1. Edward Omron MD, MPH, FCCPPulmonary, Critical Care, and Internal MedicineMorgan Hill, CA 95037408-778-0022deepbreath@docmron.comwww.docomron.com

2. Reversible inflammatory lung disease The airways of the lung are swollen andnarrowed resulting in wheezing Recurrent cough, chest tightness, shortnessof breath, and exercise limitation Symptoms worsen withexercise, infection, changes in weather, orat night. Can occur at any age or gender 3. Beta2 receptors lie within airway smooth muscleAlbuterol causes the muscle to relax and the airway to dilate 4. In 2009, 25 million Americans had asthma Of these 13 million have had an asthma attack In 2007 there were 3500 deaths fromasthma 63% of these deaths occurred in women The prevalence of adult asthma in CA 2009is 8% Asthma accounts for 50 billion health caredollars yearly 5. Evidence of airway disease and an objectivemeasure of airway function i.e. spirometry Wheezing, cough, tightness, shortness ofbreath are commonly reported Just because you wheeze doesnt mean youhave asthma! A diagnosis of asthma may last a lifetime and mayhave unintended consequences! May sure the clinician verifies the diagnosis beforeinitiating therapy 6. Pattern of symptoms Episodic vs continual; seasonal Onset, duration and frequency (weekly) Diurnal variations (Nocturnal) Aggravating Factors Environmental allergens(mold, dust-mite, cockroach) Occupational chemicals Family History Nasal Polyps Runny nose/congestion/heartburn 7. Blood Tests CBC with differential IGE level in some patients Region 14 Respiratory Allergy Profile fornorthern California Allergic Asthma Diagnose suspected IgE antibody-mediatedrespiratory reactions This test includes total IgE and 23 ImmunoCapspecific IgE allergens Bermuda grass, birch, cat epithelium anddander, cockroach, common ragweed, dustmite, dog dander, and mold (Alternariaalternata, Aspergillus fumigatus) 8. Asthma Clinical Suspicion Airway muscle spasm hyperreactivity All patients should undergo spirometry Be careful of office based spirometry in primarycare offices! Normal Spirometry does not exclude the diagnosis Methacholine bronchoprovocation to confirm Exercise challenge and testing in some cases 9. Not using medications correctly or unmotivated Diagnosis wrong or secondary diagnosis Secondary Gain steroid resistant Asthma phenotypes STOP SMOKING Approach Repeat spirometry and peak flow log Cardiopulmonary exercise testing Bronchoscopy High resolution CT of chest Immunologic markers 10. Pulmonary Specialist Referral Initially to confirm the diagnosis ALWAYS after life threatening asthmatic attack Exercise limitation not improving therapies Pregnant patients with asthma Other conditions complicate asthma(e.g., sinusitis, severe rhinitis, VCD, GERD) Patient is being considered for immunotherapy Occupational asthma evaluation 11. Most common potentially serious medicalproblem in pregnancy: 8% of pregnantwomen Higher risk of complications to includepreterm birth, low birth weight, congenitalmalformations, and perinatal death Pregnancy may affect the course of asthma Treatment reduces risk to both mother andinfant Choice of medications is key to preventadverse effects on the fetus 12. Shortness of breath in pregnancy Normal as gestation evolves Asthma, reflux, postnasaldrip, bronchitis, pulmonaryembolism, cardiomyopathy NO smoking Pregnancy class B medications Budesonide (inhaled steroid) Montelukast (leukotriene antagonist) Cromolyn puffer Necessary pregnancy class C medication Albuterol inhaler or nebulized therapy 13. There is no cure of asthma thus far in 2013 CONFIRM the diagnosis before anyaugmentation of treatment of regimens Rule out vocal cord dysfunction Cystic fibrosis Pertussis infection Reflux disease Interstitial Lung Diseases Severe persistent asthma is a great challengeto both the patient and the physician 14. Severe persistent asthmatics with allergiesand an elevated IgE antibody level IgE is an allergy antibody It binds to allergens and causes the release ofinflammatory mediators which makes asthmaworse Xolair binds to IgE antibody and turns it off Reduced medication use, symptoms, andimproved quality of life Cost about $1500.00 monthly Monthly subcutaneous injections 15. Severe asthmatics have excessive smoothmuscle in the airways BT is a non-drug procedure that reducesairway smooth muscle by applying heat tothe airways This reduces the frequency of asthma attacks Three outpatient procedures performedthree weeks apart under sedation 16. Severe exacerbations: 32% reduction Emergency Department Visits: 84%reduction Days missed from work or school: 1.3 vs3.9 days Asthma Quality of Life Score: BT 1.35 vs1.16 No significant adverse effects for up to 5years 17. FDA Indication: approved for the treatmentof severe persistent asthma in patients 18years or older whose asthma is not wellcontrolled on inhaled corticosteroids andlong acting beta agonists Exercise limitation persists despiteaggressive inhalational and oral therapeuticagents. 18. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm http://www.thoracic.org/education/breathing-in-america/resources/chapter-3-asthma.pdf NEJM 2006;35:2689-2695 NEJM 2009; 360: 1002-1014 Am J Respir Crit Care Med 2012; 185: 709714 Lancet 2012; 380: 651-659 NEJM 2009; 360: 1862-1869