Asthma Medicine 5

8/14/2019 Asthma Medicine 5

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Asthma Diagnosis &Asthma Diagnosis &Treatment:Treatment:

Update & Quality CareUpdate & Quality CareDr. Imad Salah Ahmed HassanDr. Imad Salah Ahmed Hassan

MD MRCP MScMD MRCP MScConsultant Physician & PulmonologistConsultant Physician & Pulmonologist


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Burden of AsthmaBurden of Asthma

Asthma is one of the most common chronicdiseases worldwide

Prevalence increasing in many countries,especially in children

A major cause of school/work absence

An overall increase in severity of asthmaincreases the pool of patients at risk for death


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Problem Scale: 350 million people around the globe

Deaths from this condition have reached 280,000 annually

Worldwide, costs of asthma greater than Tuberculosis

and HIV / AIDS

Major factors contributing to asthma morbidity andmortality are under-diagnosis and inappropriate treatment

Ref. WHO Fact Sheet N 206, Revised January 2001

GINA guidelines 1998

Bronchial AsthmaBronchial AsthmaFacts and FiguresFacts and Figures


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HeadingsHeadings

Pathogenesis of AsthmaPathogenesis of Asthma

Diagnosing AsthmaDiagnosing Asthma

Treatment:Treatment:

Classification of severityClassification of severity

Therapeutic ModalitiesTherapeutic Modalities

Quality Care InterventionsQuality Care Interventions Indications for referral to the specialistIndications for referral to the specialist

Failed TreatmentFailed Treatment


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Asthma is aAsthma is a chronic inflammatorychronic inflammatory disorderdisorder

of theof the airwaysairways.. Airway inflammation results in:Airway inflammation results in:

AirwayAirway obstructionobstruction through airway edema, mucusthrough airway edema, mucus

plugs and bronchoconstriction.plugs and bronchoconstriction.AirwayAirway hyperresponsiveness.hyperresponsiveness.

AirwayAirway remodeling.remodeling.


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Understanding of the airway inflammatory processUnderstanding of the airway inflammatory process

continues to evolvecontinues to evolve

mast cellsmast cells eosinophilseosinophils

airway epithelial cellsairway epithelial cells

lymphocytes (Th2 response)lymphocytes (Th2 response)

cytokinescytokines

leukotrienesleukotrienes


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Symptoms and use of reliever

medication

Time

Exacerbation

Oral course of

steroids

Effect of steroids during

periods of worsening

Exacerbation

Asthma is aAsthma is a variablevariable diseasedisease

Medication plans need to accommodate variability among patients as

well as within individual patients over time. An essential aspect of any

treatment plan is the need to monitor the effect of the treatment and

adapting the treatment to the variability of the asthma (GINA 2002).


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What isWhat is inin Bronchial Asthma?Bronchial Asthma?

Chronic inflammatory diseaseChronic inflammatory disease

Long-term therapy and care: financial,Long-term therapy and care: financial,

psychosocial, medication S/Epsychosocial, medication S/E

compounding it.compounding it.

Intermittent or persistent withIntermittent or persistent with

progressive loss of lung function.progressive loss of lung function.

Dynamic severity dictate the choice ofDynamic severity dictate the choice of

therapy: Stepwise approach.therapy: Stepwise approach.

May be fatal: no complacency is allowed.May be fatal: no complacency is allowed.


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Asthma Care PlanAsthma Care Plan

Is it Asthma?Is it Asthma?

Assessment of Severity?Assessment of Severity?

Pharmacological and non-Pharmacological and non-

pharmacological therapy?pharmacological therapy?

Can I prevent re-modelling?Can I prevent re-modelling? Monitoring.Monitoring.

Prevention of Asthma.Prevention of Asthma.

Six-part Asthma Management ProgramSix-part Asthma Management Program


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Is it Asthma?Is it Asthma?

