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Asthma Medication Administration
Marcia Winston, MSN,CPNP,[email protected]
The Children’s Hospital of PhiladelphiaDivision of Pulmonary Medicine
Clinical Management of Asthma
NIHNIHNHLBINHLBINAEPPNAEPPExpert Report 3 released in 2007 (1991, 1997, 2002)Expert Report 3 released in 2007 (1991, 1997, 2002)
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
EPR-3 Classification of Asthma Severity
Determines treatmentEach age group (0-4 years of age, 5-11 years of age and
12-adult)
Six stepsLong-term control: preferred and
alternativeStep 1 Intermittent asthmaStep 2-6 Persistent asthma
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
EPR-3: Goals of Therapy: Control of Asthma
REDUCE RISK
Prevent recurrent:ExacerbationsE.R. visitsHospitalizations
Prevent loss of lung function/for children prevent reduced lung growth
Provide optimal pharmacotherapy with minimal or no adverse effects of therapy
Medications to Treat Asthma
Two major categories of medications are:
Long-term control Quick relief
QVAR/beclomethasone dipropionate HFA40mcg, 80mcg/inhalation
Pulmicort Flexhaler/budesonide90 mcg and 180 mcg/inhalation
Pulmicort Respules/budesonide0.25mg/2ml, 0.5mg/2ml and 1mg/2ml nebulizer
suspension
Alvesco (ciclesonide) 80 mcg, 160 mcg/inhalation
Flovent HFA/fluticasone propionate44mcg, 110mcg, 220mcg/inhalation
Asmanex Twisthaler/mometasone furoate110mcg, 220mcg/inhalation
Medications to Treat Asthma:Quick-Relief
Used in acute asthma episodes, relieve symptomsGenerally they are short-acting beta2-agonists:
albuterol (ProAir HFA, Proventil HFA, Ventolin HFA) levalbuterolpirbuterolipratropium Systemic corticosteroids
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
than2 times/year
*one albuterol MDI=200 puffs/medicine=100 two puff doses*
Medication Administration
Oral Metered dose inhaler (MDI) and spacer
Dry powder inhaler(DPI) Air Compressor/Nebulizer Injection
Asthma Devices:Medication Administration
Metered dose inhalers (MDIs) w/CFC propellant have been discontinued
Maxair (pirbuterol) will be off the market in 2013
Asthma Devices:Medication Administration
Metered dose inhalers (MDIs) w/ HFA (as of 2008) require maintenance: priming and rinsing
Medication Administration
One way valve holding chambers
Medication Administration
Dry powder inhalers (DPI)
Medication Administration
Nebulizer/air compressor
Medication Administration
Nebulizer/air compressor
InCheck Dial: Measures Inspiratory flow rate
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
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
Managing Asthma:Sample Asthma Action Plan
National Heart, Lung, and Blood Institute
Describes what medicines Describes what medicines to use and actions to take to use and actions to take when well and when when well and when symptomatic/for attacks symptomatic/for attacks and emergency and emergency instructionsinstructions
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