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Managing Asthma During Pregnancy and Lactation Mary McMahon, RNC, MS

Managing Asthma During Pregnancy and Lactation Mary McMahon, RNC, MS. Guidelines for Asthma during Pregnancy. National Asthma Education and Prevention Program (NAEPP) Working Group Report on Managing Asthma during Pregnancy: Recommendations for Pharmacologic Treatment – Update 2004

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Managing Asthma During Pregnancy and Lactation Mary McMahon, RNC, MS

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  1. Managing Asthma During Pregnancy and Lactation Mary McMahon, RNC, MS

  2. Guidelines for Asthma during Pregnancy National Asthma Education and Prevention Program (NAEPP) • Working Group Report on Managing Asthma during Pregnancy: Recommendations for Pharmacologic Treatment – Update 2004 American College of Obstetrician and Gynecologist (ACOG) • Asthma in Pregnancy Bulletin 90, 2008, Reaffirmed 2012

  3. Let’s Discuss… • Asthma Control • Management of Asthma during Pregnancy and Lactation • Educational Resources for Patients and Professionals

  4. Respiratory Physiology in Pregnancy Changes in respiratory status occur more rapidly in pregnant patients than in nonpregnant patients

  5. Effects of Pregnancy on Asthma When women with asthma become pregnant: • One-third of the patients improve, • One-third worsen, • Last third remain unchanged

  6. Effects of Asthma on Pregnancy • One of the most common chronic medical problem that occurs during pregnancy • Approximately 8% of pregnancy women • Let’s take a deep look at this……..

  7. Asthma is Characterized by • Inflammation of the airways, with an abnormal accumulation of eosinophils, lymphocytes, mast cells, macrophages, dendritic cells, and myofibroblasts. • Leads to a reduction in airway diameter caused by smooth muscle contraction, vascular congestion, bronchial wall edema and thick secretions.

  8. Airway Inflammation& Symptoms Risk Factors Inflammation Airway Obstruction Airway Hyperresonsiveness Precipitating Factors Clinical Symptoms Adapted from NAEPP Expert Panel Report 2 & 3

  9. Clinical Symptoms • Cough • Wheeze • Shortness of breath • Chest tightness

  10. Asthma • Impairment • Frequency and intensity of symptoms • Functional limitations • Risk • Likelihood of asthma exacerbations • Progressive decline in lung functions • Risk of adverse effects from treatment Adapted from NAEPP, Expert Report 3

  11. What Are Goals of Treatment? • Your patient should be able to • Participate in activities, including physical activity without asthma symptoms • Sleep through the night without asthma symptoms • Have normal or near normal lung function • Minimal use of short-acting inhaled beta2-agonist • Have few, if any side effects from medication taken

  12. Goals of Therapy:Asthma Control • Reduce impairment • Prevent chronic and troublesome symptoms (e.g. coughing or breathlessness in the daytime, in the night or after exertion) • Require infrequent use (<2 days a week) of SABA for quick relief of symptoms • Maintain (near) normal pulmonary function • Maintain normal activity levels (including exercise and other physical activity and attendance at work or school) • Meet patients’ and families’ expectations of and satisfaction with asthma care NAEPP Expert Panel Report 3

  13. Goals of Therapy:Asthma Control • Reduce risk • Prevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizations • Prevent progressive loss of lung function; blood oxygenation that ensures oxygen supply to fetus • Provide optimal pharmacotherapy with minimal or no adverse effects NAEPP Expert Panel Report 3

  14. Treatment Goal - Pregnant Asthma Patient To provide optimal therapy to maintain control of asthma for maternal health and quality of live as well as for normal fetal maturation.

  15. When Asthma is not Controlled Maternal health risks include: • High Blood Pressure • Preeclampsia, which can affect • Placenta • Kidneys • Liver • Brain

  16. When Asthma is not Controlled Risks to the Fetus include: • Perinatal Mortality • Intrauterine Growth Restriction • Preterm Birth • Low Birth Weight

  17. Differential Diagnosis Patients presenting with new respiratory symptoms during pregnancy; Is it......? • Dyspnea • GERD • Chronic cough from postnasal drip • Bronchitis

  18. Goals • What are the patient’s and family’s personal goals?

  19. Asthma Severity • Severe persistent asthma 4 • Moderate persistent asthma 3 • Mild persistent asthma 2 • Intermittent asthma 1

  20. Classification of Asthma Severity and Control in Pregnant Patients

  21. Asthma Severity Dictates only initial therapy in the untreated patients. • Intermittent asthma is appropriately treated with only short-acting beta-agonists for rescue and prevention of symptoms, such as those that occur with exercise. • Persistent asthma should be treated with inhaled corticosteroids (ICS). If symptoms or rescue inhaler use are daily, nighttime awakenings at least weekly, there is moderated interference with normal activities, or there is reduced pulmonary function when not having symptoms, then initial treatment should be medium doses of ICS or a combination of low-dose ICS and a long-acting inhaled beta-agonist. Once the patient with asthma is receiving controller medication, further adjustments to asthma therapy are based on the level of asthma control.

