1. Is it Just Asthma or Should We Know More? Presented by: Karen Kiburz, BS, RRT, AE-C, CPFT Thayer Medical Director of Clinical Applications Tucson, AZ April 2016

2. Learning Objectives: After you have completed this training, you will be able to: 1. Asthma disease information: Highlight current US prevalence Define Asthma Describe causes and Symptoms 2. Basic anatomy and pathophysiology of Asthma: Describe the anatomy of the upper and lower airway Recognize the factors that influence the asthmatic process 3. Selecting the appropriate medication during an acute asthma episode: Identify controllers vs rescue medications Describe rescue medication delivery methods Explain the differences: spacers vs. holding chamber devices

3. In the United States approximately 22 million people are affected by Asthma¹ 18.7 million adults currently have asthma (8% of adults)¹ 6.8 million children currently have asthma (9.3% of children)¹ 3,630 deaths in 2013² 1. http://www.cdc.gov/nchs/fastats/asthma.htm 2. Deaths: Final Data for 2013, tables 10, 11[PDF - 1.5 MB] http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf

4. What is considered the most common chronic illnesses of childhood? 1. Obesity- Approximately 17% (or 12.7 million) of children and adolescents aged 2—19 years are obese http://www.cdc.gov/obesity/data/childhood.html 2. Diabetes- Approximately 1.25 million American children and adults have type 1 diabetes (2012). http://www.diabetes.org/diabetes-basics/statistics/ 3. Asthma- 6.8 million http://www.nhlbi.nih.gov/files/docs/guidelines/02_sec1_intro.pdf 1. Obesity 2. Asthma 3. Diabetes

5. Asthma Definition? Asthma is defined by the National Heart, Lung and Blood Institute as a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness and an underlying inflammation. http://www.nihlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report. August 28, 2007

6. What are the causes/triggers of Asthma? The exact cause of asthma is unknown. What we know is the airways of an asthmatic are often swollen or inflamed. This makes them extra sensitive to things that they are exposed to in the environment every day, or asthma "triggers." http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/learn-about-asthma/what-is-asthma.html

7. Host Factors and Environmental Trigger Host Factors (3): 1. Genetic- Parental asthma *Atopic (Allergic) - Predisposed to IGE 2. Innate Immunity- Childhood infections Environmental Triggers: Allergens Infections Exercise Stress Pollutions Weather http://www.nihlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report. August 28, 2007 3. Gender *Atopic is the most common type

8. Does a child need to wheeze to have asthma? Coughing BreathlessnessChest tightnessWheezing NO! http://www.nihlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report. August 28, 2007

9. Anatomy of the Respiratory System: Nasal cavity Nostril Lips Pharynx Larynx Trachea Right lung Left lung Rib Left bronchus Right bronchus Bronchioles Intercostal muscles Diaphragm Lower Airway Upper Airway http://pharmatips.doyouknow.in/images/2013.07/Introduction-To-Anatomy-Of-The-Respiratory-System-070431064180461.png

10. Normal Airway Muscles - Decrease airway lumen Bronchiole Normal airway lumen Inflammation Alveoli Air Trapping Muscle tightening Increased mucus Asthmatic process Bronchial Asthma Symptoms, Causes, Treatment and Natural Remedies, When You Have Asthma, http://Healthvigil.blogspot.com

11. Airway Hyperresponsiveness Airflow obstruction Symptoms Inflammation http://www.nihlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report. August 28, 2007 Contributing factors in the manifestation of Asthma

12. Trigger Mast Cell- inflammatory mediators (activators) Macrophage- M1 & M2 Increase inflammation Eosinophil Neutrophil Hypersecretion hyperplasia Vasodilation Pseudostratified epithelium cilia Nerve activation Plasma exudate Fibroblast Cholinergic reflex Airway smooth muscle Bronchoconstriction Sensory nerve activation Adapted from:

13. Asthma Medications Medications for asthma are categorized into two general classes: long-term control medications used to achieve and maintain control of persistent asthma and quick-relief medications used to treat acute symptoms and exacerbations. http://www.nihlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report. August 28, 2007

14. Asthma Rescue : Quick-Relief Medications  Short-acting beta₂-agonist, bronchodilators (SABA): Dilate the bronchi by a direct action on the beta₂- adrenoreceptors on the bronchial smooth muscle and relax the muscle. 4-6 hour duration of action.  SABA- Brand Name/generic: ProAir® HFA/albuterol sulfate*® HFA ProAir® RespiClick/albuterol sulfate powder Proventil® HFA/albuterol sulfate Proventil Ventolin ® HFA/albuterol sulfate Xopenex® HFA/albuterol sulfate® HFA hydrofluoroalkane (HFA) propellant http://www.nihlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report. August 28, 2007

