9 asthma

AsthmaAsthma

Zhiwen ZhuZhiwen Zhu

Pulmonary & Critical Care Medicine Pulmonary & Critical Care Medicine

1st Affiliated Hospital of Sun Yat-Sen 1st Affiliated Hospital of Sun Yat-Sen UniversityUniversity

Beethoven Ludwig van

He was a patient with asthma, and died in 1827.

Teresa Deng

She was also a patient with asthma, and died in 1995.

哮喘造成的负担:13-14岁儿童喘息的发病率

> 20%> 20%

ISAAC, Eur Respir J, 1998

5 to < 10%5 to < 10%10 to < 20%10 to < 20% < 5%< 5%

Asthma incidence of children

G INA

G INA

lobal

itiative for

sthma

lobal

itiative for

sthma

Asthma (GINA Workshop) Asthma (GINA Workshop)

Topics:Topics: DefinitionDefinition EpidemiologyEpidemiology Risk FactorsRisk Factors Pathogenesis & MechanismsPathogenesis & Mechanisms Diagnosis and ClassificationDiagnosis and ClassificationSix Part Asthma Management PlanSix Part Asthma Management Plan

Topics:Topics: DefinitionDefinition EpidemiologyEpidemiology Risk FactorsRisk Factors Pathogenesis & MechanismsPathogenesis & Mechanisms Diagnosis and ClassificationDiagnosis and ClassificationSix Part Asthma Management PlanSix Part Asthma Management Plan

Definition of AsthmaDefinition of Asthma

Asthma is Asthma is a chronic inflammatory disordera chronic inflammatory disorder of the of the airways in which many cells and cellular elements play airways in which many cells and cellular elements play a role a role

Chronic inflammation causes an associated increase in Chronic inflammation causes an associated increase in airway hyperresponsivenessairway hyperresponsiveness that leads to recurrent that leads to recurrent episodes of wheezing, breathlessness, chest tightness, episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early and coughing, particularly at night or in the early morning morning

These episodes are usually associated with These episodes are usually associated with widespread but variable widespread but variable airflow obstructionairflow obstruction that is often that is often reversiblereversible either spontaneously or with treatment either spontaneously or with treatment

Asthma is Asthma is a chronic inflammatory disordera chronic inflammatory disorder of the of the airways in which many cells and cellular elements play airways in which many cells and cellular elements play a role a role

Chronic inflammation causes an associated increase in Chronic inflammation causes an associated increase in airway hyperresponsivenessairway hyperresponsiveness that leads to recurrent that leads to recurrent episodes of wheezing, breathlessness, chest tightness, episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early and coughing, particularly at night or in the early morning morning

These episodes are usually associated with These episodes are usually associated with widespread but variable widespread but variable airflow obstructionairflow obstruction that is often that is often reversiblereversible either spontaneously or with treatment either spontaneously or with treatment

EpidemiologyEpidemiologyEpidemiologyEpidemiology

Asthma is one of the most common chronic Asthma is one of the most common chronic diseases worldwide —160 millions patients diseases worldwide —160 millions patients suffered from asthmasuffered from asthma

Prevalence increasing in many countries, Prevalence increasing in many countries, especially in children — 1~4% in adult, 3~5% in especially in children — 1~4% in adult, 3~5% in children in Chinachildren in China

A major cause of school/work absenceA major cause of school/work absence

An overall increase in severity of asthma An overall increase in severity of asthma increases the pool of patients at risk for deathincreases the pool of patients at risk for death

Asthma is one of the most common chronic Asthma is one of the most common chronic diseases worldwide —160 millions patients diseases worldwide —160 millions patients suffered from asthmasuffered from asthma

Prevalence increasing in many countries, Prevalence increasing in many countries, especially in children — 1~4% in adult, 3~5% in especially in children — 1~4% in adult, 3~5% in children in Chinachildren in China

A major cause of school/work absenceA major cause of school/work absence

An overall increase in severity of asthma An overall increase in severity of asthma increases the pool of patients at risk for deathincreases the pool of patients at risk for death

Worldwide Worldwide Variation in Variation in Prevalence of Prevalence of Asthma Asthma SymptomsSymptoms

International Study of International Study of Asthma and Allergies Asthma and Allergies in Children (ISAAC)in Children (ISAAC)

Worldwide Worldwide Variation in Variation in Prevalence of Prevalence of Asthma Asthma SymptomsSymptoms

