Asthma Grand Rounds

Questions and Answers

April 22, 2014 9:30-11:30am

  1. Dr. Barone, when do you use a short-acting beta agonist (SABA) vs. a long-acting beta agonist (LABA) inhalers?

Long-acting bronchodilators(LABA) should only be used in combination with an inhaled steroid as ADD-ON therapy. LABA’s should never be used as single therapy for any type of asthma. Also, it is recommended to use LABA’s cautiously in African American population due to some studies suggesting a possible increased risk of death from asthma with use of LABA’s in this group.

  1. Can you talk about spacers? Do insurance companies cover them?

Spacers should more accurately be called a chamber, as a chamber has a one-way valve that holds medication and allows the patient to breathe in the medication without great timing. A spacer still requires good timing between dispensing and inhaling the medication and does not contain a valve.

Chambers are typically covered by Medicaid plans. For privately insured, a co-pay is usually required for durable medical equipment, or may not be covered. We recommend getting free samples whenever possible:)

  1. What are the biggest compliance issues related to asthma?

The biggest compliance issues related to asthma are lack of adherence to daily medications. We recommend using claims data or pharmacy data through your primary insurance carriers to assess prescription refills and medication use. You can typically access this in your EHR or through a web-based access provided by your main insurance providers by formal request.

Prior to increasing a dose of medication, you should assess, ICE

Inhaler Technique- check to make sure technique is appropriate for device

Compliance- adherence to prescribed medication regimen. Consider using higher doses less often to ensure recommended dose is achieved.

Environment- are they in season? New pet? Water damage in the house? Visible mold? Furnace turned on? etc.

  1. Describe a possible exercise challenge test in the school-based health center that could help with appropriate diagnosis.

First and foremost, an exercise-challenge test should ONLY be done on a student that has a NEGATIVE pre-post spirometry- in other words a preliminary spirometry is NORMAL. Never do an exercise challenge on a

patient that demonstrates any type of obstruction on spirometry. If there is obstruction on spirometry, the student has PERSISTENT asthma and NOT EIB. The exercise challenge test is purely to determine EIB, and not EIA.

Generally speaking, performing pre-exercise testing, and performing an exercise for 6- 8 minutes that typically induces symptoms to 80% of maximum heart rate (220-age in years x 0.8), followed by post-exercise spirometry is recommended. a decline in FEV1 by 10-15% is considered diagnostic for EIB.

*** Caution should be used by the clinician to avoid situations in which liability may be an issue- (i.e. stairs, etc).

  1. How do we get an asthma action plan from a primary care provider?

We suggest that you communicate with the PCP via telephone, and completing a medical release with the patient and forwarding the information to the provider. Otherwise, asking the student to bring in his/her APP may be necessary. Completing an AAP yourself, and communicating the AAP to the PCP is another way to go. That way, we are communicating our plan of care to the PCP, and they are aware of our treatment interventions.

  1. If you think the patient is “out of shape” what advice to you give and what is your treatment plan? When do you see the patient back?

The treatment plan would be to continue conditioning with the team. Following up with the patient 2 weeks into the season to see if symptoms persist. Of course, normal spirometry and/or exercise testing can rule-out an EIB diagnosis or asthma diagnosis.

  1. It was my understanding that only who require a controller medication need an asthma action plan. It is not written as such in the reporting tools.

According to the reporting requirements, asthma action plans are required for ANY diagnosis of asthma (493.xx codes), excluding EIB (493. 81). Therefore, be careful how you CODE your EIB. If you code as asthma, it will require an AAP. For example, students who have symptoms with exercise and colds, DO NOT have EIB, but have intermittent asthma and SHOULD have an AAP.

  1. If a patient has EIB related to their sport, when would you have them re-start using their medication? Just with conditioning, or also with “easy exercise” like a “pick up game.”

I will typically instruct the student to use their inhaler PRIOR to any activity that they know induces symptoms. If a “pick up” game does not typically induce symptoms, prophylaxis is not necessary. However, the student should ALWAYS carry their inhaler. Regardless of severity of asthma, all severities have an equal risk of dying from an exacerbation. In this situation, it is very important to make sure that ordinary activity does not trigger symptoms, as that could indicate asthma triggered by exercise, and is a different diagnosis than EIB.

  1. Where can we find the resource list for the studies you reviewed in this presentation?

Information can be found in the RESOURCES TAB and by clicking on the PAPERCLIP ICON at the bottom right screen.

  1. So do you Rx Fish Oil supplements if they are not eating enriched foods? If so, how much per day?

See Summary Statement 49 and Reference 34

  1. Where is the PowerPoint available?

Information can be found in the RESOURCES TAB and by clicking on the PAPERCLIP ICON at the bottom right screen.

  1. If the school-based clinic does not perform spirometry, do you recommend referral to the primary care, if available, for the diagnosis?

Ideally, you would have a spirometer in your practice setting. When a spirometer is not available, it would be best practice to refer for spirometry. However, if a student is participating in a sport, I would not clear them until they had diagnostic spirometry, or were prescribed an inhaler to use with activity in the meantime. Each clinician should work out their personal standard of care.

  1. Are you looking for the cpt code of asthma plan code at every visit, or annually as long as there are no changes? I am assuming you are only looking for this at primary diagnosis visit for asthma.

EVERY patient with a diagnosis of asthma should have an asthma action plan. Many times in the SBHC setting you do not see the student at initial diagnosis. Every student in your clinic should have an asthma action plan in the chart, and it should be reviewed AT MINIMUM annually. Therefore, we are only looking for the code annually, but it is not only provided at initial diagnosis as some patients have never received an asthma action plan from a provider.

  1. Does normal spirometry, negative review of systems, and no past medical history need a cardiac review?

Symptoms such as shortness of breath in addition to lightheadedness, dizziness, pre-syncope or syncopal episodes, are typically related to NON-cardiac diagnoses, ie heat stroke or anxiety. An absence of symptoms prior to a syncopal or pre-syncopal episode or an episode that occurs DURING activity is actually more worrisome and suggestive of heart disease in children and should be referred to Cardiology.

Children with poor exercise tolerance, with or without wheezing, and other cardiac signs (poor perfusion, decreased pulses. poor growth, tachycardia, arrythmia, murmur, etc) also need a cardiac referral.

Use of a spirometer should help to confirm a respiratory condition vs a cardiac condition. Other options include starting with chest xray or EKG prior to Cardiology referral.

  1. Can you talk about clients who have asthma and severe allergies? Treatment plan... any difference?

A student with significant allergies requires very good management of allergy symptoms to optimally control asthma symptoms. ONE AIRWAY! The upper airway significantly effects the lower airway. Treatment of allergic rhinitis depends on they symptom presentation. Treatment of CONGESTION can often alleviate shortness of breath symptoms with exercise as poor nasal flow and mouth breathing can mimic or contribute to EIB. The PREFERRED treatment is a nasal steroid. LTRA’s (Singulair) can be used as a substitute if the patient is intolerant to nasal sprays. However, Singulair only block THREE of the chemical mediators versus a steroid that blocks ALL of the chemical mediators associated with inflammation which number in the the hundreds. ITCHING and WATERY symptoms are best managed with an antihistamine. The additions of guaifenesin, and sudafed are also options for congestion. SINGULAIR would be a preferred add on therapy for an asthmatic with significant allergic disease.

Avoidance education is another important measure in treating asthmatics with significant allergies.

  1. Can you talk about pulse oximetry as a pre/post exercise test?

Pulse oximetry has no clinical relevance in exercise testing for asthma.

ABR 5.2014