medical treatment of asthma and related equipment / gadgets
DESCRIPTION
Medical Treatment of Asthma and Related Equipment / Gadgets. Overview. Review of asthma medications Review and demonstration of common asthma equipment and gadgets Practical tips for integrating asthma medication and equipment/gadget knowledge into daily practice E8. - PowerPoint PPT PresentationTRANSCRIPT
Medical Treatment Medical Treatment of Asthma and Related of Asthma and Related Equipment / GadgetsEquipment / Gadgets
OverviewOverview
Review of asthma medicationsReview of asthma medications Review and demonstration of Review and demonstration of
common asthma equipment and common asthma equipment and gadgetsgadgets
Practical tips for integrating Practical tips for integrating asthma medication and asthma medication and equipment/gadget knowledge intoequipment/gadget knowledge into daily practicedaily practice
E8E8
Medication Treatment Medication Treatment GoalsGoals
Safe and effective medication deliverySafe and effective medication delivery Provide the least amount of medication Provide the least amount of medication
needed to allow the student to be needed to allow the student to be active and symptom- free active and symptom- free
Avoid adverse effects from medicationsAvoid adverse effects from medications Meet students and families Meet students and families
expectations regarding medicationexpectations regarding medication
Key Aspects In The Key Aspects In The Medical Treatment Of Medical Treatment Of
AsthmaAsthma Relationship with a primary Health Care Relationship with a primary Health Care
Provider who is knowledgeable of Provider who is knowledgeable of current asthma treatment guidelines current asthma treatment guidelines
Development, sharing, and use of a Development, sharing, and use of a personalized Asthma Action Plan or personalized Asthma Action Plan or Asthma Management PlanAsthma Management Plan
Monitoring of symptoms with a peak Monitoring of symptoms with a peak flow meter and pulmonary function flow meter and pulmonary function testing testing
Key Aspects Key Aspects Continued…Continued…
Catching early warning signs and Catching early warning signs and referring for assessment or treatment referring for assessment or treatment
Well asthma check-upsWell asthma check-upsEvery 6 months for asthma that is under Every 6 months for asthma that is under
controlcontrolMore frequently for asthma that is out of More frequently for asthma that is out of
controlcontrolStepping up and down therapy as neededStepping up and down therapy as needed
Asthma Medication Asthma Medication OverviewOverview
Controller vs. Reliever Controller vs. Reliever MedsMeds
Controller medicationController medication • Daily medications for all persistent asthmaDaily medications for all persistent asthma
Long term controlLong term controlAnti-inflammatory Anti-inflammatory
Reliever or Quick-relief medicationReliever or Quick-relief medication • Bronchodilators - As needed for all asthma Bronchodilators - As needed for all asthma
severity levelsseverity levelsBronchodilatorsBronchodilatorsOral corticosteroid burstsOral corticosteroid bursts
Methods Of DeliveryMethods Of Delivery
• Medications may be given by:Medications may be given by: Metered Dose Inhaler (MDI) Metered Dose Inhaler (MDI) Dry Powdered Inhaler (DPI)Dry Powdered Inhaler (DPI) OrallyOrally
• Important to review technique for Important to review technique for all delivery methodsall delivery methods
InhalersInhalers
Press and Breathe Breath Actuated Dry PowderPress and Breathe Breath Actuated Dry Powder AerosolAerosol
Aerosol Metered Dose Aerosol Metered Dose Inhalers and Chambers / Inhalers and Chambers /
