1

Module 4

Special Populations

Geneva Briggs

Pre-Assessment Exercise

2

Question #1

Which medication is NOT used in preventing exercise induced bronchospasm?a. Cromolynb. Albuterolc. Theophyllined. Montelukast

Question #2

Exercise induced bronchospasm is caused by a loss of heat, water, or both from the lung during exercise. a. True b. False

3

Question #3

Which of the following is an accurate statement about asthma in children?

a. Males have a greater prevalence than femalesb. Long acting beta agonists are ineffectivec. Low dose inhaled corticosteroids are preferred first step in persistent asthmad. In the U.S, Puerto Ricans have the highest prevalence

Question #4

When counseling an adolescent with asthma, assessing whether the patient smokes is important.a. True b. False

4

Question #5

Which of the following is an accurate statement about asthma and pregnancy?

a. Patients with adequately controlled asthma has birth outcomes similar to non-asthmatic populations.

b. The rate of low birth weight is high even in well controlled asthmatic mothers.

c. The risk of adverse effects with inhaled beta agonists is higher during pregnancy.

d. Symptoms of asthma typically improve dramatically during pregnancy allowing medication reductions.

Choose your option below.Next Topic: Exercise Induced Bronchospasm

5

Exercise Induced Bronchospasm

Exercise Induced Bronchospasm (EIB)

• Airway narrowing 5-10 minutes after the cessation of vigorous exercise

• Bronchoconstriction only, no inflammatory response

• Cause: loss of heat and water from the lungs during exercise and leukotriene release

• Not prolonged or dangerous

6

Difficulty with EIB is the resulting limitation on activity

Diagnosis of EIB

• History• 15% decrease in peak flow between

measurements taken before and after vigorous activity

7

Symptoms of EIB

• During exercise– Rapid breathing– Irregular breathing– Decreased

endurance

• Following exercise– Cough– Wheezing– Shortness of breath– Chest tightness

Influencing Factors

• Type of exercise– Intensity– Duration

• Environment– Warm vs. cold air– Humid vs. dry air

8

Goals of Therapy

• Allow patients to live a normal active life style• Prevention of exercise induced symptoms

Prevention

• Increase physical conditioning • Warm up for at least 10 minutes before actual

exercise begins • Cover mouth and nose with scarf or mask during cold

weather • Exercise in warm, humidified environment, if possible • Avoid aeroallergens and pollutants • Cool down or gradually lower the intensity of the

exercise before stopping • Wait at least 2 hours after a meal before exercising

9

Interactive Check Point

Which of the following is first line therapy for EIB?

a. Inhaled ipratropiumb. Inhaled cromolync. Inhaled corticosteroids (ICS)d. Inhaled short acting β2 agonists (SABA)

Interactive Check PointAnswer

d. Inhaled SABAThese agents are first line because of their quick onset of action in reversing bronchospasm

10

Drug Treatment

• First line treatment – Inhaled SABA

• Second line treatment– Cromolyn / Nedocromil– Leukotriene modifiers– LABA

Use of SABA in EIB

• 2 puffs, 10-15 minutes before exercise• Duration of protection = 2-2.5 hours• May also use after exercise for slow to resolve

symptoms

11

Use of LABA in EIB

• Salmeterol: 2 puffs 30 minutes before exercise• Formoterol : 1 inhalation 15 minutes before

exercise • Duration of protection = 10-12 hours• Consider using:

– If exercise planned for > 3 hours– In children or adolescents to avoid inhaler use in

front of peers

Use of Cromolyn in EIB

• 2 puffs, 10-15 minutes before exercise• Duration of protection = 1.5-2 hours• Somewhat less effective• May have role as add on therapy to SABA

12

Use of Leukotriene Modifiers in EIB

• Advantages– Oral administration– Long duration of action (24 hrs)

Medication Use in Competition

• U.S. Olympic Committee– Allowed without prior approval:

cromolyn, nedocromil, ipratropium, theophylline, leukotriene modifiers

– Require prior approval: inhaled β2 agonists (short and long-acting), ICS

• NCAA – Permits most medications except oral β2 agonists

13

Choose your option below.Next Topic: Asthma in Children and Adolescents

Asthma in Children and Adolescents

14

Prevalence

• Asthma affects 6.2 million children < 18 • 50 – 80% of children with asthma develop

symptoms before age 5• Prevalence rates are highest among Puerto

Ricans (131/1000), Native Americans (99/1000) and African Americans (95/1000) and greater in boys than girls

Prevalence

• From 1980 to 1996:– Prevalence increased 160% in children < 4 years old– Increased 72% in children 5 to 16 years old

• Rates have remained stable from 1997 - 2004

15

Each Year Asthma in Children Accounts for:

• 2.7 million doctor visits • 720,000 ER visits • 200,000 hospitalizations• Over 8.7 million prescriptions for children under

17 years old• 14.7 million school days are missed annually

due to asthma• In 2002, 187 children died from asthma

Costs

• Lost productivity among parents of children with asthma = $1 billion each year

• Annual cost of treating children with asthma = $1.9 billion

16

Factors Associated with ONSET of Asthma Symptoms in Children

• Allergy• Family history of asthma and/or allergy• Perinatal exposure to tobacco smoke• Viral respiratory infections• Smaller airways at birth and in early life• Male gender• Low birth weight

