Diagnosis and Management of Obstructive Lung Diseases

Diagnosis and Management of Obstructive Lung Diseases

ASTHMA: IS YOUR COMPANY AT RISK? Barbara Hickcox, RN, MS Asthma Coordinator Ohio Department of Health What Will We Talk About? What is Asthma? What is Occupational Asthma and how does it affect people?

How does asthma affect your organization? What does asthma cost your company? What can you and your company do about your risk? Company wide For individuals So Lets Talk About Asthma What is happening with asthma in the general population? Who has it? How many people have it? What is it? What does it look like?

What can be done about it? Hospital Discharges for Patients with a Primary Diagnosis of Asthma Ohio, 2003 Compared to Healthy People 2010 Goals 45 40 35 per 10,000 30 25 20 Ohio

HP 2010 39.5 15 25.2 25 10 12.8 5 11 7.7

0 0-4 5-64 65 + Age Group Source: Ohio Hospital Association Discharge Data Set, 2003, Analysis by Injury Prevention Section, BHPRR, Prevention, Ohio Department of Health ED Visits for Patients with a Primary Diagnosis of Asthma Ohio, 2003 Compared to Healthy People 2010 Goals

160 140 120 per 10,000 100 80 Ohio HP 2010 146 60 80

40 54 20 50 15.4 15 0 0-4 5-64

65 + Age Group Source: Ohio Hospital Association Discharge Data Set, 2003, Analysis by Injury Prevention Section, BHPRR, Prevention, Ohio Department of Health Asthma Mortality for Ohio, 2003 Compared to Healthy People 2010 Goals 100 87 90 80

per million 70 61 57 60 HP 2010 Ohio 50 40 30 19

20 10 13 3 2 5 3 7 0

<5 5-14 15-34 35-64 65+ Age Category Source: Ohio Department of Health, Center for Vital and Health Statistics, Year 2003. Ohio Asthma Almost 750,000 adults

8.5% of all Ohio adults 5.0% of Men 11.8% of Women 18-24 25-34 35-49 45-54 55-64 65+ 9.4%

7.9% 9.3% 7.7% 10.6% 6.9% Less than high school High School or GED Some College College Graduate Source: Centers for Disease Control and Prevention, Behavior Risk Factor Surveillance System, 2004 17.2% 8.9%

8.6% 6.0% Estimated Current Asthma Prevalence by Income, 2004 25 Percentage 20 15 10 5 OH US

16.3 11.1 13.2 8.5 8.8 7.3 5.2 6.9 5.6

6.6 0 <$15,000 $15,000-24,999 $25,000-34,999 $35,000-49,999 Income Source: Centers for Disease Control and Prevention, Behavior Risk Factor Surveillance System, 2004

$50,000+ Asthma is: Life-long inflammatory disease of lungs Excessive sensitivity of the airways Episodes of airway narrowing Mucous production Difficulty breathing - asthma episodes Some Ideas about Causes

Environmental Factors Indoor Air Hazards Outdoor Air Hazards Lack of exposure to the environment Genetic factors Infections and immune response Cause or Trigger? Cause

Causes Inflammation Probably combination of factors Longer term problem Underlying problem Trigger Stimulates reaction when inflammation present, i.e. asthma episode Usually an episodic, short term problem

May be the same as the cause Relationships Between Airway Inflammation, Airway Hyper-responsiveness, Airway Obstruction and Asthma Symptoms Stimuli Allergen Irritant Virus Cold air Exercise Activation of Inflammatory Cells Mast cells

Macrophages Lymphocytes Eosinophils T- Migration into Airways and Activation of More Inflammatory Cells Neutriphils LymphocytesInflammatory Mediators Eosinophils Monocytes

Inflammatory Mediators Airway Obstruction Airway Hyperresponsiveness Stimuli Allergen Irritant Virus Cold air Exercise Contraction of airway smooth

muscle Swelling Mucus secretion Asthma Symptoms Wheezing Shortness of breath Coughing Chest tightness What is an Asthma Episode?

Inflammation Irritation happens Swelling of airway Mucus is produced Airways narrow Breathing gets more difficult Limitation in activity What does an episode look like?

Varies from person to person Can develop suddenly or slowly Common symptoms Coughing Breathing speeds up Wheezing Air hunger Depression of chest tissue

Grayness of lips, fingertips Inability to talk, be active What Is Happening in the Lung? Normal Lung vs Lung During Asthma Episode Causes of Asthma Episodes Some sort of TRIGGER Environmental

Animals Fungi Insects Chemicals Dusts

Infections Exercise Stress Changes of temperature/relative humidity TRIGGERS! Consequences of Asthma

Less Breathing Capacity More visits to the doctor Emergency room visits Missed work and school Disrupted sleep Decrease in activity Limited activity Death What Can be Done About Asthma? Major Treatment Goals Assessment/Monitoring by objective tests

Education for a partnership in asthma care Control of environmental factors and comorbid conditions Pharmacologic therapy USDHHS, NHLBI, Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. NIH Publications NO. 07-4051, Revised August, 2007, Full Report, 2007. Assessment All wheezing is not asthma Airway narrowing is reversible to some extent in asthma