International Study of International Study of Asthma and Allergies Asthma and Allergies in Children (ISAAC)in Children (ISAAC)

Lancet 1998;351:1225

Increasing Prevalence of Asthma in Increasing Prevalence of Asthma in Children/AdolescentsChildren/AdolescentsIncreasing Prevalence of Asthma in Increasing Prevalence of Asthma in Children/AdolescentsChildren/Adolescents

00 55 1010 1515 2020 2525 3030 3535

19921992198219821989198919751975199219921982198219941994198919891992199219821982199219921982198219911991197919791989198919661966FinlandFinland

(Haahtela (Haahtela et alet al))

SwedenSweden(Aberg (Aberg et alet al))

JapanJapan(Nakagomi (Nakagomi etet al al))

ScotlandScotland(Rona (Rona et alet al))

UKUK(Omran (Omran et alet al))

USAUSA(NHIS)(NHIS)

New ZealandNew Zealand(Shaw (Shaw et alet al))

AustraliaAustralia(Peat (Peat et alet al))

{{

Prevalence (%)Prevalence (%)

{{

{{{{{{{{{{{{

7070

6060

5050

4040

3030

20208585 8686 8787 8888 8989 9090 9191 9292 9393 9494

Rate/1,000 PersonsRate/1,000 Persons

YearYear

<18

18-44

45-64

65+

Total (All Ages)

<18

18-44

45-64

65+

Total (All Ages)

Age (years)Age (years)

Trends in Prevalence of AsthmaTrends in Prevalence of Asthma By Age, U.S., 1985-1996By Age, U.S., 1985-1996

9595 9696

8080

Risk Factors for AsthmaRisk Factors for AsthmaRisk Factors for AsthmaRisk Factors for Asthma

Host factors: predispose individuals to, or protect them from, developing asthma

Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist

Host factors: predispose individuals to, or protect them from, developing asthma

Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist

Risk Factors that Lead to Risk Factors that Lead to Asthma DevelopmentAsthma Development

Host Factors Genetic predisposition Atopy Airway hyperresponsiveness Gender Race

Host Factors Genetic predisposition Atopy Airway hyperresponsiveness Gender Race

Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Parasitic infections Socioeconomic factors Family size Diet and drugs Obesity

Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Parasitic infections Socioeconomic factors Family size Diet and drugs Obesity

Factors that Exacerbate AsthmaFactors that Exacerbate AsthmaFactors that Exacerbate AsthmaFactors that Exacerbate Asthma

AllergensAllergens Air PollutantsAir Pollutants Respiratory infectionsRespiratory infections Exercise and hyperventilationExercise and hyperventilation Weather changesWeather changes Sulfur dioxideSulfur dioxide Food, additives, drugsFood, additives, drugs

AllergensAllergens Air PollutantsAir Pollutants Respiratory infectionsRespiratory infections Exercise and hyperventilationExercise and hyperventilation Weather changesWeather changes Sulfur dioxideSulfur dioxide Food, additives, drugsFood, additives, drugs

Mechanisms Underlying the Mechanisms Underlying the Definition of AsthmaDefinition of AsthmaMechanisms Underlying the Mechanisms Underlying the Definition of AsthmaDefinition of Asthma

Risk FactorsRisk Factors(for development of asthma)(for development of asthma)

Risk FactorsRisk Factors(for development of asthma)(for development of asthma)

INFLAMMATIONINFLAMMATIONINFLAMMATIONINFLAMMATION

AirwayAirway

HyperresponsivenessHyperresponsiveness

AirwayAirway

HyperresponsivenessHyperresponsiveness Airflow ObstructionAirflow ObstructionAirflow ObstructionAirflow Obstruction

Risk FactorsRisk Factors(for exacerbations)(for exacerbations) Risk FactorsRisk Factors(for exacerbations)(for exacerbations)

SymptomsSymptomsSymptomsSymptoms

Antigen PresentingCell

TH2

MastCell

Mediators

SurvivalActivation

AttractionAdhesion

Priming

Eosinophil

Endothelium

Ag:

Production

M I nman

BronchoconstrictionHyperresponsiveness

Asthma DiagnosisAsthma Diagnosis

History and patterns of symptoms

Physical examination

Measurements of lung function

Measurements of allergic status to identify risk factors

History and patterns of symptoms

Physical examination

Measurements of lung function

Measurements of allergic status to identify risk factors

Clinical Manifestation of AsthmaClinical Manifestation of AsthmaClinical Manifestation of AsthmaClinical Manifestation of Asthma