Detailed medical history: symptoms of asthma,Detailed medical history: symptoms of asthma,

aggravators etcaggravators etc

FH/SH/Occupational History/DrugFH/SH/Occupational History/Drug

History/AllergiesHistory/Allergies

Physical examPhysical exam

Spirometry to demonstrate reversibilitySpirometry to demonstrate reversibility


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Diagnosis of Asthma: History

Episodes (especially recurrent) of cough,

wheeze, shortness of breath or chesttightness

Colds that go to the chest and stay there for> 10 days


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Diagnosis of Asthma: HistoryDiagnosis of Asthma: History

Cough, wheeze, shortness of breath or chest

tightness during particular seasons (Fall orSpring) or with certain exposures (animals,smoke, or strong odors) or under certainconditions (exercise or strong emotions)

Use of over-the-counter medications(inhalers) which relieve these symptoms


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Historical Clues to Asthma

Childhood lung disease (BPD, parentalChildhood lung disease (BPD, parental

smoking, pneumonias)smoking, pneumonias)

Allergies, hay fever, sinusitis, rhinitis, nasalAllergies, hay fever, sinusitis, rhinitis, nasal

polyps, eczema, aspirin sensitivitypolyps, eczema, aspirin sensitivity

Family history of asthmaFamily history of asthma


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Is it Asthma: SpirometryIs it Asthma: Spirometry

Home PEFR Charting:Home PEFR Charting: 20%20% dipsdips FEVFEV11 < 80%< 80% predicted;predicted;

FEVFEV11/FVC/FVC 12%12% andand

at leastat least 200200 ml after using a short-acting inhaledml after using a short-acting inhaledbetabeta22-agonist.-agonist.


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Is it Asthma: SpirometryIs it Asthma: Spirometry

Steroid Trial: Increase bySteroid Trial: Increase by 12%12% in FEV1 afterin FEV1 afteraa 22 wks PO steroid orwks PO steroid or66 wks inhaled steroid.wks inhaled steroid.

Exercise test.Exercise test.

Methacholine challengeMethacholine challenge


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Patient/parent Confident ;to manage own medication,

increasing and decreasing usingPEF,

start oral steroid and attend clinic.

Patient/parent Knows ;how to monitor PEF & symptoms,

when to increase dose of inhaledsteroids,

how to contact med practice.

Patient/parent ACCEPTS & AGREES ;about use of medication,

importance of preventers,

recognition of symptoms.

Ladder of Asthma Knowledge

Patient/parent UNDERSTANDS ;what relief medication does,

side effects which may occur,

aims of treatment,

what is happening to them in their chest,educational material is made available.

3

1

2

4

3

1

2

4


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Additional TestsAdditional Tests

Reasons for Additional TestsReasons for Additional Tests The TestsThe TestsPatient has symptoms but spirometry

is normal or near normal.

Assess diurnal variation of peak flow

over 1 to 2 weeks.

Refer to a specialist for

bronchoprovocation with methacholine ,histamine, or exercise; negative test

may help rule out asthma.

Suspect infection (TB), large airway lesions, heart

disease, orobstruction by foreign object

Chest x-ray


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Additional TestsAdditional Tests

Reasons for Additional TestsReasons for Additional Tests The TestsThe Tests

.

Suspect coexisting chronic obstructive pulmonary

disease, restrictive defect, or central airway

obstruction

Additional pulmonary function studies

Diffusing capacity test

Suspect other factors contribute to asthma

(These are not diagnostic tests for asthma.) Allergy testsskin or in vitro

Nasal examination

Gastroesophageal

reflux assessment


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Assessment of Severity?Assessment of Severity?

SymptomsSymptoms

SpirometrySpirometry

OthersOthers


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Classification of SeverityClassification of Severity

CLASSIFY SEVERITYClinical Features Before Treatment

SymptomsSymptoms NocturnalNocturnalSymptomsSymptoms

FEVFEV11 or PEFor PEF

STEP 4STEP 4

SevereSevere

PersistentPersistent

STEP 3STEP 3

ModerateModeratePersistentPersistent

STEP 2STEP 2

MildMildPersistentPersistent

STEP 1STEP 1

MildMild

IntermittentIntermittent

ContinuousContinuous

Limited physicalLimited physicalactivityactivity

DailyDaily

Attacks affect activityAttacks affect activity

> 1 time a week> 1 time a week

but < 1 time a daybut < 1 time a day

< 1 time a week< 1 time a week

Asymptomatic andAsymptomatic and

normal PEFnormal PEF

between attacksbetween attacks

FrequentFrequent

> 1 time week> 1 time week

> 2 times a month> 2 times a month

< 2 times a month2 times a month

60% predicted60% predicted

Variability > 30%Variability > 30%

60 - 80% predicted60 - 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.