  22. Spirometry • Get Valid Spirometry Results EVERY Time • DHHS (NIOSH) Publication No. 2011-135

  23. Stepwise Approach to Asthma Int. Asthma Persistent Asthma Step 6 Step Up Assess Control Step Down Step 5 Step 4 Step 3 Step 2 Step 1 Long Term Control Medication Patient Education, Environmental Control, Comorbidities Quick Relief Medication for all patients

  24. Level of Asthma Control • Well-Controlled • Not Well-Controlled • Very poorly controlled • Many patients experience poor control of asthma Adapted from NAEPP, Expert Report 3

  25. Asthma Control Test • Simple self assessment questionnaire (takes few minutes) • Patient fills out while waiting • 70-75% accuracy in determining level of asthma control • Validated & Guidelines recommended • Educates the goals of ‘Well Controlled’

  26. Asthma Control Test • 5 items completed by the patient reflecting on the past 4 weeks • Daytime and nighttime symptoms • Activity limitations • Rescue inhaler use • Add up: 0 - 25 • > 20: well controlled • 16 – 19: not well controlled • < 15: very poorly controlled

  27. A 23 year old patient, G1P0 at 11 wks with history of asthma was seen by her provider with recurrent cough and wheeze. She admits to waking twice per month with a cough and requiring albuterol twice per week. The provider knows that according to the EPR-3 guidelines, this woman’s level of asthma control would be classified as: • Very well controlled • Well controlled • Not well controlled • Very poorly controlled

  28. Controlling Asthma Triggers • Smoking • Avoiding Allergens • Pollen • Dust mites • Pet dander

  29. Team Approach to Managing Asthma During Pregnancy • Expectant Mother and her family • Obstetrical Provider • Primary Care Provider • Asthma Specialist • Refer to a specialist if asthma is poorly controlled.

  30. Asthma Action Plan • Everyone with asthma should have an asthma action plan. • Developed with patient and provider • Shows daily treatment • What kind of medicines to take • When to take medicines • How to control asthma long term • How to handle worsening asthma • When to call the doctor or go to the ED

  31. U.S. FDA Pregnancy Categories

  32. How Medications Work? Bronchodilator Anti-Inflammatory

  33. Stepwise Approach to Manage Asthma Step Up Step Down

  34. Stepwise Approach to Asthma Asthma Medications Quick relief Taken when asthma symptoms present Long term control Taken daily, even when asthma well controlled

  35. Stepwise Approach to Asthma Medications Preferred treatment Alternative treatment Consider variability in response based on the individual

  36. Stepwise Approach - 12 yrs-Adult (revised) Int. Asthma Persistent Asthma • Step 6 • Preferred • ICS • (high dose) • + • LABA • + • Oral • Corticosteroid • And • Consider • Omalizumab • (if allergens) • Step 5 • Preferred • ICS • (high dose) • & • LABA • + • Omalizumab • (if allergens) • Step 4 • Preferred • ICS • (med dose) • & • LABA • Step 3 • Preferred • ICS • (low dose) • Or ICS • (med dose) • & • LABA Step Up Assess Control Step Down • Step 2 • Preferred • ICS • (low dose) Step 1 SABA prn Long Term Control Medication Patient Education, Environmental Control, Comorbidities Quick Relief Medication for all patients (SABA) Adapted from NAEPP, Expert Report 3

  37. Quick Relief Medication All levels of asthma severity require short-acting beta2-agonist (SABA) Anyone with asthma can have a severe exacerbation

  38. Short-Acting Beta2-Agonists Used as a pretreatment before exercise Used to treat asthma symptoms Increased use >2 days per week indicates inadequate asthma control Regular use not recommended

  39. Long Term Control Medication Preferred treatment Inhaled Steroids Most effective long term control medication for mild, moderate and severe persistent asthma

  40. Inhaled Steroids Improve asthma control Improve quality of life Improve spirometry Decrease airway hyper responsiveness Prevent exacerbations Reduce severity of symptoms Reduce systemic steroids, ED visits, hospitalizations and death

  41. Inhaled Steroids Mometasone Twisthaler® Ciclesonide MDI Fluticasone MDI Budesonide Flexhaler ®, Respules® Beclomethasone MDI (HFA propellant)

  42. Comparative Daily DosageInhaled Corticosteroids Adapted from NAEPP Expert Panel Report 3 & ACOG Bulletin No. 90

  43. Inhaled Steroids Increased effect in lungs with decreased systemic side effects Side effects Thrush (oral candidiasis) Sore throat Hoarseness Dry mouth

  44. Combination Therapy Preferred treatment Varies with age The combination of long-acting inhaled beta2-agonists (LABA) added to low-to-medium doses of inhaled steroids leads to improvements in: Lung function Symptoms Reduced use of short-acting beta2-agonists Increase in inhaled steroid given equal weight

  45. Anti-IGE Treatment Omalizumab Approved for: Poorly controlled moderate to severe persistent asthma Year round allergies Individuals taking routine inhaled steroids Not recommended to initiate during pregnancy

  46. Oral Corticosteroids Action - Reduces and prevents inflammation Pills Prednisone Methylprednisolone Short course to speed recovery with moderate to severe exacerbation

  47. Medication Technique Is Important Check inhalation technique at every visit

  48. Medication Technique Is Important Patients should know How to use the device How to tell when the device is empty How to clean the device www.NJHealth.org

  49. Maintaining Asthma Control • Once asthma control achieved • Gradual reduction of pharmacotherapy (Step Down) • Monitor asthma control with the goal of providing optimal pharmacotherapy with minimal or no adverse effects

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