Often a process over time to diagnose Frequent bronchitis Cough at night Cough without illness Wheezing in bouts relieved by albuterol Tools for Monitoring Asthma

Spirometry Symptoms Peak Flow Meters Symptoms Not much Cough

Sleep disturbance Tightness in the chest Anxiety Shortness of breath Decreased ability to do multiple tasks Peak Flow Meters Peak Flow Monitoring 80% to 100% of personal best 50% to 80% of personal best < 50% of personal best

Good Job! Keep going. Begin agreed upon, written plan of action. Take short acting -agonist.agonist. Call primary care giver for further instructions. What Is Your Peak Expiratory Flow? Medications Controller Medications Inhaled Anti-inflammatory agents Long Acting Bronchodilators

Oral Anti-Leukotrienes Reliever Medications Inhaled Short-acting Beta2-Agonists Oral Corticosteroids Anti-cholinergics http://www.ama-assn.org/special/asthma/treatmnt/drug/drugtop.htm 100% Percent of days 80%

60% Prescribed use Overuse Underuse No use 40% 20% 0% 1 2

3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 S ubjects Pattern of Use for Inhaled Corticosteroids (ICS N=25) (Vargas et al. under Asthma Therapy Adherence

Enhanced Through Use of: Effective doctor-patient communication Education about asthma therapies, asthma selfmonitoring and asthma management Tailoring of asthma therapies and management regimens to match patients lifestyles and abilities Ongoing monitoring of patient adherence and asthma management Metered Dose Inhalers Breath Propelled Inhalers Why Use a Spacer?

Spacers and Holding Chambers Control Contributing Factors Identify possible triggers Reduce exposure to the trigger by: Removing the trigger from the environment, if possible Controlling aerosolization of the trigger Limiting personal contact with the trigger Management

A Decision Tool Green, Yellow, Red Stepping up to more treatment Partnership between Caregiver/Asthmatic The education process The asthmatic learns to make decisions Teaching the caregivers to assist Asthma Management Plan

So Is asthma controlled? Goals of Asthma Care Goal of asthma care is to maintain control of asthma with the least amount of medication and hence minimal risk of adverse effects. Reduce impairment Prevent Chronic or troublesome symptoms

Infrequent use of quick relief for symptoms Maintain (near) normal pulmonary function Maintain normal activity levels Reduce risk Prevent recurrent exacerbations: ED visits, hospitalizations Prevent progressive lung function loss Provide optimal pharmacotherapy w/ minimal/no adverse effects USDHHS, NHLBI, Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. NIH Publications NO. 07-4051, Revised August, 2007, Full Report, 2007. Some Factors in Performance

Poor communication between physicians and patients Patient un-awareness that asthma means airway inflammation Insidious nature of effects of asthma Lack of understanding of symptoms Lack of asthma education Physician failure to know current guidelines

What is the Real Impact of Treatment for Asthma? Asthma Episodes/Services Used in the Past 12 Months by Adults with Asthma, 2004 60 Percentage 50 40 30 52.3 20 29.6

10 13.3 13 0 Episode or attack ER or urgent care visit Urgent treatment Inablity to work or do activities

Frequency Source: Centers for Disease Control and Prevention, Behavior Risk Factor Surveillance System, 2004 Does Asthma Really Affect Lives? Asthma Symptoms in the Past 30 days, for Adults with Asthma, 2004 60 Percentage 50 40 30 51.6

47.9 20 10 22.4 0 Symptoms every day Difficulty staying asleep Meds 1 or 2 times a day Frequency

Source: Centers for Disease Control and Prevention, Behavior Risk Factor Surveillance System, 2004 Patients and Inhaled Corticosteroids Medicines Used to Treat Asthma by NIH Severity Index: Inhaled Corticosteroids vs Quick-Relief Medications Inhaled Corticosteroids 80 80% Quick-Relief Medication

78% 75% 70% 70 61% % of Patients 60 50

40% 40 30 20 15% 18% 20% 18% 16% 10%

10 0 Total All Persistent (NET) Severe Persistent Moderate Persistent Base: All patients (unweighted N=2509).

Mild Persistent Mild Intermittent Any Questions About Asthma in General? Work-Related Asthma Whats so Important about WorkRelated Asthma?

15-20% of all asthma is Work-Related (Occupational) Asthma More asthmatics entering the workplace Often a specific chemical, animal or particle agent can be identified as a cause Removal of the cause may remove the symptoms of asthma Treatment may be mostly environmental Causes of Work-Related Asthma High (mainly protein)

molecular causes include: Castor bean dust Western red cedar Gum acacia Wood dust Locust and mayfly Low Molecular Weight Causes Low (mainly chemical) Molecular Weight Causes include: Platinum and platinum salts Chromium and chromates Phthalic anhydride Sulfonechloramides

Toluene diisocyanate Chrome, nickel and aniline Rubber, lacquer and shellac (Latex) Huge Increase in Substances Causing Work-Related Asthma From 1960 on - rapid increase began 1980 - more than 200 causes had been identified 1980: 2000 new substances

developed each year 2000: 347 clearly identified agents and the list is growing Most substances have not been tested for human toxicity Work-Related Asthma Defined Airway inflammation Increased airway responsiveness Airway obstruction - partially reversible