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Seven Goals Asthma Management ProgramSeven Goals Asthma Management Program

Goals of Long-term ManagementGoals of Long-term Management

Achieve and maintain control of symptomsAchieve and maintain control of symptoms

Prevent asthma episodes or attacksPrevent asthma episodes or attacks

Maintain pulmonary function as close toMaintain pulmonary function as close to

normal levels as possiblenormal levels as possible Maintain normal activity levels, includingMaintain normal activity levels, including

exerciseexercise

Avoid adverse effects from asthmaAvoid adverse effects from asthmamedicationsmedications

Prevent development of irreversible airflowPrevent development of irreversible airflowlimitationlimitation

Prevent asthma mortalityPrevent asthma mortality


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Therapy:Therapy:

Control of AsthmaControl of Asthma

Least cost from medicationLeast cost from medication


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Bronchial

Asthma

Avoidance of

Triggers

Pharmacotherapy Immunotherapy

Inhalants

IngestantsBronchodilators

Anti-inflammatory

Drugs

Desensitization

IgE Antibodies

Control of

Aggravators

GERD

Sinusitis

Smoking

Drugs

Non-Pharmacological

Education


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Pharmacotherapy in AsthmaPharmacotherapy in Asthma

A stepwise approach to pharmacological therapy isA stepwise approach to pharmacological therapy is

recommendedrecommended

The aim is to accomplish the goals of therapy withThe aim is to accomplish the goals of therapy with

the least possible medicationthe least possible medication

Although in many countries traditional methods ofAlthough in many countries traditional methods ofhealing are used, their efficacy has not yet beenhealing are used, their efficacy has not yet been

established and their use can therefore not beestablished and their use can therefore not be

recommendedrecommended


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Pharmacotherapy in AsthmaPharmacotherapy in Asthma

Mild, intermittentMild, intermittent

as-needed relieveras-needed reliever

Mild, persistentMild, persistent


controllercontroller

Moderate, persistentModerate, persistent


two controllerstwo controllers

Severe, persistentSevere, persistent


two controllerstwo controllers High dose ICS andHigh dose ICS and

possibly oral CSpossibly oral CS


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Relievers in Bronchial Asthma

Rapid-acting inhaled 2-agonistsSalbutamol, Terbutaline

Inhaled Long-acting 2-agonistsFormoterol

AnticholinergicsIpratropium

MethylxanthinesTheophylline

Short-acting oral 2-agonists

Salbutamol, Terbutaline


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Long Term ControllersLong Term Controllers

1.1. Inhaled glucocorticosteroidsInhaled glucocorticosteroids

2.2. Long-acting inhaled 2-agonistsLong-acting inhaled 2-agonists

3.3. Leukotriene modifiersLeukotriene modifiers

4.4. Systemic glucocorticosteroidsSystemic glucocorticosteroids

5.5. CromonesCromones

6.6. MethylxanthinesMethylxanthines

7.7. Long-acting oral 2-agonistsLong-acting oral 2-agonists

8.8. Anti-IgEAnti-IgE


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Whats New in the Guidelines?Whats New in the Guidelines?

When to Use INHALED STEROIDSWhen to Use INHALED STEROIDS

Early use is recommendedEarly use is recommended

HIGH vs LOW DOSE inhaled steroidsHIGH vs LOW DOSE inhaled steroidsHigh doses of inhaled glucocorticosteroids: limitedHigh doses of inhaled glucocorticosteroids: limited

benefit and potential adverse eventsbenefit and potential adverse events

Therefore add other therapies to moderate dosesTherefore add other therapies to moderate doses

-long-acting 2-agonists-long-acting 2-agonists

-leukotriene receptor antagonists-leukotriene receptor antagonists

-theophylline-theophylline At the consensus conference most would consider high dose more than 1000At the consensus conference most would consider high dose more than 1000g. (400-500g. (400-500

in children BDP e uivalentg in children) BDP equivalent


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Whats New in the Guidelines?Whats New in the Guidelines?