Recurrent episodes of wheezingRecurrent episodes of wheezing Troublesome cough at nightTroublesome cough at night Cough or wheeze after exerciseCough or wheeze after exercise Cough, wheeze or chest tightness after Cough, wheeze or chest tightness after

exposure to airborne allergens or exposure to airborne allergens or pollutantspollutants

Colds “go to the chest” or take more than Colds “go to the chest” or take more than 10 days to clear10 days to clear

Recurrent episodes of wheezingRecurrent episodes of wheezing Troublesome cough at nightTroublesome cough at night Cough or wheeze after exerciseCough or wheeze after exercise Cough, wheeze or chest tightness after Cough, wheeze or chest tightness after

exposure to airborne allergens or exposure to airborne allergens or pollutantspollutants

Colds “go to the chest” or take more than Colds “go to the chest” or take more than 10 days to clear10 days to clear

Physical ExaminationPhysical ExaminationPhysical ExaminationPhysical Examination

Because of variable symptoms, the physical Because of variable symptoms, the physical examination of the respiratory system may be examination of the respiratory system may be normal. normal.

Dyspnea, airflow limitation (wheeze), and Dyspnea, airflow limitation (wheeze), and hyperinflation are likely to be present if hyperinflation are likely to be present if patients are examined during symptomatic patients are examined during symptomatic periods.periods.

Silent chest, cyanosis, drowsiness, difficult Silent chest, cyanosis, drowsiness, difficult speaking, tachycardia and use of accessory speaking, tachycardia and use of accessory muscles in severe asthma. muscles in severe asthma.

Measurement of Lung FunctionMeasurement of Lung Function

Spirometry: FEV1, FVC,FEV1/FVC

Bronchial Provocation Test (BPT)

FEV1>70% predicted

Histamine,methacholine, or exercise

FEV1↓≥20% at a dose of ≤16mg/ml

Spirometry: FEV1, FVC,FEV1/FVC

Bronchial Provocation Test (BPT)

FEV1>70% predicted

Histamine,methacholine, or exercise

FEV1↓≥20% at a dose of ≤16mg/ml


Bronchial Dilation Test (BDT)

FEV1<70% predicted

FEV1↑≥12% and 200ml, FVC↑≥15% and 200ml, after inhaling a short-acting bronchodilator

Typical Spirometric (FEV1) TracingsTypical Spirometric (FEV1) Tracings

11Time (sec)Time (sec)

22 33 44 55

FEV1FEV1

VolumeVolume

Normal SubjectNormal Subject

Asthmatic (After Bronchodilator)Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)Asthmatic (Before Bronchodilator)

Note: Each FEVNote: Each FEV11 curve represents the highest of three repeat measurements curve represents the highest of three repeat measurements


Peak Expiratory Flow (PEF) and PEF Variation.

PEF Variation ≥20%

Peak Expiratory Flow (PEF) and PEF Variation.

PEF Variation ≥20%

PE

F (

L/m

in)

300

400

500

600

700

800

Days70 14

Lowest morning PEF (570)

Highest PEF (670)

Morning PEFEvening PEF

Minimum morning PEF ( % recent best): 570/670 = 85%(From Reddel, H.K. et al. 1995)

Arterial blood gas

• Respiratory alkalosis, during a mile asthma exacerbation

• Respiratory acidosis and hypoxemia, during a severe asthma exacerbation

Measurement of Allergic StatusMeasurement of Allergic Status

Skin test

Measurement of specific IgE in serum

Skin test

Measurement of specific IgE in serum

Standards of DiagnosisStandards of Diagnosis

Recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, Recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning particularly at night or in the early morning

Dyspnea, airflow limitation (wheeze), and hyperinflation are likely to be present if Dyspnea, airflow limitation (wheeze), and hyperinflation are likely to be present if patients are examined during symptomatic periodspatients are examined during symptomatic periods

These episodes and symptoms are often reversible either spontaneously or with These episodes and symptoms are often reversible either spontaneously or with treatmenttreatment

Exclude other diseases that manifested with similar symptomsExclude other diseases that manifested with similar symptoms

At least one or more of the following three: At least one or more of the following three:

Bronchial Provocation Test (BPT)Bronchial Provocation Test (BPT)

Bronchial Dilation Test (BDT) Bronchial Dilation Test (BDT)

Peak Expiratory Flow (PEF) VariationPeak Expiratory Flow (PEF) Variation

Recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, Recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning particularly at night or in the early morning

Dyspnea, airflow limitation (wheeze), and hyperinflation are likely to be present if Dyspnea, airflow limitation (wheeze), and hyperinflation are likely to be present if patients are examined during symptomatic periodspatients are examined during symptomatic periods

These episodes and symptoms are often reversible either spontaneously or with These episodes and symptoms are often reversible either spontaneously or with treatmenttreatment

Exclude other diseases that manifested with similar symptomsExclude other diseases that manifested with similar symptoms

At least one or more of the following three: At least one or more of the following three:

Bronchial Provocation Test (BPT)Bronchial Provocation Test (BPT)

Bronchial Dilation Test (BDT) Bronchial Dilation Test (BDT)

Peak Expiratory Flow (PEF) VariationPeak Expiratory Flow (PEF) Variation

Differential DiagnosisDifferential Diagnosis

Congestive Heart Failure

Pseudoasthma caused by vocal cord dysfunction

Chronic bronchitis & COPD

Lung cancer

Congestive Heart Failure

Pseudoasthma caused by vocal cord dysfunction

Chronic bronchitis & COPD

Lung cancer

Definition of COPDDefinition of COPD

Chronic obstructive pulmonary disease(COPD) is a disease state characterized by airflow limitation that is not fullyreversible. The airflow limitation is usuallyboth progressive and associated with anabnormal inflammatory response of thelungs to noxious particles or gases.

Chronic obstructive pulmonary disease(COPD) is a disease state characterized by airflow limitation that is not fullyreversible. The airflow limitation is usuallyboth progressive and associated with anabnormal inflammatory response of thelungs to noxious particles or gases.

GOLD 2004

Pointers that differentiate asthma from COPD

Pointers that differentiate asthma from COPD

COPD Asthma

History

Smoker or ex-smoker Nearly all Possibly

Symptoms under age 45 Uncommon Often

Chronic productive cough Common Uncommon

Breathlessness Persistent and progressive Variable

Winter bronchitis Common Uncommon

Investigations

Serial PEF Obstructive picture May be normal Day to day and diurnal variation

Reversibility testing Minimal variationUsually<15% or 200mlchange

Usually>15% or 200ml change

Classification of SeverityClassification of Severity

Asthma severity is classified by the presence of clinical features before treatment is started and/or by the amount of daily medication required for optimal treatment

Asthma severity is classified by the presence of clinical features before treatment is started and/or by the amount of daily medication required for optimal treatment

Classification of Severity of Classification of Severity of chronic stable asthmachronic stable asthma

CLASSIFY SEVERITYClinical Features Before Treatment

SymptomsSymptoms NocturnalNocturnalSymptomsSymptoms

FEVFEV1 1 or PEFor PEF

STEP 4STEP 4

Severe Severe PersistentPersistent

STEP 3STEP 3

Moderate Moderate PersistentPersistent

STEP 2STEP 2

Mild Mild PersistentPersistent

STEP 1STEP 1

IntermittentIntermittent

ContinuousContinuous

Limited physical Limited physical activityactivity

DailyDailyAttacks affect activityAttacks affect activity

> 1 time a week > 1 time a week but < 1 time a day but < 1 time a day

< 1 time a week< 1 time a week

Asymptomatic Asymptomatic and normal PEF and normal PEF between attacksbetween attacks

FrequentFrequent

> 1 time a week> 1 time a week

> 2 times a month> 2 times a month

2 times a 2 times a monthmonth2 times a 2 times a monthmonth

60% predicted60% predicted

Variability > 30%Variability > 30%

60 - 80% predicted 60 - 80% predicted

Variability > 30%Variability > 30%


Variability 20 - 30%Variability 20 - 30%


Variability < 20%Variability < 20%

The presence of one feature of severity is sufficient to place patient in that category.The presence of one feature of severity is sufficient to place patient in that category.

