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Slide 1 - Update on Acute Asthma Carlos Camargo, MD, DrPH Emergency Medicine, MGH Channing Laboratory, BWH Harvard Medical School www.emnet-usa.org
Slide 2 - Outline of Presentation Background NAEPP guidelines Novel therapies Preventive interventions Summary
Slide 3 - ppt slide no 3 content not found
Slide 4 - Definition of Asthma Chronic lung disease characterized by: Airway narrowing that is reversible (± completely) either spontaneously or with treatment Airway inflammation Airway hyper-responsiveness to a variety of stimuli. Episodic dyspnea with associated wheezing Heterogeneous group with: Shortness of breath Wheezing Cough ATS. ARRD 1987
Slide 5 - NAEPP Guidelines, 1997 National Asthma Education and Prevention Program (NAEPP) Classification of chronic asthma: Mild intermittent asthma Mild persistent asthma (>2 days/wk, >2 nights/mo) Moderate persistent asthma Severe persistent asthma Inhaled corticosteroids (ICS) are “preferred treatment” for all patients with persistent asthma
Slide 6 - Epidemiology 17 - 27 million Americans (6-10% prevalence) 10 million office visits + 2 million ED visits + 500,000 hospitalizations + 5,000 deaths Major cause of school and work absences At least $12 billion per year Increasing burden for years ... but now flat (or  )
Slide 7 - Asthma Prevalence, 1980-2001 * 11.3 * 4.3 * 7.3 NHIS 2001
Slide 8 - Asthma Prevalence, 1980-2001 * 11.3 * 4.3 * 7.3 NHIS 2001
Slide 9 - Asthma Mortality, 1980-1999
Slide 10 - ED Visits for Asthma, 1992-2000 Visits in thousands NHAMCS Database
Slide 11 - MARC Founded 1996 Goal: To improve care of acute asthma & other airway disorders Funded by NIH, industry, foundations Emergency Medicine Network www.emnet-usa.org
Slide 12 - EMNet Sites (137 US sites) 9/22/04
Slide 13 - Potential for Improving Asthma ED is often used for asthma care 2 million ED visits per year Most asthma hospitalizations begin in the ED Among ED patients (MARC data): 74% adults (63% children) use ED for all “problem” asthma care 45% adults (31% children) receive all asthma Rx from ED With PCP: 63 + 61% for problem care; 24 + 25% for all Rx High-risk population
Slide 14 - ED Patients with Acute Asthma
Slide 15 - ED and Hospital Management: Goals Correct significant hypoxemia Rapidly reverse airflow obstruction Decrease likelihood of recurrence NAEPP, 1997
Slide 16 - ED and Hospital Management: Initial Treatment Mild-to-Moderate Exacerbation (PEF > 50%) Oxygen to achieve O2 sat > 90% Inhaled  2-agonist by MDI or neb, up to 3 in 1st hr Oral corticosteroid if no immediate response or if patient recently took oral corticosteroid NAEPP, 1997
Slide 17 - ED Treatment, 1992-1999 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 1993 1994 1995 1996 1997 1998 1999 Antiasthmatic Corticosteroid Antimicrobial % Usage National Center for Health Statistics, CDC ED Treatment, 1992-1999
Slide 18 - Systemic Steroids at Discharge P for trend <0.001
Slide 19 - ED and Hospital Management:Initial Treatment (continued) Severe Exacerbation (PEF < 50%) Oxygen to achieve O2 sat > 90% Inhaled high-dose 2 -agonist and anticholinergic by neb q 20 minutes or continuously for 1 hour Oral corticosteroid NAEPP, 1997
Slide 20 - ED and Hospital Management:Initial Treatment (continued) Impending or Actual Respiratory Arrest Intubation and mech ventilation with 100% O2 Nebulized 2-agonist and anticholinergic IV corticosteroid Admit to hospital intensive care NAEPP, 1997
Slide 21 - 2002 Update on Selected Topics Antibiotics not recommended for acute asthma ICS are preferred treatment for children of all ages with persistent asthma ICS + long-acting -agonist is the preferred treatment for moderate or severe persistent asthma in individuals age 6 and older NAEPP, 2002
Slide 22 - Dual Therapy with ICS + LABA (weeks)
Slide 23 - Dual Therapy with ICS + LABA (days)
Slide 24 - Novel Therapies in the ED IV magnesium Heliox IV leukotriene modifiers www.emnet-usa.org
Slide 25 - IV Mg for Acute Asthma – Admit Rate
Slide 26 - Heliox for Severe Acute Asthma – PEF
Slide 27 - IV Montelukast for Acute Asthma – FEV1
Slide 28 - ED-Initiated Preventive Interventions High-risk population Use of ED for “problem asthma” care + asthma Rx What interventions are feasible in the ED setting? Examples from MARC: ICS initiation at discharge from ED Asthma education programs Bridging the gap between ED & primary asthma care
Slide 29 - Initiation of ICS at Discharge *
Slide 30 - ICS after the ED -- Relapse at 20-24 Days
Slide 31 - Prevention of Repeat ED Visits
Slide 32 - Prevention of Fatal Asthma Suissa & Ernst, JACI 2001.
Slide 33 - Mission Statement To promote optimal asthma management and quality of life among individuals with asthma, their families and communities, by advancing excellence in asthma education through the Certified Asthma Educator process. National Asthma Educator Certification Board www.naecb.org
Slide 34 - ppt slide no 34 content not found
Slide 35 - Follow-up with PCP Philadelphia study randomized trial, 1 center, n=178 $25 intervention (free meds, taxi vouchers, 48-hr call) f/u with PCP: usual care (29%) vs. intervention (46%), p=0.02 RR=1.6 (95%CI, 1.1-2.4) EMF Center of Excellence Award Recently completed RCT at 9 EMNet sites 1 month: 50% increase in PCP follow-up (ACEP 2001) Baren et al, Ann Emerg Med 2001
Slide 36 - Follow-up with PCP Philadelphia study randomized trial, 1 center, n=178 $25 intervention (free meds, taxi vouchers, 48-hr call) f/u with PCP: usual care (29%) vs. intervention (46%), p=0.02 RR=1.6 (95%CI, 1.1-2.4) EMF Center of Excellence Award Recently completed RCT at 9 EMNet sites 1 month: 50% increase in PCP follow-up (ACEP 2001) 6 and 12 months: no diff in clinical outcomes … (ACEP 2002) Next steps … facilitated referral to specialists?
Slide 37 - Summary Asthma epidemiology NAEPP guidelines 1997: O2 prn, inhaled ß-agonist + antichol, systemic steroids 2002: ICS for children of all ages with persistent asthma ICS + LABA for age 6+ with moderate-severe persistent Novel treatments – severe exacerbations only Prevention at all clinical encounters! Start ICS at ED discharge … consider ICS + LABA Asthma education (brief) … consider outpatient session Arrange continuing care … consider referral to specialist