SpacersSpacers
Use a spacer with an aerosol inhalerUse a spacer with an aerosol inhalerGets more medication into the lungs (~5 x more Gets more medication into the lungs (~5 x more
than MDI alone)than MDI alone)Fewer side effects such as smaller amount of Fewer side effects such as smaller amount of
absorbed medication systemically, less oral absorbed medication systemically, less oral thrush and dyphoniathrush and dyphonia
F27F27
How MDI Technology How MDI Technology WorksWorks
Holding Chamber / Holding Chamber / Spacer UseSpacer Use
Common Valved Common Valved Holding Chambers and Holding Chambers and
SpacersSpacers
Chamber / Spacer Chamber / Spacer DemonstrationDemonstration
MDI with common chambers / MDI with common chambers / spacersspacersValved holding chamber (Aerochamber, Valved holding chamber (Aerochamber,
Optichamber) Optichamber) Spacer (Ellipse, Optihaler)Spacer (Ellipse, Optihaler)
MDI with Inspirease spacer MDI with Inspirease spacer Cleaning chambers/ spacersCleaning chambers/ spacers
F27F27
How To Use Your How To Use Your InhalerInhaler
MDI Not Needing A MDI Not Needing A Separate Chamber / Separate Chamber /
SpacerSpacer Maxair AutohalerMaxair Autohaler - Reliever /Rescue - Reliever /Rescue
medmedBreath actuated and should not be used Breath actuated and should not be used
with a chamber or spacerwith a chamber or spacer
AzmacortAzmacort - Controller (daily) med - Controller (daily) medHas a built-in spacerHas a built-in spacer
Minnesota Inhaler Minnesota Inhaler LawLaw
MN Asthma Inhaler Law MN Asthma Inhaler Law Summary (2001)Summary (2001)
Allows MN students to self-carry and Allows MN students to self-carry and administer inhalersadminister inhalers
In order for a child to carry his/her In order for a child to carry his/her inhaler at school, authorization and inhaler at school, authorization and signatures from the following signatures from the following individuals are required:individuals are required:
Child’s health care providerChild’s health care providerParent/guardian Parent/guardian Assessment and approval of the school Assessment and approval of the school
nursenurse (if present in district)(if present in district)R8, R9R8, R9
The Statute: Key PointsThe Statute: Key Points
Public elementary and secondary Public elementary and secondary school students can possess and school students can possess and use inhalers use inhalers ififThe parent has not requested that school The parent has not requested that school
personnel administer the medication personnel administer the medication andandThe school district receives annual written The school district receives annual written
parental authorization parental authorization andandThe inhaler is properly labeled The inhaler is properly labeled andand
Key Points Key Points Continued...Continued...
The school nurse or other The school nurse or other appropriate party assesses the appropriate party assesses the student’s knowledge and skills to student’s knowledge and skills to safely possess and use the inhaler safely possess and use the inhaler and enters a plan into the student’s and enters a plan into the student’s health record health record
ORORFor schools without a school nurse, For schools without a school nurse,
the student’s physician conducts the the student’s physician conducts the assessment and submits written assessment and submits written verification verification
DiscussionDiscussion
• What knowledge and skills do What knowledge and skills do students need to obtain before being students need to obtain before being allowed to independently carry and allowed to independently carry and administer their inhalers?administer their inhalers?