Place of long actingPlace of long acting 2 AGONISTS2 AGONISTS Many studies have repeatedly demonstrated that adding aMany studies have repeatedly demonstrated that adding a

long-acting beta2-agonist to a lower dose of inhaledlong-acting beta2-agonist to a lower dose of inhaled

corticosteroids produces superior outcomes compared withcorticosteroids produces superior outcomes compared with

doubling or even greater dosage increases in the ICdoubling or even greater dosage increases in the IC Sole use (Salmeterol) may be fatalSole use (Salmeterol) may be fatal

Place of anti-Leukotriene blockersPlace of anti-Leukotriene blockers Improves lung function when added to inhaledImproves lung function when added to inhaled

corticosteroidscorticosteroids

Not as effective as inhaled corticosteroidsNot as effective as inhaled corticosteroids


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Add-on ControllersAdd-on Controllers

Long-acting inhaledLong-acting inhaled 22-agonists-agonistsEffective bronchodilators for 12 hoursEffective bronchodilators for 12 hours

Protects against nocturnal asthmaProtects against nocturnal asthmaProtects against exercise inducedProtects against exercise induced

asthmaasthma

Improves asthma control more thanImproves asthma control more thanincreasing dose of inhaledincreasing dose of inhaledcorticosteroidscorticosteroids

Allow a reduction in the dose ofAllow a reduction in the dose ofinhaled steroid.inhaled steroid.


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Long-acting Inhaled 2-Long-acting Inhaled 2-

agonistsagonists

Regular use with inhaled corticosteroidsRegular use with inhaled corticosteroids

reduces the rate of both mild and severereduces the rate of both mild and severe

exacerbations in asthmaexacerbations in asthma

May be considered as an alternative to increased dosesMay be considered as an alternative to increased doses

of inhaled steroids and should be used as add-onof inhaled steroids and should be used as add-on

therapy to glucocorticosteroidstherapy to glucocorticosteroids

Formoterol but not Salmeterol may be used for reliefFormoterol but not Salmeterol may be used for relief

of acute symptomsof acute symptoms


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Add-on ControllersAdd-on Controllers

MontelukastMontelukast

Improves lung function and asthma controlImproves lung function and asthma control

May protect against exercise induced andMay protect against exercise induced and

aspirin-induced bronchoconstrictionaspirin-induced bronchoconstriction

Improves lung function when added to inhaledImproves lung function when added to inhaled

corticosteroidscorticosteroidsNot as effective as inhaled corticosteroidsNot as effective as inhaled corticosteroids


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AsthmaAsthma Non-pharmacologicalNon-pharmacological

Quality of Care IssuesQuality of Care Issues

Education:Education:

What is AsthmaWhat is Asthma

Avoidance of Precipitants/Triggers:Avoidance of Precipitants/Triggers: Environmental ControlEnvironmental Control

Recognition of symptoms of poor-controlRecognition of symptoms of poor-control

Self-management plan:Self-management plan:

Home Peak Flow MeterHome Peak Flow Meter

Partnership AgreementPartnership Agreement

Regular Follow-up:Regular Follow-up: at least every 1 to 6 months.at least every 1 to 6 months.

Follow-up Indices of Control (Follow-up Indices of Control (Follow-up FormFollow-up Form))


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Asthma Action PlanAsthma Action Plan

(PEFR-Based Self Management Plan)(PEFR-Based Self Management Plan)

Best


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Asthma Action PlanAsthma Action Plan

(Symptom-Based Self Management Plan)(Symptom-Based Self Management Plan)

Asthma under control

Waking with asthma at night

Increased breathlessness or

poor response to

Severe attack

Continue regular treatment

Double dose of:

Start prednisone & ring

Doctor

Call emergency Dr. or Dial

---- for ambulance


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OBJECTIVE:

A morally and mutually beneficial gentlemans agreement to

enhance physician and

patient medical knowledge and

communication, set standards and targets for care and

impart a stronger sense of accountability on both.