Factors Associated with Continuing Asthma

• Allergy• Family history of asthma and/or allergy• Perinatal exposure to passive smoke and

aeroallergens

17

Symptoms in Young Children

• Cough may be only symptom• Wheezing• Tachypnea with accessory muscle use• Decreased activity level and alertness• Symptom precipitant - recurrent sinusitis, rhinitis,

or an upper respiratory tract infection

Considerations

• Children < 5 years old are unable to use peak flow meters, so assessment of severity is based on symptoms

18

Classifying Severity and Assessing Control

• Assessed in children the same way as in adults –impairment and risk domains

• Severity is either intermittent or mild, moderate, or severe persistent

• Control is either well controlled, not well controlled, and very poorly controlled

Pharmacologic management of children and adolescents follows same basic principles as those for adults with special consideration for

growth, school and social development

19

Drug Treatment in Children

• Intermittent asthma – SABA prn (Step 1)• Low dose inhaled corticosteroids (ICS) are

preferred first agent in persistent asthma (Step 2)

• Alternatives– Cromolyn, nedocromil, leukotriene modifiers, or

theophylline in 5-11 years old– Cromolyn or montelukast in 0-4 years old

Stepwise Approach for Managing Asthma in Children 0-4

Intermittent

Asthma

Persistent Asthma: Daily MedicationICS, inhaled corticosteroid; LABA, inhaled long acting beta agonist;LTRA, leukotrienereceptor antagonist; SABA, inhaled short acting beta agonist;steroids, corticosteroids

Step 1Preferred: SABA prn

Step 2Preferred:Low-dose ICS

Alternative:Montelukast,Cromolyn

Step 3

Preferred:Medium-dose ICS

Step 4Preferred:Medium-dose ICS

ANDEither:Montelukast or LABA

Step 5Preferred:High-dose ICS

ANDEither:Montelukastor LABA

Step 6Preferred:High-dose ICS

ANDEither:Montelukastor LABA

ANDoral steroids

20

Stepwise Approach for Managing Asthma in Children 5-11

Intermittent

Asthma

Persistent Asthma: Daily MedicationICS, inhaled corticosteroid; LABA, inhaled long acting beta agonist;LTRA, leukotrienereceptor antagonist; SABA, inhaled short acting beta agonist; steroids, corticosteroids

Step 1Preferred: SABA prn

Step 2Preferred:Low-dose ICSAlternative:LTRACromolynNedocromil or Theophylline

Step 3Preferred:Medium-dose ICS

OR

Low-dose ICS + either LABA,LTRA orTheophylline

Step 4Preferred:Medium-dose ICS + LABA

Alternative:

Medium-dose ICS + either LABA orTheophylline

Step 5Preferred:High-dose ICS + LABA

Alternative:

High-dose ICS + either LTRA orTheophylline

Step 6Preferred:High-dose ICS + LABA + Oral steroid

Alternative:High-dose ICS + either LTRA orTheophylline + oral steroid

Drug Treatment in Children

• Oral medications• Nebulizers• Metered dose inhalers with holding chambers • Dry powder inhalers

21

Adherence Problems in Children

• Unpalatable• Difficulty swallowing• Medication regimen conflicts with parents’

schedule or school• Child is not actively involved in medication

regimen

School Days

• Asthma Action Plan • Medication letter to school nurse• Provide extra labeled medication containers• Ensure the patient has medications for home

and school

22

When possible, schedule daily medications so they do not need to be taken at school

How Asthma Friendly is Your School or Child-Care Setting?

• www.nhlbi.nih.gov/health/public/lung/asthma/chc_chk.htm

• Seven item checklist designed to help parents evaluate the setting

• Addresses:– Environmental issues– Medication management– Availability of health professionals

• Helpful list of resources for parents and child-care staff

23

Counseling Children

• Educate both parent and child• Talk directly to the child • Encourage questions and feedback from the

child

Adolescents

• More likely to be in denial• Peer pressure• Nonadherence used as

control over parents• Do not see long term benefits

24

Counseling Adolescents

• Listen to the patient– Find out their expectations and goals

• Find out what the adolescent is willing to do and then work out a management plan together

• Ask about smoking, exposure to tobacco smoke and possible drug use

Treatment Strategies

• Develop a medication plan that does not require teen to use medications around peers

• Encourage the parent to allow teen to have more control over treatment

25

Choose your option below.Next Topic: Managing Asthma During Pregnancy

Managing Asthma During Pregnancy

26

Asthma During Pregnancy

• Asthma is one of the most common potentially serious problem to complicate pregnancy

• 4% of pregnancies are complicated with asthma• 33% of asthmatics symptoms worsen during

pregnancy• Severe asthmatics are at the highest risk

Asthma During Pregnancy

• Small changes in lung function can dramatically affect fetal oxygenation

• Uncontrolled asthma– Fetal death– Low birth weight– Preterm birth– Preeclampsia