F19, F20F19, F20
Medication: Determined Medication: Determined By Severity Level By Severity Level
ClassificationClassification1.1. Mild IntermittentMild Intermittent
Reliever only prn Reliever only prn
2.2. Mild PersistentMild Persistent Controller and reliever Controller and reliever
3.3. Moderate PersistentModerate PersistentController plus long-acting bronchodilator Controller plus long-acting bronchodilator and relieverand reliever
4.4. Severe PersistentSevere PersistentController plus long-acting bronchodilator Controller plus long-acting bronchodilator and relieverand reliever
Order Of Medication Order Of Medication AdministrationAdministration
If a student is taking both an inhaled If a student is taking both an inhaled reliever and an inhaled controller at reliever and an inhaled controller at the same time:the same time:Give the reliever medication first, Give the reliever medication first,
before taking the controllerbefore taking the controllerWait a few minutes between Wait a few minutes between
medications medications
ControllersControllers Inhaled CorticosteroidsInhaled Corticosteroids
Reduces airway swelling over time, Reduces airway swelling over time, decreases airway hyper-decreases airway hyper-responsivenessresponsiveness
Must be taken daily, even if no Must be taken daily, even if no symptomssymptoms
Will Will notnot relieve acute asthma relieve acute asthma symptomssymptoms
ControllersControllers Inhaled Corticosteroids Inhaled Corticosteroids
Cont...Cont...When used consistently over time will When used consistently over time will
prevent/control inflammation and acute prevent/control inflammation and acute episodesepisodes
Dose/strength may need to be increased Dose/strength may need to be increased or decreased depending on season of or decreased depending on season of the year (step up / step down)the year (step up / step down)
Inhaled steroids start to work in days to Inhaled steroids start to work in days to weeks, oral steroids within 6-24 hoursweeks, oral steroids within 6-24 hours
Inhaled Inhaled CorticosteroidsCorticosteroids
• FloventFlovent (Fluticasone (Fluticasone - MDI- MDI))• PulmicortPulmicort (Budesonide - (Budesonide - DPI or nebsDPI or nebs) ) • AsmanexAsmanex (Mometasone) (Mometasone)• AzmacorAzmacortt (Triamcinolone) (Triamcinolone)• Beclovent, Qvar, VancerilBeclovent, Qvar, Vanceril
(Beclomethasone)(Beclomethasone)• AerobidAerobid (Flunisolide) (Flunisolide)
Inhaled Corticosteroids Inhaled Corticosteroids
• Potential adverse effectsPotential adverse effectsCough, dysphonia, thrushCough, dysphonia, thrush
• Therapeutic issuesTherapeutic issuesChambers/spacers necessary for MDIsChambers/spacers necessary for MDIsDifferent inhaled corticosteroids are not Different inhaled corticosteroids are not
interchangeableinterchangeableAzmacort and Aerobid reportedly have Azmacort and Aerobid reportedly have
particularly bad taste, Pulmicort particularly bad taste, Pulmicort Turbuhaler has no tasteTurbuhaler has no taste
Steroid Phobia: Steroid Phobia: Unfounded!Unfounded!
Inhaled steroids in doses most often Inhaled steroids in doses most often prescribed are very safeprescribed are very safe
Inhaled meds delivered directly to Inhaled meds delivered directly to lungs where they are neededlungs where they are needed
Little systemic absorption if proper Little systemic absorption if proper technique used technique used
Turbuhaler Use DemoTurbuhaler Use Demo
Need deep, forceful inhalationNeed deep, forceful inhalation May use Turbutester to help May use Turbutester to help
determine if an individual is able to determine if an individual is able to useuse
Counter (dots in window) turns red Counter (dots in window) turns red when doses running outwhen doses running out
Non-Steroidal Anti-Non-Steroidal Anti-inflammatoriesinflammatories
• IntalIntal (Cromolyn) (Cromolyn) (also available as Intal (also available as Intal HFA)HFA)
• TiladeTilade (Nedocromil) (Nedocromil) For symptom prevention or as preventive For symptom prevention or as preventive
treatment prior to allergen exposure or treatment prior to allergen exposure or exerciseexercise
Potential adverse effectsPotential adverse effects None (Tilade tastes badNone (Tilade tastes bad) )