The Physician-Asthma Patient

Partnership Agreement


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You can expect your physician toprovide the following services, which

are an essential part of asthmamanagement.OFFICE VISITS- every three to twelve monthsfor reviewing your progress or as frequently as yourcondition dictates.MONITORINGin every Visit Weight, lungfunction, oxygen saturation and other vital signs.EDUCATION:Provision of educational material,education by a pulmonary educator, review ofinhaler technique, provision of a self-management

The Physician-Asthma PatientPartnership Agreement

PHYSICIAN DUTIES/RESPONSIBILITIES


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PERSONAL GOALS

The Physician-Asthma Patient

Partnership Agreement

PERSONAL GOALS


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Current Weight/

Body MassIndex:

Goal for 3months:

Current PEFR:Ideal PEFR

Goal for 3months:

Goal for 3 months:

Current FEV1:Ideal FEV1

Goal for 3 months:

CurrentAsthma

symptoms:

Goal for 3 months:

Smoking: Y/N Goal for 3 months:

Frequency ofattacks/ER visit:

Goal for 3 months:

PERSONAL GOALS


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YOUR RESPONSIBILITIES

Adhere to your allergen avoidance/smoke cessation instructions,

prescribed drugs and exercise advice.Schedulefollow-up appointments every three months or as

indicated by your doctor.Monitor Peak Expiratory Flow Rate at home at the agreed testing

frequency: _______.Always bring your prescribed medications with you.Worktoward attaining the personal goals noted above.

PATIENT SIGNATURE/ Date:

PHYSICIAN SIGNATURE/Date:

he Physician-Asthma PatientPartnership Agreement

PATIENT DUTIES/RESPONSIBILITIES


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Monitoring Asthma ControlMonitoring Asthma ControlFollow-up Indices of Control (Follow-up Indices of Control (Follow-up FormFollow-up Form))

Symptoms:Symptoms: Daytime and nighttime symptomsDaytime and nighttime symptoms

Severity:Severity: subjective and PEFR/Spirometrysubjective and PEFR/Spirometry

Compliance to therapy/Preventive MeasuresCompliance to therapy/Preventive Measures Use of inhaler/inhaler techniqueUse of inhaler/inhaler technique

Medication refillsMedication refills

Frequency of oral corticosteroid burst therapyFrequency of oral corticosteroid burst therapy

Side effects of medicationsSide effects of medications

Exacerbations/ER visitsExacerbations/ER visits

Psychofunctional /Social Impact:Psychofunctional /Social Impact: Missed work or schoolMissed work or school


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Indications for specialist referral:Indications for specialist referral:

s Patient has had a life-threateningPatient has had a life-threatening

asthma exacerbation.asthma exacerbation.

s Patient is not meeting the goals ofPatient is not meeting the goals of

asthma therapy.asthma therapy.

s Signs and symptoms are atypical.Signs and symptoms are atypical.

s Other conditions complicate asthma.Other conditions complicate asthma.


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s Additional diagnostic testing is indicated.Additional diagnostic testing is indicated.

s Patient requires additional education.Patient requires additional education.

s Patient is being considered forPatient is being considered for

immunotherapy.immunotherapy.

s Patient has severe persistent asthma.Patient has severe persistent asthma.


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s Patient requires continuous oralPatient requires continuous oral

corticosteroid therapy or high-dosecorticosteroid therapy or high-doseinhaled corticosteroids.inhaled corticosteroids.

s

ChildChild


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Patient is not improving:Patient is not improving:

Wrong diagnosisWrong diagnosis

Inadequate/deficient treatmentInadequate/deficient treatment Poor inhaler techniquePoor inhaler technique

Uncontrolled aggravatorsUncontrolled aggravators

Continuous exposure to allergensContinuous exposure to allergens S/E of asthma therapy.S/E of asthma therapy.


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Influence of pharmacotherapy on natural history of

disease still not well understood

Effect of Therapy on Remodelling?


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Asthma in SudanAsthma in Sudan

No studies on epidemiologyNo studies on epidemiology Set-up for asthma care is notSet-up for asthma care is not

satisfactorysatisfactoryAsthma EducationAsthma EducationOutpatient careOutpatient careEmergency careEmergency care


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Asthma Medicine 5

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