• Adequately controlled asthma has outcomes similar to non-asthmatic populations

27

Goals of Treatment

• Control symptoms• Prevent exacerbations• Maintain normal lung function• Maintain normal activity levels• Avoid adverse drug reactions• Deliver a healthy infant

Drug Treatment

• Risks associated with uncontrolled asthma far outweigh possible side effects associated with drug therapy

28

Drug Treatment

• Individualize treatment plan– Step approach based on severity

• Inhaled medications are preferred over oral• Medications with a history of use during

pregnancy are preferred

NAEPP Managing Asthma During Pregnancy: Recommendations for Pharmacologic

Treatment—Update 2004

• Intermittent – Step 1– Inhaled SABA prn

• Persistent – Step 2– Low dose ICS– Alternatives: cromolyn, leukotriene modifier, or

sustained release theophylline

www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg.htm

29

Recommendations

• Persistent – Step 3– Preferred: Low dose ICS + LABA– Medium dose ICS

• Persistent – Step 4– Medium dose ICS + LABA

• Persistent – Step 5– High dose ICS + LABA

• Persistent – Step 6– High dose ICS + LABA + oral steroids

Asthma Medications and Pregnancy

• SABA– May be used– Albuterol is preferred agent

• Salmeterol– No human data on use during pregnancy– Generally not recommended– May be continued for patients well controlled

on prior• Ipratropium

– No human data on use during pregnancy– May be used during acute attack if not responsive

to first β2 agonist treatment

30

Asthma Medications and Pregnancy

• Cromolyn– May be used

• Nedocromil– No human data on use during pregnancy– Generally not recommended– May be continued for patients well controlled

before pregnancy

Asthma Medications and Pregnancy

• Inhaled corticosteroids– Medication of choice in persistent asthma unless

well controlled on cromolyn– Budesonide first choice– Continue a patient on corticosteroid patient well

controlled on prior• Theophylline

– May be used in patients not controlled with inhaled corticosteroids

– 5-12 mcg/ml

31

Asthma Medications and Pregnancy

• Montelukast or zafirlukast– No human data on use during pregnancy– Generally not recommended– May be used in patients well controlled on prior

• Zileuton– Animal studies have shown harmful effects– Do not use during pregnancy

Asthma Medications and Pregnancy

• Omalizumab– Category B– No adequate and well controlled studies in

pregnant women

32

Choose your option below.Next Topic: Application Exercise

Application Exercise

Exercise Induced Bronchospasm

33

Case Presentation

• Steven is a 16 year old competitive swimmer with EIB

• Past medical history: Asthma

Case Presentation

• Medications– PRN albuterol– Flunisolide (Aerobid®) 1 puff bid

• When he picks up his prescription today, you note he has been using 3-4 canisters of a SABA per month

34

What may his use of 3-4 albuterol canisters/month indicate?

a. He has severe EIBb. He is exercising too muchc. He needs to institute some nonpharmacologic

measuresd. His asthma is not well controlled

Best Answer

• His asthma is not well controlled– Excessive use of SABA indicates his asthma

is not well controlled. Although he has EIB, he also appears to have persistent asthma because he is receiving an ICS. His dose may need to be increased but his adherence should be assessed first. The frequency of his use for EIB also needs to be assessed

35

Case Presentation

• Upon further review of Steven’s medication profile, you note he is refilling his ICS about every 45 days when it should be every 30 days

Which of the following would be the most important point to make with Steven today?

a. Need for warming up before swimming to reduce episodes of EIB

b. Need to take albuterol 10-15 minutes before swimming

c. Need to take his daily controller (ICS) to improve control of his asthma and reduce need for SABA

36

Best Answer

c. Need to take his daily controller (ICS) to improve control of his asthma and reduce need for SABAAlthough all three points are important, he needs to begin to control his asthma. Improving his adherence with the ICS should help reduce his need for SABA. His inhaler technique should be reviewed

Case Presentation

• Steven admits it is hard to remember to take his corticosteroid twice a day. He takes it first thing in the morning (7AM) and has no trouble remember this dose. He has trouble remembering the 7PM dose because he is usually at swim team practice

37

Which of the following would be the best schedule for his inhaled corticosteroid?

a. Take all doses once dailyb. Continue 7AM and 7PM schedulec. Suggest he take it at 7AM and then when he

gets home from swim practiced. Suggest he take it at 7AM and then just prior

to bedtime

Best Answer

d. Suggest he take it at 7AM and then just prior to bedtimeThis is the best option, if it is an acceptable schedule to him. Taking his dose right after swimming practice may be a problem because he may be having bronchospasm related to the exercise. It may be best to wait some time before taking the evening dose

38

Case Presentation

• He agrees that 7AM and at bedtime will work for him

• While talking with him, you notice he smells like cigarettes

Summarize Action Plan for Steven

• Continue therapy with SABA PRN, before exercise, and ICS bid

• Demonstrate use of MDI to insure drug delivery• Monitor use• Monitor symptoms and activity• Discuss smoking cessation and impact on his

asthma

39

Thank you for your participation.

Click below to proceed to the post test