Therapeutic issuesTherapeutic issues Must be taken up to 4 times a day, Must be taken up to 4 times a day,
maximum benefit after 4-6 weeksmaximum benefit after 4-6 weeks
IgE Blocker TherapyIgE Blocker Therapy
Xolair Xolair (Omalizumab)(Omalizumab)Dosing based on IgE levels and weightDosing based on IgE levels and weightOnly for ages over 12 years oldOnly for ages over 12 years oldUse in conjunction with other medsUse in conjunction with other medsMust have evidence of specific allergy Must have evidence of specific allergy
sensitivity sensitivity Used for those with poorly controlled Used for those with poorly controlled
asthma and non-compliant with standard asthma and non-compliant with standard recommended therapyrecommended therapy
Delivered by SQ injection Delivered by SQ injection
Serevent Diskus Serevent Diskus (Salmeterol)(Salmeterol)
Foradil (FormoterolForadil (Formoterol))
Long-acting Beta-Long-acting Beta-agonistsagonists
• SereventSerevent (Salmeterol(Salmeterol) ) (Diskus(Diskus))• ForadilForadil ( (FomoterolFomoterol) ) ((DPIDPI))
Potential adverse effectsPotential adverse effectsTachycardia, tremors, hypokalemia Tachycardia, tremors, hypokalemia
Therapeutic issuesTherapeutic issuesShould not be used in place of anti-Should not be used in place of anti-
inflammatory therapyinflammatory therapy
MethylzanthinesMethylzanthines
• TheophylineTheophyline For prevention of symptoms For prevention of symptoms
(bronchodilation, and possible epithelial (bronchodilation, and possible epithelial effectseffects))
Potential adverse effectsPotential adverse effectsInsomnia, upset stomach, hyperactivity, Insomnia, upset stomach, hyperactivity,
bed wetting bed wetting Therapeutic issuesTherapeutic issues
Must monitor serum concentrations, not Must monitor serum concentrations, not helpful in acute exacerbations, absorption helpful in acute exacerbations, absorption and metabolism affected by many factorsand metabolism affected by many factors
Combination Combination MedicationMedication
AdvairAdvair (Flovent + Serevent) (Flovent + Serevent) Combo Combo corticosteroidcorticosteroid and and long acting long acting
beta-agonistbeta-agonist3 strengths: 3 strengths: 100/50, 250/50, 500/50 100/50, 250/50, 500/50 Strengths based on Flovent doses, Strengths based on Flovent doses,
Serevent dose remains the same in all Serevent dose remains the same in all three strengths. three strengths.
Diskus Dry Powdered Inhaler Diskus Dry Powdered Inhaler Usual dosing, 1Usual dosing, 1 inhalation every 12 hoursinhalation every 12 hoursHas remaining-dose counter Has remaining-dose counter
F28F28
Diskus DemonstrationDiskus Demonstration
Diskus (Advair and SereventDiskus (Advair and Serevent)) • Breath in deep and steady Breath in deep and steady • 1 breath per dose1 breath per dose• Counter tracks remaining dosesCounter tracks remaining doses• 3 strengths Advair 100 (green 3 strengths Advair 100 (green
label),label),
250 (yellow label), 500 (red label)250 (yellow label), 500 (red label)• 60 doses per diskus60 doses per diskus
Leukotriene ModifiersLeukotriene Modifiers• Singulair Singulair (Montelukast)(Montelukast)• Accolate Accolate (Zafirlukast(Zafirlukast))• ZyfloZyflo
Oral: Prevention of symptoms in mild persistent Oral: Prevention of symptoms in mild persistent asthma, and/or to enable a reduction in dosage asthma, and/or to enable a reduction in dosage of inhaled steroids in moderate to severe of inhaled steroids in moderate to severe persistent asthmapersistent asthma
Potential adverse effectsPotential adverse effects
None significant elevation of liver enzymesNone significant elevation of liver enzymesTherapeutic issuesTherapeutic issues
Drug interactions, monitor hepatic enzymes (esp. Drug interactions, monitor hepatic enzymes (esp. Zyflo)Zyflo)
“ “Relievers”Relievers” (Bronchodilators)(Bronchodilators)
Relaxes muscles in the airways to help Relaxes muscles in the airways to help relieve asthma symptomsrelieve asthma symptoms
Should be taken as needed for symptomsShould be taken as needed for symptomsNeed to wait 1-2 minutes between puffs Need to wait 1-2 minutes between puffs
for best deposition of medication in the for best deposition of medication in the lungslungs
Overuse is a big warning sign indicating Overuse is a big warning sign indicating the child’s asthma may not be well the child’s asthma may not be well controlledcontrolled
