Asthma Q&A With Dr Kurtis Elward: Part 2

Asthma Q&A With Dr Kurtis Elward: Part 2 Posted By:
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PCE recently held our Series 1 Live Stream events. During the Live Streams, attendees have the chance to ask expert faculty specific questions, though we often run out of time to address all of the questions. For our last Series 1 Live Stream, Dr Kurtis Elward, faculty for the asthma presentation, clinical professor at Virginia Commonwealth University and family physician at Sentara Family Medicine, was kind enough to provide written responses to the asthma questions that were not able to be addressed live. We hope you will find his answers relevant and helpful to your clinical practice.

These questions will be answered in 2 posts; this is post 2.

 

Can you elaborate on avoiding the use of nebulizer treatments during the current COVID-19 pandemic?

Certainly. The major risk of nebulizer treatments is that they involve a lot of mist and have a very high potential for allowing viral droplets to spread out into the air. If a person is using nebulizer treatments only at home, this may not be an issue. However, in the healthcare setting, it essentially contaminates an entire room if a patient has COVID-19.

This of course has to be balanced by determination of whether the best treatment can only be delivered by a nebulizer. If so, the patient's needs may come first, but full PPE and making sure that the virus is not spread to others as a result is essential.

 

Because of the increased risk for stroke, shouldn't caution should be used if we give an inhaled short-acting beta-agonist (SABA) via metered-dose inhaler (MDI)+spacer instead of via nebulizer during an acute asthma exacerbation?

The risks would be similar and must be balanced with the cerebrovascular risks of uncontrolled asthma. Usually, the tremors and increased heart rate from nebulizers is greater than with MDI+spacer. One approach would be to use 2 puffs every 10 minutes while monitoring heart rate and blood pressure.

 

Do you recommend the use of budesonide nebulizer treatments for acute illness? It is usually a less expensive option.

Budesonide via nebulizer is indeed often less expensive and is a very good option for in-home use, and sometimes is easier for people. In Medicare especially, the cost of budesonide for nebulizers is far less than metered dose inhalers. It works very well and if cost is an issue (or if they cannot use an MDI+spacer well) it is a very reasonable approach.

 

How is FeNO measured? Please explain.

The American Academy of Allergy, Asthma & Immunology provides a good review: www.aaaai.org/conditions-and-treatments/library/asthma-library/feno-test. I'd also steer you to the GINA guidelines, which provide information on incorporating FeNO measurements into assessment and management (see pages 46-48): ginasthma.org/wp-content/uploads/2020/06/GINA-2020-report_20_06_04-1-wms.pdf.

 

Are blood eosinophils to rule out type 2 inflammation checked any time or just during a flare?

It is usually best to get these during a flare or when the patient is not taking a burst of OCS. More information can be found here: www.ncbi.nlm.nih.gov/pmc/articles/PMC3990389/.

 

Are the biologic medications that need to be given at an infusion center typically ordered by an asthma specialist, or does primary care order these as well?

In almost all cases they would be ordered by an asthma specialist. I have extensive experience in primary care and hospital medicine but would not order these myself. They should only be given after a specialist consultation and within that context.

 

What is the relationship between acetylsalicylic acid (aspirin), NSAIDs, and asthma?

Aspirin and NSAIDs work on the leukotriene pathway and they can trigger asthma reactions. Two good resources for this are: www.aaaai.org/conditions-and-treatments/library/asthma-library/aspirin-exacerbated-respiratory-disease and en.wikipedia.org/wiki/Aspirin_exacerbated_respiratory_disease.

 

Do you have experience in following asthmatic patients who have had a bronchial thermoplasty procedure? How they do?

My experience has been limited with this. Bronchial thermoplasty should be used in relatively rare situations. There is a very helpful evidence-based review on bronchial thermoplasty that I could recommend: effectivehealthcare.ahrq.gov/products/asthma-nonpharmacologic-treatment/thermoplasty-systematic-review.

 

How do you manage exercise-induced asthma in a college athlete who is active daily?

Exercise-induced asthma in athletes is very important, and I'm glad you're focusing on this. There are several approaches, and the basic version is to use two puffs of albuterol with a spacer before exercise. There's also some evidence now for using a dose of inhaled corticosteroid (ICS)/long-acting beta-agonist (LABA) an hour or so before exercise, or even in the morning if the athlete will be exercising during the day.

Since college athletes are usually active every day, I think you can make the case of using something at the start of each day to make it easier. However, they should always have their short-acting inhaler available in their gym bag. There's nothing wrong with taking an additional couple of puffs if they need it, even if they have taken the ICS/LABA earlier. More information can be found at these sites: www.aafa.org/exercise-induced-asthma/, acaai.org/asthma/types-asthma/exercise-induced-bronchoconstriction-eib.


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Filed under: Pulmonary Medicine , Allergy/Immunology

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