%)     54         63          64
Ever intubated (%)               15         17          17
ED visits in past year (%)       76         90          79


Used inhaled corticosteroids
   in past 4 weeks (%)
                                 42         44          46



                                                       www.emnet-usa.org
              ED and Hospital Management:
                        Goals



        1. Correct significant hypoxemia

        2. Rapidly reverse airflow obstruction

        3. Decrease likelihood of recurrence



NAEPP, 1997                             www.emnet-usa.org
              ED and Hospital Management:
                    Initial Treatment

   Mild-to-Moderate Exacerbation (PEF > 50%)

   • Oxygen to achieve O2 sat > 90%

   • Inhaled  2-agonist by MDI or neb, up to 3 in 1st hr

   • Oral corticosteroid if no immediate response or if
     patient recently took oral corticosteroid

NAEPP, 1997                                    www.emnet-usa.org
              ED and Hospital Management:
                 Initial Treatment (continued)


    Severe Exacerbation (PEF < 50%)


    • Oxygen to achieve O2 sat > 90%

    • Inhaled high-dose 2 -agonist and anticholinergic
      by neb q 20 minutes or continuously for 1 hour

    • Oral corticosteroid

NAEPP, 1997                                 www.emnet-usa.org
              ED and Hospital Management:
                 Initial Treatment (continued)


    Impending or Actual Respiratory Arrest

    • Intubation and mech ventilation with 100% O2

    • Nebulized 2-agonist and anticholinergic

    • IV corticosteroid

    • Admit to hospital intensive care

NAEPP, 1997                                  www.emnet-usa.org
              2002 Update on Selected Topics


   • Antibiotics not recommended for acute asthma

   • ICS are preferred treatment for children of all ages
     with persistent asthma

   • ICS + long-acting -agonist is the preferred
     treatment for moderate or severe persistent asthma
     in individuals age 6 and older


NAEPP, 2002                                   www.emnet-usa.org
     Dual Therapy with ICS + LABA   (weeks)




Nelson et al, JACI 2000.            www.emnet-usa.org
       Dual Therapy with ICS + LABA   (days)




Nelson et al, JACI 2000.          www.emnet-usa.org
Novel Therapies in the ED


• IV magnesium

• Heliox

• IV leukotriene modifiers




                             www.emnet-usa.org
        IV Mg for Acute Asthma – Admit Rate




Rowe et al, Ann Emerg Med 2000.      www.emnet-usa.org
      Heliox for Severe Acute Asthma – PEF




Kass and Terregino, Chest 1999.     www.emnet-usa.org
   IV Montelukast for Acute Asthma – FEV1
                                                 30


          LSMean % Change from baseline (+-SE)   25



                                                 20



                                                 15



                                                 10



                                                 5



                                                 0
                                                      0   10      20          30          40   50   60

                                                               Minutes after treatment dose

                                                                       Montelukast IV 7 mg
                                                                       Montelukast IV 14 mg
                                                                       Placebo



Camargo et al, AJRCCM 2003.                                                                              www.emnet-usa.org
ED-Initiated Preventive Interventions

•   High-risk population
•   Use of ED for “problem asthma” care + asthma Rx
•   What interventions are feasible in the ED setting?
•   Examples from MARC:

    1. ICS initiation at discharge from ED
    2. Asthma education programs
    3. Bridging the gap between ED & primary asthma care


                                            www.emnet-usa.org
Initiation of ICS at Discharge
100

 90

 80

 70

 60

 50

 40

 30

 20              F           F
 10

  0
      *
      1996    1997-1998   1999-2001


                                 www.emnet-usa.org
   ICS after the ED -- Relapse at 20-24 Days




Edmonds et al, Cochrane Library 2001.   www.emnet-usa.org
     Prevention of Repeat ED Visits




Sin and Man, Arch Int Med 2002.   www.emnet-usa.org
             Prevention of Fatal Asthma
                                 2.0
    Rate Ratio of Asthma Death




                                 1.5



                                 1.0



                                 0.5



                                 0.0
                                       0   1   2         4         6          8           10         12
                                               MDIs of Inhaled Corticosteroids per Year


Suissa & Ernst, JACI 2001.                                                                     www.emnet-usa.org
                National Asthma Educator
                   Certification Board


     Mission Statement
     To promote optimal asthma management and
     quality of life among individuals with asthma,
     their families and communities, by advancing
     excellence in asthma education through the
     Certified Asthma Educator process.

www.naecb.org                                www.emnet-usa.org
www.emnet-usa.org
  Follow-up with PCP

  • Philadelphia study
      – randomized trial, 1 center, n=178
      – $25 intervention (free meds, taxi vouchers, 48-hr call)
      – f/u with PCP: usual care (29%) vs. intervention (46%), p=0.02
        RR=1.6 (95%CI, 1.1-2.4)


  • EMF Center of Excellence Award
      – Recently completed RCT at 9 EMNet sites
      – 1 month: 50% increase in PCP follow-up (ACEP 2001)




Baren et al, Ann Emerg Med 2001.                        www.emnet-usa.org
Follow-up with PCP

• Philadelphia study

• EMF Center of Excellence Award
   – Recently completed RCT at 9 EMNet sites
   – 1 month: 50% increase in PCP follow-up (ACEP 2001)
   – 6 and 12 months: no diff in clinical outcomes … (ACEP 2002)

   – Next steps … facilitated referral to specialists?




                                                    www.emnet-usa.org
Summary
• Asthma epidemiology

• NAEPP guidelines
   – 1997: O2 prn, inhaled ß-agonist + antichol, systemic steroids
   – 2002: ICS for children of all ages with persistent asthma
           ICS + LABA for age 6+ with moderate-severe persistent

• Novel treatments – severe exacerbations only

• Prevention at all clinical encounters!
   – Start ICS at ED discharge … consider ICS + LABA
   – Asthma education (brief) … consider outpatient session
   – Arrange continuing care … consider referral to specialist

                                                       www.emnet-usa.org

				
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posted:10/10/2011
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