1. Management of Pulmonary Disease and Asthma Terry Flotte, M.D. University of Massachusetts Medical School

2. Overview of Presentation Impact of Pulmonary Disease: Haiti and the World Causes of Acute and Chronic Pulmonary Syndromes Chronic Outpatient Management of Asthma

4. Risk factors for Pneumonia morbidity and mortality (WHO-GAPP) Nutritional deficiency –Shortened breast-feeding time –Underweight –Zinc deficiency Indoor air pollution –Wood-burning –Tobacco smoke –Urban air pollution Immunization status (measles, pertussis, Hib, Pneumococcus) Case Management –Prompt detection and Antibiotic therapy HIV status

5. Management of Acute Lower Respiratory Tract Infection Rule-out and treat malnutrition Evaluate for signs of sepsis or acute decompensation –In this case, stabilize, give first dose IM and ship to hospital Oral therapy with TMP/sulfa or amoxicillin Parenteral therapy with Amp/Pen and Gentamicin or Ceftriaxone

6. Evaluation of children with recurrent pneumonia in Haiti Heffelfinger, et al., Peds Inf Dis Journal 2002 –Screened for TB, immune deficiency, HIV –Most were sporadic –Only association was with Asthma

7. © 2002 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.2 Table 1 Evaluation of children with recurrent pneumonia diagnosed by World Health Organization criteria. HEFFELFINGER, JAMES; DAVIS, TIMOTHY; GEBRIAN, BETTE; BORDEAU, ROYNELD; SCHWARTZ, BEN; DOWELL, SCOTT Pediatric Infectious Disease Journal. 21(2):108-112, February 2002. Table 1. Characteristics of study subjects and potential risk factors for pneumonia

8. © 2002 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.4 Table 3 Evaluation of children with recurrent pneumonia diagnosed by World Health Organization criteria. HEFFELFINGER, JAMES; DAVIS, TIMOTHY; GEBRIAN, BETTE; BORDEAU, ROYNELD; SCHWARTZ, BEN; DOWELL, SCOTT Pediatric Infectious Disease Journal. 21(2):108-112, February 2002. Table 3. History of wheezing, matching for community health worker and adjusting for age

9. The Other Side Adding simple markers like history of previous respiratory distress and response to brochodilator therapy to the existing WHO guidelines it is possible to reliably differentiate pneumonia from acute exacerbation of asthma…. Bringing the overuse of antibiotics from 78.9% to 26.3% (p <0.001) Redefining the WHO algorithm for DX of PNA w/Simple Additional Markers Savitha MR. Khanagavi JB. Indian Journal of Pediatrics. 75(6):561-5, 2008 Jun.

10. Diagnosis of Asthma Episodic symptoms of airflow obstruction or airway hyperresponsiveness are present –Cough –Wheeze –Difficulty breathing/chest tightness Airflow obstruction is at least partially reversible (low FEV1, low FVC, low flows) Alternative Diagnoses are excluded

13. “All that wheezes (or coughs) is not asthma” Allergic rhinitis Foreign body Vocal cord dysfunction Vascular rings or laryngeal webs Laryngotracheomalacia External compression by lymph nodes or tumor Viral bronchiolitis Obliterative bronchiolitis Cystic fibrosis Bronchopulmonary dysplasia Heart disease Gastroesophageal reflux with or without aspiration

18. Classification of Asthma Severity: The intrinsic intensity of the disease process –Intermittent –Persistent: Mild, Moderate, Severe Control: The degree to which manifestations are controlled Responsiveness: the ease with which control is achieved by therapy

20. Important Environmental Factors in Asthma control Tobacco Smoke exposure Other irritants: auto exhaust, dust, chemicals Allergens –Dust mites –Molds –Cockroach –Animal fur/dander (cat, dog, other) –Outdoor aeroallergens

21. Co-morbid Conditions GE reflux Obstructive Sleep apnea Rhinitis or Sinusitis Stress and depression Obesity Allergic Bronchopulmonary Aspergillosis

23. Short-acting Beta Agonist (SABA) Albuterol/Salbutamol in various forms –MDI can be used in all ages all severities –Nebulizer acceptable alternative Levalbuterol SQ epi may still have a role

24. Inhaled Corticosteroids (ICS) Fluticasone Budesonide Others

25. Combination Inhalers (ICS + LABA) Advair –Fluticasone + Salmeterol Symbicort –Budesonide + Formoterol

26. Leukotriene inhibitors and others Montelukast Cromolyn Nedocromil

27. Sequential therapy Daily Controller Med –ICS, montelukast, etc based on steps SABA –up to every 6 hours as needed only Oral Prednisone, prednisolone, or methylpredniosolone short course: –1 to 2 mg/kg/day x 5 days

33. Management of Acute Asthma Exacerbations Assessment Oxygenation Bronchodilators Systemic Steroids Adjunctive therapies

35. …and now Dr. Tina Slusher….

36. A 10-year old known asthmatic presents with 3 day history of cough, wheeze with exertion and mild dyspnea. Has not been user controller medicine. Feels better after albuterol inhaler use.

37. FEV1 = 60% predicted FVC = 100% predicted FEV1/FVC ratio = 60% predicted FEF 25-75 = 45% predicted Peak flow = 100%

38. A 7-year old with known asthma presents with an acute exacerbation and is tachyneic, with a respiratory rate of 60 bpm. You obtain an ABG: pH/pCO2/pO2/bic 7.42/42/51/22 What is the most likely cause of hypoxemia? How can CO2 and O2 be so disparately affected? What level of monitoring is appropriate for this patient?