Classification of SeverityClassification of Severity

Classification of severity of asthma exacerbation

breathlessness RR HR PEF/FEV1 PaO2 PaCO2 SaO2

Mild With activity ↑ <100 >80% normal <45 >95

Moderate With talking ↑ 100~120 60-80% 60~80 <45 91~95

Severe At rest >30 >120 <60% <60 >45 <91

Impending respiratory failure

Consciousness Relative bradycardia

<60 >45 <91

Six-Part Asthma Management Six-Part Asthma Management ProgramProgram

1. Educate patients to develop a partnership in asthma management

2. Assess and monitor asthma severity with symptom reports and measures of lung function as much as possible

3. Avoid exposure to risk factors

4. Establish medication plans for chronic management in children and adults

5. Establish individual plans for managing exacerbations

6. Provide regular follow-up care

1. Educate patients to develop a partnership in asthma management

2. Assess and monitor asthma severity with symptom reports and measures of lung function as much as possible

3. Avoid exposure to risk factors

4. Establish medication plans for chronic management in children and adults

5. Establish individual plans for managing exacerbations

6. Provide regular follow-up care

Six-part Asthma Management ProgramSix-part Asthma Management Program

Goals of Long-term ManagementGoals of Long-term Management

Achieve and maintain control of symptoms Prevent asthma episodes or attacks Maintain pulmonary function as close to normal

levels as possible Maintain normal activity levels, including

exercise Avoid adverse effects from asthma medications Prevent development of irreversible airflow

limitation Prevent asthma mortality

Achieve and maintain control of symptoms Prevent asthma episodes or attacks Maintain pulmonary function as close to normal

levels as possible Maintain normal activity levels, including

exercise Avoid adverse effects from asthma medications Prevent development of irreversible airflow

limitation Prevent asthma mortality

Six-part Asthma Management ProgramSix-part Asthma Management Program

Control of AsthmaControl of Asthma

Minimal (ideally no) chronic symptoms Minimal (infrequent) exacerbations No emergency visits Minimal (ideally no) need for “as needed” use of

β2-agonist

No limitations on activities, including exercise PEF circadian variation of less than 20% (Near) normal PEF Minimal (or no) adverse effects from medicine

Minimal (ideally no) chronic symptoms Minimal (infrequent) exacerbations No emergency visits Minimal (ideally no) need for “as needed” use of

β2-agonist

No limitations on activities, including exercise PEF circadian variation of less than 20% (Near) normal PEF Minimal (or no) adverse effects from medicine

Six-Part Asthma Management Six-Part Asthma Management ProgramProgram

The most effective management is to prevent airway inflammation by eliminating the causal factors

Asthma can be effectively controlled in most patients, although it can not be cured

The major factors contributing to asthma morbidity and mortality are under-diagnosis and inappropriate treatment

Any asthma more severe than intermittent asthma is more effectively controlled by treatment to suppress and reverse airway inflammation than by treatment only of acute bronchoconstriction and symptoms

The most effective management is to prevent airway inflammation by eliminating the causal factors

Asthma can be effectively controlled in most patients, although it can not be cured

The major factors contributing to asthma morbidity and mortality are under-diagnosis and inappropriate treatment

Any asthma more severe than intermittent asthma is more effectively controlled by treatment to suppress and reverse airway inflammation than by treatment only of acute bronchoconstriction and symptoms

.

Six-part Asthma Management Program

Part 1: Educate Patients to Develop a Partnership


Part 1: Educate Patients to Develop a Partnership

Educate continually

Include the family

Provide information about asthma

Provide training on self-management skills

Emphasize a partnership among health care providers, the patient, and the patient’s family

Educate continually

Include the family

Provide information about asthma

Provide training on self-management skills

Emphasize a partnership among health care providers, the patient, and the patient’s family

Six-part Asthma Management ProgramPart 2: Assess and Monitor Asthma Severity with Symptom Reports and Measures of Lung Function

Six-part Asthma Management ProgramPart 2: Assess and Monitor Asthma Severity with Symptom Reports and Measures of Lung Function

Symptom reports Use of reliever medication Nighttime symptoms Activity limitations

Spirometry for initial assessment. Peak Expiratory Flow for follow-up: Assess severity Assess response to therapy

PEF monitoring at home Important for those with poor perception of symptoms Daily measurement recorded in a diary Assesses the severity and predicts worsening Guides the use of a zone system for asthma self-management

Arterial blood gas for severe exacerbations

Symptom reports Use of reliever medication Nighttime symptoms Activity limitations