15. Controller Medications Controller therapy is used daily to achieve and maintain symptom control of persistent asthma. Three Categories of Controller Medications: 1. Inhaled Corticosteroids (ICS) 2. Inhaled Long-acting Bronchodilators Anticholinergic bronchodilators (LAMA) Long-acting beta₂-agonist (LABA) in combination only 3. Combination Medication 1. Inhaled Corticosteroids: Are considered the most effective long term usage medication for control and management of asthma. Rinse and spit after use. QVAR® HFA/beclomethasone dipropionate HFA Pulmicort Flexhaler®/budesonide Aerospan®/flunisolide Arnuity® Ellipta®/fluticasone furoate (≥12 y.o) Flovent® Diskus®/fluticasone Propionate Flovent® HFA/fluticasone Propionate Azmanex® Twisthaler®/mometasone furoate Azmanex® HFA/mometasone furoate Alvesco® HFA/ciclesoinde http://www.nihlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report. August 28, 2007

16. Controller medications continued… Controller Medications:  Anticholinergics (short-acting): Competitive inhibition of muscarinic cholinergic receptors. Work by stopping the smooth muscles around the airways from tightening. Reserved for use in the Emergency Room.  Anticholinergic- Brand Name/generic Atrovent®/ipratropium  Anticholinergics/SABA- Brand Name/generic: Combivent® Respimat®/albuterol + ipratropium 2. Inhaled long-acting bronchodilators: Long-acting beta₂-agonist (LABA) only in combination with an ICS Anticholinergics  Long-acting beta₂-agonist (LABA): 12-24 hour duration of action  Generic Formoterol fumarate (+ ICS) Salmeterol Xinafoate (+ ICS) http://www.nihlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report. August 28, 2007

17. Controller Medications Continued… Controller Medications: Combinations 3. Combination drugs are medications that contain two different types of medication in the same inhaler in short-acting and long-acting combinations. Note: Combivent Respimat/Albuterol + ipratropium- Short-acting beta-agonist and short-acting anticholinergic combination medication  Long-acting beta₂-agonist and ICS combinations: Rinse and spit after use. LABA/ICS Brand/generic name: Symbicort®/Budesonide +Formoterol Breo® Ellipta®/Fluticasone furoate + Vilanterol (≥18 y.o.) Advair® HFA/Fluticasone + Salmeterol Advair® Diskus®/Fluticasone + Salmeterol Dulera®/Mometasone + Formoterol http://www.nihlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report. August 28, 2007

18. Medication Delivery Devices

19. What’s the difference?

20. Is it a Holding Chambers or a Spacer? Valved Holding Chamber Extends the mouthpiece of the MDI Contains a chamber for the medication to disperse Provides directionality Contains a valve system to help with coordination Regulated by the Food and Drug Administration (FDA) *May exhale into the device before actuating the medication “Spacer” Extends the mouthpiece of the MDI Contains a chamber for the medication to disperse Provides directionality No valve system Regulated by the FDA *Exhale away from the device

21. Valved Holding Chamber, Spacer or Neither?

22. Additional Resources Asthma and Allergy Network Mothers of Asthmatics, http://www.allergyasthmanetwork.org/ http://www.allergyasthmanetwork.org/ American Lung Association, http://www.lung.org/http://www.lung.org/ American Academy of Allergy Asthma & Immunology, http://www.aaaai.org/conditions-and-treatments/asthma.aspx http://www.aaaai.org/conditions-and-treatments/asthma.aspx Asthma and Allergy Foundation of America, http://www.aafa.org/page/welcome.aspx http://www.aafa.org/page/welcome.aspx NHLBI National Asthma Education and Prevention Program, http://www.nhlbi.nih.gov/about/org/naepp/ http://www.nhlbi.nih.gov/about/org/naepp/ Albuquerque Public Schools (APS) Asthma Program, http://www.aps.edu/nursing/asthma http://www.aps.edu/nursing/asthma

23. Were the objectives met? 1. Asthma disease information: Highlight current US prevalence Define Asthma Describe causes and Symptoms 2.Basic anatomy and pathophysiology of Asthma: Describe the anatomy of the upper and lower airway Recognize the factors that influence the asthmatic process 3. Selecting the appropriate medication during an acute asthma episode: Identify controllers vs rescue medications Describe rescue medication delivery methods Explain the differences: spacers vs. holding chamber devices

24. Thank You! Presented by: Karen Kiburz, BS, RRT, AE-C, CPFT Thayer Medical Director of Clinical Applications Tucson, AZ April 2016