Name:
A 24-Year-Old with Asthma
Description:
A 24-Year-Old with Asthma
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/2af143a2-b29e-4d9d-a7b0-ec897351a919/thumbnails/2af143a2-b29e-4d9d-a7b0-ec897351a919.jpg?sv=2019-02-02&sr=c&sig=Qf7rya1qckpPzu0NvJNDmmIMBD1osPwXOZ06s4EC24k%3D&st=2024-04-29T20%3A06%3A54Z&se=2024-04-30T00%3A11%3A54Z&sp=r
Duration:
T00H07M17S
Embed URL:
https://stream.cadmore.media/player/2af143a2-b29e-4d9d-a7b0-ec897351a919
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/2af143a2-b29e-4d9d-a7b0-ec897351a919/16724647.mp3?sv=2019-02-02&sr=c&sig=UXCyeUZGC0NHqYvhMp68iFTb2znBZtNb3CWXonhlqYM%3D&st=2024-04-29T20%3A06%3A54Z&se=2024-04-29T22%3A11%3A54Z&sp=r
Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
♪ (music) ♪
CATHY: Hi. Welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine.
CATHY: Welcome to Episode 13: A 24-year-old with Asthma.
CHARLIE: Here's the question: A 24-year-old woman was diagnosed with asthma, four months ago, and was treated with inhaled albuterol, as needed. Since your last visit, she feels generally well and typically requires using her inhaler approximately 4-7 times a week when around pollen or cats, or when she's exercising in cold air. The inhaled albuterol generally helps, and she only requires a repeat round of inhalations approximately two times a week. She's on no other medications and is a non-smoker.
CHARLIE: Her only pet is a goldfish named Puffer. Cathy, what do you think so far?
CATHY: What we hear so far is that we have a young woman with asthma as her main diagnosis. This can be a hard diagnosis because there's really no single way to diagnose asthma. It's really a syndrome characterized by mostly reversible narrowing of their airways, and that leads to reduced airflow and symptomatic wheezing and dyspnea. Clinically, we use the history to help guide us. So, for example, episodic wheezing is a classic story. And also, sometimes we hear that a person would have atopy as a child.
CATHY: Another way we can help guide the diagnosis is with pulmonary function lab tests. And there we would be looking for a reduced peak flow during episodes, or the presence of an obstructive ventilatory defect.
CHARLIE: I'll also point out there are some newer techniques that are used to diagnose asthma and are focusing on detecting airway inflammation. The most commonly used one right now is measurement of exhaled nitric oxide concentration, although this is not yet in routine clinical practice. Also, recall that while the airway obstruction is the hallmark of asthma, the sensitivity of a single spirometric examination for obstruction is low because this is by definition an episodic disease. So Cathy, what about the reported triggers in this patient?
CATHY: So, in her history we hear that pollen, cats, and exercise done in cold air, usually require her inhaler. These are typical triggers for asthma exacerbations. But we also think about cigarette smoke and infections as other common precipitants.
CHARLIE: How do we approach the treatment of asthma?
CATHY: There are two main goals of treatment. So, the first goal is to treat the acute symptoms, and we typically do this with short-acting bronchodilators. These strategies are called rescue therapy. And the second goal is to avoid the acute symptoms altogether, and this we call the controller therapy. This is done by reducing airway inflammation and using long-acting drugs, like bronchodilators. In this case, our patient was only on albuterol, which is a short-acting bronchodilator, and that quickly relaxes the airway smooth muscle.
CATHY: Albuterol is a beta2-agonist, and that's the most common bronchodilator used in asthma. Short-acting anticholinergic medications, such as glycopyrrolate, may also be used as rescue therapy, but these are generally less effective. And these medications have no effect on the underlying inflammatory process so are not sufficient to control asthma in patients with persistent symptoms.
CHARLIE: So, you've mentioned the short-acting medications are called rescue therapies. How do we define the controller therapies?
CATHY: So, these are really anti-inflammatory medications mostly, and some guidelines will suggest that all patients with asthma be on at least one anti-inflammatory medication. Inhaled corticosteroids are the most effective anti-inflammatory agents that are used in asthma therapy, and they work because they reduce the inflammatory cell numbers and their activation in the airways. Another class of medications are the antileukotrienes. An example of this being montelukast.
CATHY: This blocks the cysteinyl leukotriene receptors and provides modest clinical benefit in asthma. They are less effective than inhaled corticosteroids in controlling asthma and have less effect on airway inflammation. But they can be useful as add-on therapy in some patients who aren't controlled with low doses of inhaled corticosteroids. Although, remember that they're not usually as effective as long-acting beta-agonists, such as salmeterol.
CHARLIE: What about new biologic treatments?
CATHY: There are some new biologic treatment options. One example is omalizumab, and this binds to circulating IgE, regardless of allergen specificity. They form small, biologically inert IgE and anti-IgE complexes, and it does this without activating the complement cascade. These drugs are really expensive, though, and there is still controversy about which patients would benefit most.
CHARLIE: So, let's just summarize that. We've talked about rescue therapy, and we were mentioning controller therapy which usually starts with an anti-inflammatory. There are some other classes of agents that are used. But it's also important to point out that the most commonly used second line of controller therapy is a long-acting bronchodilator; and typically, those are the long-acting beta-agonists, such as salmeterol. Alright, so let's summarize this case.
CATHY: So, we have a 24-year-old asthmatic on an inhaled short-acting beta-agonist, as needed. With this treatment, she's still using her inhaler 4-7 times a week, which is pretty regular use and points to the fact that her disease is not adequately controlled. Once a patient is using a rescue inhaler more than twice a week, they should start an anti-inflammatory medication.
CHARLIE: Okay. Let's get to the question now. The question asks, based on this information, you advise which of the following? a) Add inhaled beclomethasone; b) Add inhaled salmeterol, twice a day; c) Add inhaled tiotropium; d) Continue the present therapy; or e) Think of a new name for the goldfish named Puffer.
CATHY: Obviously, changing the name of the goldfish won't do anything for her asthma, and continuing present therapy isn't a good option either. The patient is using her rescue medication frequently, so I think we need to add a controller medication. Of the choices listed, inhaled beclomethasone-- which, remember, is an inhaled corticosteroid-- is the correct answer. Inhaled salmeterol-- which is a long-acting beta agonist, and inhaled tiotropium-- which is a long-acting anticholinergic drug, can be added subsequently if symptoms aren't controlled with the original therapy.
CATHY: So, I would go with a) inhaled beclomethasone.
CHARLIE: And do you typically have a quick order, how you usually sequence these medications?
CATHY: First, I start with an inhaled corticosteroid to reduce airway inflammation. And I also add to that a short-acting beta-agonist, which people take, as needed, for symptom control. Then I do a long-acting beta-agonist, if needed, and then high-dose inhaled corticosteroids or oral corticosteroid, or azithromycin. And then, less commonly used agents if the disease is still severe.
CHARLIE: And I would just add, if a patient is not well-controlled on those medications, then it's time to involve a specialist because they may be using, or they may need one of the new biologic therapies. So, the teaching point here is that you judge asthma control by the frequency of use of rescue inhalers. And as the asthma gets worse, you sequentially add therapies, starting with inhaled corticosteroid, to try to improve the control of disease. However, as we mentioned earlier, some experts are recommending that you initiate controller therapies even in mild cases of asthma, as part of the initial treatment regimen.
CATHY: And for more information, you can read about this in Diseases of the Respiratory System, chapter on asthma. ♪ (music) ♪