1. Asthma Medication Administration Marcia Winston, MSN,CPNP,AE-C winstonm@email.chop.edu The Children’s Hospital of Philadelphia Division of Pulmonary Medicine

2. Clinical Management of Asthma NIHNHLBINAEPP Expert Report 3 released in 2007 (1991, 1997, 2002)

3. Level of Severity -EPR-3 To be determined at time of Diagnosis to Initiate Treatment Classification of level severity is based on assessment of:  Number of days/week symptoms occur  Number of night awakenings/month  Interference with normal activity  Peak Flow (PEFR) or FEV1 (forced expiratory volume in 1 second)  Exacerbations requiring oral corticosteroids

4. EPR-3 Classification of Asthma Severity Determines treatment Each age group ( 0-4 years of age, 5-11 years of age and 12- adult) Six steps Long-term control: preferred and alternative Step 1 Intermittent asthma Step 2-6 Persistent asthma

5. EPR-3: Goals of Therapy: Control of Asthma  REDUCE IMPAIRMENT  Prevent chronic and troublesome symptoms (in the daytime, at night, or after exertion)  Maintain (near) normal pulmonary function  Maintain normal activity levels (including exercise)  Infrequent use of SABA </= twice a week NOT including pre-treatment of EIB  Satisfy and meet patient/families expectations

6. EPR-3: Goals of Therapy: Control of Asthma  REDUCE RISK  Prevent recurrent: Exacerbations E.R. visits Hospitalizations  Prevent loss of lung function/for children prevent reduced lung growth  Provide optimal pharmacotherapy with minimal or no adverse effects of therapy

7. Medications to Treat Asthma Two major categories of medications are:  Long-term control  Quick relief

8. QVAR/beclomethasone dipropionate HFA 40mcg, 80mcg/inhalation

9. Pulmicort Flexhaler/budesonide 90 mcg and 180 mcg/inhalation

10. Pulmicort Respules/budesonide 0.25mg/2ml, 0.5mg/2ml and 1mg/2ml nebulizer suspension

11. Alvesco (ciclesonide) 80 mcg, 160 mcg/inhalation

12. Flovent HFA/fluticasone propionate 44mcg, 110mcg, 220mcg/inhalation

13. Asmanex Twisthaler/mometasone furoate 110mcg, 220mcg/inhalation

14. Medications to Treat Asthma: Quick-Relief  Used in acute asthma episodes, relieve symptoms Generally they are short-acting beta 2 -agonists: albuterol (ProAir HFA, Proventil HFA, Ventolin HFA) levalbuterol pirbuterol ipratropium  Systemic corticosteroids

15. Asthma: Under Control or Out of Control? Baylor Rule of Twos:  Take quick relief medicine > 2 times/week  Wake up at night due to asthma > 2 times/month  Refill quick relief inhaler prescription more than 2 times/year *one albuterol MDI=200 puffs/medicine=100 two puff doses*

16. Medication Administration  Oral  Metered dose inhaler (MDI) and spacer  Dry powder inhaler(DPI)  Air Compressor/Nebulizer  Injection

17. Asthma Devices: Medication Administration Metered dose inhalers (MDIs) w/CFC propellant have been discontinued Maxair (pirbuterol) will be off the market in 2013

18. Asthma Devices: Medication Administration Metered dose inhalers (MDIs) w/ HFA (as of 2008) require maintenance: priming and rinsing

19. 10/3/2014

22. Medication Administration  One way valve holding chambers

25. Medication Administration Dry powder inhalers (DPI)

26. Medication Administration  Nebulizer/air compressor

27. Medication Administration  Nebulizer/air compressor

28. InCheck Dial: Measures Inspiratory flow rate

29. Medication Administration Air Compressor and Nebulizer: As per Rubin & Fink, “Aerosol Therapy for Children”  Home versus hospital: not the same  No published data supports the use of the blow-by technique  Aerosol deposition studies suggest that virtually no drug enters the airway  If not using a mouthpiece then the mask should be close fitting  If the mask is not close fitting or patient is crying aerosol deposition can also be affected Respiratory Care Clinics of North America 7:2 June 2001

30. Asthma Out of Control *Frequent flyers* (symptoms, ER, hospital, over use of albuterol)  Assess and re-assess:  Observe patient’s medication administration technique, equipment and medications  Ask directly about adherence, “How often do you miss a dose of your long-term control medicine?”  Ask about the environment: pets and ETS.  Consider alternative diagnosis/comorbid conditions

31. Managing Asthma: Sample Asthma Action Plan National Heart, Lung, and Blood Institute Describes what medicines to use and actions to take when well and when symptomatic/for attacks and emergency instructions

32. Resources  Association of Asthma Educators-AAE: www.asthmaeducators.org  National Asthma Education and Prevention Program (EPR3 Guidelines) www.nhlbi.nih.gov/about/naepp/index.htm