Spirometry for initial assessment. Peak Expiratory Flow for follow-up: Assess severity Assess response to therapy

PEF monitoring at home Important for those with poor perception of symptoms Daily measurement recorded in a diary Assesses the severity and predicts worsening Guides the use of a zone system for asthma self-management

Arterial blood gas for severe exacerbations


Part 3: Avoid Exposure to Risk Factors


Part 3: Avoid Exposure to Risk Factors

Reduce exposure to indoor allergensReduce exposure to indoor allergens Avoid tobacco smokeAvoid tobacco smoke Avoid vehicle emissionAvoid vehicle emission Identify irritants in the workplaceIdentify irritants in the workplace Explore role of infections on asthma Explore role of infections on asthma

development, especially in children and development, especially in children and young infantsyoung infants

Reduce exposure to indoor allergensReduce exposure to indoor allergens Avoid tobacco smokeAvoid tobacco smoke Avoid vehicle emissionAvoid vehicle emission Identify irritants in the workplaceIdentify irritants in the workplace Explore role of infections on asthma Explore role of infections on asthma

development, especially in children and development, especially in children and young infantsyoung infants


Part 4: Establish Medication Plans for Long-Term Asthma Management


Part 4: Establish Medication Plans for Long-Term Asthma Management

A stepwise approach to pharmacological A stepwise approach to pharmacological therapy is recommended therapy is recommended

The aim is to accomplish the goals of The aim is to accomplish the goals of therapy with the least possible medicationtherapy with the least possible medication

Although in many countries traditional Although in many countries traditional methods of healing are used, their efficacy methods of healing are used, their efficacy has not yet been established and their use has not yet been established and their use can therefore not be recommendedcan therefore not be recommended

A stepwise approach to pharmacological A stepwise approach to pharmacological therapy is recommended therapy is recommended

The aim is to accomplish the goals of The aim is to accomplish the goals of therapy with the least possible medicationtherapy with the least possible medication

Although in many countries traditional Although in many countries traditional methods of healing are used, their efficacy methods of healing are used, their efficacy has not yet been established and their use has not yet been established and their use can therefore not be recommendedcan therefore not be recommended

Part 4: Long-term Asthma Management

Stepwise Approach to Asthma TherapyPart 4: Long-term Asthma Management

Stepwise Approach to Asthma Therapy

The choice of treatment should be guided by: Severity of the patient’s asthma Patient’s current treatment Pharmacological properties and availability of

the various forms of asthma treatment Economic considerations

Cultural preferences and differing health caresystems need to be considered..

The choice of treatment should be guided by: Severity of the patient’s asthma Patient’s current treatment Pharmacological properties and availability of

the various forms of asthma treatment Economic considerations

Cultural preferences and differing health caresystems need to be considered..


Pharmacologic TherapyPart 4: Long-term Asthma Management

Pharmacologic Therapy

Controller Medications: Inhaled glucocorticosteroids Systemic glucocorticosteroids Cromones Methylxanthines Long-acting inhaled β2-agonists Long-acting oral β2-agonists Leukotriene modifiers

Controller Medications: Inhaled glucocorticosteroids Systemic glucocorticosteroids Cromones Methylxanthines Long-acting inhaled β2-agonists Long-acting oral β2-agonists Leukotriene modifiers


Pharmacologic TherapyPart 4: Long-term Asthma Management

Pharmacologic Therapy

Reliever Medications:

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids

Anticholinergics

Methylxanthines

Short-acting oral β2-agonists

Reliever Medications:

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids

Anticholinergics

Methylxanthines

Short-acting oral β2-agonists


Stepwise Approach to Asthma Therapy - Adults



Reliever: Rapid-acting inhaled β2-agonist prn

Controller: Daily inhaledcorticosteroid

Controller: Daily inhaled

corticosteroid Daily long-

acting inhaled β2-agonist


corticosteroid Daily long –


plus (if needed)

When asthma is controlled, reduce therapy

Monitor

STEP 1:STEP 1:IntermittentIntermittent

STEP 2:STEP 2:Mild PersistentMild Persistent

STEP 3:STEP 3: Moderate Moderate PersistentPersistent


STEP 4:STEP 4:Severe Severe

PersistentPersistentSTEP DownSTEP DownSTEP DownSTEP Down

Outcome: Asthma Control Outcome: Best Possible Results

Alternative controller and reliever medications may be considered (see text). Alternative controller and reliever medications may be considered (see text).