Association with workplace exposures Aggravated by workplace exposures Massachusetts Workers Compensation Reform Act 1991, Guideline No. 28 How do people react to agents? Sensitization A specific immune system response to a specific protein or chemical that a person has come in contact with over time. Non-Sensitization

Airway symptoms that occur in response to exposure to a chemical the person has been exposed to over time. No specific immune response. Inflammation becomes chronic. List of Sensitizers and Irritants How is Work Related Asthma Diagnosed? Refer

to Handout - Diagram behind slides Diagnostic Tests Include: History and physical examination Respiratory function testing (spirometry) Measurements of peak flow(PEF)

during days at work and days away from work Nonspecific and specific inhalation challenge tests Specific skin tests Radioallergosorbent test - specific antibody tests Occupational Asthma in Ohio Is a reportable disease in Ohio No current system for reporting BWC Claims Approved for Work-related

Asthma 61-84 per year Not broken down by specific exposure 675 during 1990-2000 What Other States are Finding? Refer to Tables 1-4 in the packet. Massachusetts SENSOR Symptoms of Work-Caused Asthma

Same as for all asthma with some differences Symptoms appear after exposure to the sensitizing or irritating agent May have no symptoms if no longer exposed to that agent Continued exposure may result in worsening, even death Testing in Asthma

Detailed history including work environmental questions Allergy testingspecific allergen tests Lung Function Testing - Spirometry Peak Flow Testing Methacholine challenge Specific broncho-challenge Workplace Asthma Management Asthma management plan on file

Asthmatics carry rescue medication Train employees Have an Asthma Emergency Protocol New Occupational Asthmatic Remove from contact with the occupational agent

As soon as possible To reduce or remove symptoms Treat for asthma The Cost of Work Related Asthma Not only is there a human case for health and safety, but there is also a very strong business case. Direct Costs

Wages paid to absent employees Property damage Production losses and delays due to the absence of the employee Legal fees in case of a lawsuit Damage to goods or equipment Direct Costs - Insurance Related

Medical expenses Physical and vocational rehabilitation costs Life insurance and/or survivor benefits Group health insurance for off the job and dependent coverage Higher insurance premiums (or even loss of insurability) Workers' compensation benefits Direct Costs are the Tip of the Iceberg! Indirect costs can

be 5-50 times the direct cost! Indirect Costs - Labor Related Supervisors' time Rescheduling staff Overtime pay

Replacing employees Hiring a permanent replacement Administrative costs Indirect Costs, Continued Lost production and quality

Process interruptions/yield losses Time off for Litigation Damage to customer relations & public image

Missed shipments Loss of morale Asthma in Workers is Costly to Employers Annual per capita costs for employers of a worker with asthma est. at $5385 vs $2121 Disability from asthma costs 3x other disabilities

Annual costs of WRA in U.S. estimated at $1.1 2.1 Billion Birnbaum et al 02, Leigh et al 02 Average Number of Claims per Individual 25 19.7 20 15 Control Asthma

12.3 10 6.9 5.2 5 4.1 1.7 0.5 2.1 0.30.7

0 Inpt Outpt Office Other Total Birnbaum, H.G.; Berger, W.E., et al. Direct and Indirect Costs of Asthma to an Employer, Journal of Allergy, Clinical Immunology, 2002: Vol. 109, Number 2, p.264- Percentage of Individuals with At Least One Claim 100 90 80 70

60 50 Control 40 Asthma 30 20 10 0 Inpt

Outpt Office Other Total Birnbaum, H.G.; Berger, W.E., et al. Direct and Indirect Costs of Asthma to an Employer, Journal of Allergy, Clinical Immunology, 2002: Vol. 109, Number 2, p.264-270. Average Number of Claims per User of a Specific Service 25 20.4

20 15 10 13.1 10.6 8.4 10.2 7.7 5.3 6.7 3.2 4

5 0 Inpt Outpt Control Asthma Office Other Total

Birnbaum, H.G.; Berger, W.E., et al. Direct and Indirect Costs of Asthma to an Employer, Journal of Allergy, Clinical Immunology, 2002: Vol. 109, Number 2, p.264-270. Breakdown of Direct Costs 9% 7% 25% 59% Medical Care Drugs Absenteeism Disability

Birnbaum, H.G.; Berger, W.E., et al. Direct and Indirect Costs of Asthma to an Employer, Journal of Allergy, Clinical Immunology, 2002: Vol. 109, Number 2, p.264-270. What was NOT considered in this study? Caregiver expenses Cost to the patient not borne by employer Employees were insured Various indirect costs Still, resource use by asthmatic patients is

substantial Why should Workers Comp costs matter to you? Cost-Estimating Exercise Formula for Direct Costs (Workers Comp Costs) Sales Equivalent Dollars (SE$) = $Losses/Savings x 100% Profit Margin as % For Example SE$ = $10,000 x 100% = $1,000,000 = $200,000

5% 5 Table of Costs/Savings Formula for Indirect Costs

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