Short-acting Inhaled Short-acting Inhaled BronchodilatorsBronchodilators
• Proventil, VentolinProventil, Ventolin (Albuterol)(Albuterol)• XopenexXopenex (Levalbuterol)(Levalbuterol) • Maxair AutohalerMaxair Autohaler (Pirbuterol)(Pirbuterol)• AlupentAlupent (Metaproterenol) (Metaproterenol)
For relief of acute symptoms or as preventive For relief of acute symptoms or as preventive treatment prior to exercisetreatment prior to exercise
Potential adverse effectsPotential adverse effectsTremors, tachycardia, headacheTremors, tachycardia, headache
Therapeutic issuesTherapeutic issues DDrugs of choice for acute bronchospasm rugs of choice for acute bronchospasm F29F29
AnticholinergicsAnticholinergicsAtroventAtrovent (Ipatromium Bromide)(Ipatromium Bromide)CombiventCombivent (Albuterol + Atrovent) (Albuterol + Atrovent)
For relief of acute bronchospasm, especially For relief of acute bronchospasm, especially if albuterol alone isn’t effective if albuterol alone isn’t effective
Potential adverse effectsPotential adverse effects Dry mouth, flushed skin, tachycardia Dry mouth, flushed skin, tachycardia
Therapeutic issuesTherapeutic issuesDoes not reverse allergy-induced Does not reverse allergy-induced
bronchospasm or block exercise-induced bronchospasm or block exercise-induced asthmaasthma
May have additive effect to beta-agonist, May have additive effect to beta-agonist, slower onsetslower onset
Systemic Systemic CorticosteroidsCorticosteroids
PediapredPediapredPrelonePrelonePrednisonePrednisoneOrapredOrapredPrevents progression of moderate to severe Prevents progression of moderate to severe
exacerbations, reduces inflammation exacerbations, reduces inflammation Potential adverse effectsPotential adverse effects
Short-term- increased appetite, fluid retention, Short-term- increased appetite, fluid retention, mood changes, facial flushing, stomachache. mood changes, facial flushing, stomachache. Long term- growth suppression, hypertension, Long term- growth suppression, hypertension, glucose intolerance, muscle weakness, glucose intolerance, muscle weakness, cataracts cataracts
Systemic Steriods Systemic Steriods ccontinued…ontinued…
• 2 or more bursts a year signifies poor 2 or more bursts a year signifies poor control and need for daily controllercontrol and need for daily controller
• 5 bursts/year in asthma is considered 5 bursts/year in asthma is considered “steroid dependent’’ and caution “steroid dependent’’ and caution should be usedshould be used
• Tapering of oral steroidsTapering of oral steroidsNot needed if less than 10-14 days of Not needed if less than 10-14 days of
burstburst
Herbal TherapyHerbal Therapy
Ephedra (Ma Huang)Ephedra (Ma Huang)Dangerous and should be avoidedDangerous and should be avoidedPotent CNS and CV stimulantPotent CNS and CV stimulantCan be a precursor for Can be a precursor for
methamphetamine methamphetamine FDA recently banned it’s use FDA recently banned it’s use
Many other herbal folk remedies Many other herbal folk remedies used by different culturesused by different cultures
Remember To...Remember To...
Ask about daytime and nighttime Ask about daytime and nighttime symptoms and the frequency of symptoms and the frequency of albuterol usealbuterol use
Assess current severity/controlAssess current severity/control If poor control, refer to Health Care If poor control, refer to Health Care
Provider to assess for need for Provider to assess for need for controller/s or dosage change (step up controller/s or dosage change (step up or step down)or step down)
Remember To Remember To (Continued)(Continued)……
Be aware of meds that are not being Be aware of meds that are not being used appropriately and educate student used appropriately and educate student and family accordingly and family accordingly
Give guidance and suggestions how to Give guidance and suggestions how to better obtain meds and gadgets for home better obtain meds and gadgets for home AND schoolAND school
Consider family dynamics when Consider family dynamics when communicatingcommunicating
Check inhaler technique at every Check inhaler technique at every opportunityopportunity
Reinforce successful behavior Reinforce successful behavior