Controller:None

-Theophylline-SR -Leukotriene -Long-acting inhaled β2- agonist -Oral corticosteroid

Stepwise Approach to Asthma Therapy: AdultsStepwise Approach to Asthma Therapy: Adults

Step 1: Intermittent Asthma Step 1: Intermittent Asthma

None requiredNone required Rapid-acting inhaled 2-agonistfor symptoms (but < once a week) Rapid-acting inhaled 2-agonist,cromone, or leukotriene modifier before exercise or exposure toallergen

Continuously review medication technique, compliance and environmental controlContinuously review medication technique, compliance and environmental control Review treatment every three months.Review treatment every three months. Step upStep up if control is not achieved; if control is not achieved; step downstep down if control is sustained for at least 3 months if control is sustained for at least 3 months Preferred treatments are in bold printPreferred treatments are in bold print

Daily Controller Medications

Reliever Medications

Inhaled glucocorticosteroid (< 500 μg BDP or equivalent)

Other options (order by cost): sustained-release theophylline, or Cromone, or leukotriene modifier

Rapid-acting inhaled 2-agonistfor symptoms (but < 3-4 times/day)

Other options: inhaled anticholinergic, or short-acting oral 2-agonist, or short-acting theophylline

Continuously review medication technique, compliance and environmental control.Continuously review medication technique, compliance and environmental control. Review treatment every three monthsReview treatment every three months Step upStep up if control is not achieved; if control is not achieved; Step downStep down if control is sustained for at least 3 months if control is sustained for at least 3 months Preferred treatments are in bold printPreferred treatments are in bold print


Step 2: Mild Persistent AsthmaStep 2: Mild Persistent Asthma



Inhaled glucocorticosteroid, (200 – 500 μg BDP or

equivalent) plus long-acting inhaled β2agonistOther options (order by cost): Inhaled glucocorticosteroid (500 – 1000 μg BDP

equivalent) plus sustained-release theophylline, or Inhaled glucocorticosteroid (500 – 1000 μg BDP

equivalent) plus long-acting inhaled β2- agonist, or inhaled glucocorticosteroid at higher doses (> 1000 μg BDP equivalent), or Inhaled glucocorticosteroid (500 – 1000 μg BDP

equivalent) plus leukotriene modifier

Rapid-acting inhaled 2-agonist for symptoms (but < 3 - 4 times/day)

Other options: inhaled anticholinergic or short-acting oral 2-agonist or short-acting theophylline

Continuously review medication technique, compliance and environmental control.Continuously review medication technique, compliance and environmental control. Review treatment every three months.Review treatment every three months. Step upStep up if control is not achieved; if control is not achieved; Step downStep down if control is sustained for at least 3 months. if control is sustained for at least 3 months. Preferred treatments are in bold print.Preferred treatments are in bold print.


Step 3: Moderate Persistent AsthmaStep 3: Moderate Persistent Asthma



Inhaled glucocorticosteroid, (> 1000 μg

BDP or equivalent) plus long-actinginhaled β2agonist

plus one or more of the following, ifneeded (order by cost): sustained-release theophylline, or leukotriene modifier or oral glucocorticosteroid

Rapid-acting inhaled 2-agonist for symptoms (but < 3-4 times/day)

Other options: inhaled anticholinergic or short-acting oral 2-agonist or short-acting theophylline

Continuously review medication technique, compliance and environmental control.Continuously review medication technique, compliance and environmental control. Review treatment every three months.Review treatment every three months. Step upStep up if control is not achieved; if control is not achieved; Step downStep down if control is sustained for at least 3 months. if control is sustained for at least 3 months. Preferred treatments are in bold print.Preferred treatments are in bold print.


Step 4: Severe Persistent AsthmaStep 4: Severe Persistent Asthma







Reliever: Rapid-acting inhaled β2-agonist prn

Controller: Daily inhaledcorticosteroid


corticosteroid Daily long-



corticosteroid Daily long –


plus (if needed)

When asthma is controlled, reduce therapy

Monitor

STEP 1:STEP 1:IntermittentIntermittent

STEP 2:STEP 2:Mild PersistentMild Persistent



STEP 4:STEP 4:Severe Severe

PersistentPersistentSTEP DownSTEP DownSTEP DownSTEP Down

Outcome: Asthma Control Outcome: Best Possible Results

Alternative controller and reliever medications may be considered (see text). Alternative controller and reliever medications may be considered (see text).

Controller:None

-Theophylline-SR -Leukotriene -Long-acting inhaled β2- agonist -Oral corticosteroid


Part 5: Establish Plans for Managing Exacerbations


Part 5: Establish Plans for Managing Exacerbations

Primary therapies for exacerbations:• Repetitive administration of rapid-acting

inhaled β2-agonist• Early introduction of systemic

glucocorticosteroids• Oxygen supplementationClosely monitor response to treatmentwith serial measures of lung function

Primary therapies for exacerbations:• Repetitive administration of rapid-acting

inhaled β2-agonist• Early introduction of systemic

glucocorticosteroids• Oxygen supplementationClosely monitor response to treatmentwith serial measures of lung function


Part 5: Managing Severe Asthma Exacerbations


Part 5: Managing Severe Asthma Exacerbations

Severe exacerbations are life-threatening medical emergencies

Care must be expeditious and treatment is often most safely undertaken in a hospital or hospital-based emergency department

Severe exacerbations are life-threatening medical emergencies

Care must be expeditious and treatment is often most safely undertaken in a hospital or hospital-based emergency department

Emergency Department Management

Acute AsthmaEmergency Department Management

Acute Asthma

Good Response

Observe for at least 1 hour

If Stable, Discharge to

Home

Initial AssessmentHistory, Physical Examination, PEF or FEV1

Initial TherapyBronchodilators; O2 if needed

Incomplete/Poor Response

Add Systemic Glucocorticosteroids

Good Response

Discharge

Poor Response

Admit to Hospital

Respiratory Failure

Admit to ICU


Part 6: Provide Regular Follow-up Care


Part 6: Provide Regular Follow-up Care

Continual monitoring is essential to assure thattherapeutic goals are met. Frequent follow-up visitsare necessary to review: Home PEF and symptom records Techniques in use of medications Risk factors and their controlOnce asthma control is established, follow-upvisits should be scheduled (at 1 to 6 month intervalsas appropriate)

Continual monitoring is essential to assure thattherapeutic goals are met. Frequent follow-up visitsare necessary to review: Home PEF and symptom records Techniques in use of medications Risk factors and their controlOnce asthma control is established, follow-upvisits should be scheduled (at 1 to 6 month intervalsas appropriate)

Six-part Asthma Management Program: SummarySix-part Asthma Management Program: Summary

Asthma can be effectively controlled, although it Asthma can be effectively controlled, although it cannot be curedcannot be cured

Effective asthma management programs include Effective asthma management programs include education, objective measures of lung function, education, objective measures of lung function, environmental control, and pharmacologic therapyenvironmental control, and pharmacologic therapy

A stepwise approach to pharmacologic therapy is A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the recommended. The aim is to accomplish the goals of therapy with the least possible medicationgoals of therapy with the least possible medication

Asthma can be effectively controlled, although it Asthma can be effectively controlled, although it cannot be curedcannot be cured

Effective asthma management programs include Effective asthma management programs include education, objective measures of lung function, education, objective measures of lung function, environmental control, and pharmacologic therapyenvironmental control, and pharmacologic therapy

A stepwise approach to pharmacologic therapy is A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the recommended. The aim is to accomplish the goals of therapy with the least possible medicationgoals of therapy with the least possible medication

Six-part Asthma Management Program: Summary (continued)

Six-part Asthma Management Program: Summary (continued)

Anything more than mild, occasional asthma is Anything more than mild, occasional asthma is more effectively controlled by suppressing more effectively controlled by suppressing inflammation than by only treating acute inflammation than by only treating acute bronchospasmbronchospasm

The availability of varying forms of treatment, The availability of varying forms of treatment, cultural preferences, and differing health care cultural preferences, and differing health care systems need to be considered systems need to be considered

Anything more than mild, occasional asthma is Anything more than mild, occasional asthma is more effectively controlled by suppressing more effectively controlled by suppressing inflammation than by only treating acute inflammation than by only treating acute bronchospasmbronchospasm

The availability of varying forms of treatment, The availability of varying forms of treatment, cultural preferences, and differing health care cultural preferences, and differing health care systems need to be considered systems need to be considered

Thank you !!Thank you !!

9 asthma

Education

Transcript of 9 asthma