MANAGEMENT OF

BRONCHIAL ASTHMA

NOOR HAFIZAH BINTI HASSAN 2007287236

REFERENCES

1. GLOBAL INITIATIVE FOR ASTHMAGLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTIONUPDATED 2009

2. GUIDELINES ON MANAGEMENT OF ADULT ASTHMAMALAYSIAN THORACIC SOCIETY2002

GOALS OF MANAGEMENT1. ACHIEVE AND MAINTAIN CONTROL OF

SYMPTOMS2. MAINTAIN NORMAL ACTIVITY LEVEL,

INCLUDING EXERCISE3. MAINTAIN PULMONARY FUNCTION AS CLOSE

TO NORMAL AS POSSIBLE4. PREVENT ASTHMA EXACERBATION5. AVOID ADVERSE EFFECT FROM ASTHMA

MEDICATIONS6. PREVENT ASTHMA MORTALITY

1. DEVELOP PATIENT/DOCTOR RELATIONSHIP

2. IDENTIFY AND REDUCE EXPOSURE TO RISK FACTORS

3. ASSESS, TREAT AND MONITOR ASTHMA

4. MANAGE ASTHMA EXACERBATION

APPROACH TO MANAGEMENT

1. DEVELOP PATIENT/DOCTOR RELATIONSHIP

• Aim of partnership guided self-management

• Patient education:– Nature of asthma– Preventive measures/avoidance of triggers– Drugs used & their side effects– Differentiate between “reliever” and “controller”– Proper use of inhaler devices– Proper use of peak flow meter– Self management plan– Recognize features of worsening asthma– Dangers of non prescribed self medication

Peak Flow Chart

People with moderate or severe asthma should take readings:– Every morning– Every evening– After an

exacerbation– Before inhaling

certain medications

Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI

CONTROLLER MEDICATIONS & THEIR SIDE EFFECTS

RELIEVERS MEDICATIONS & THEIR SIDE EFFECTS

2. IDENTIFY & REDUCE EXPOSURE TO RISK FACTORS

• Factors that may precipitate asthma attacks:o Indoor allergens: domestic mites, furred animal,

cockroaches, and fungi.o Outdoor allergens: pollens and molds.o Smoking: active or passiveo Atmospheric pollutantso Day-to-day triggers: exercise and cold airo Occupational exposureo Food & food additiveo Drugs: aspirin, NSAIDs, and B-blockero Others: obesity/ influenza vaccine/ emotional stress

a) ASSESSING ASTHMA CONTROL:– To establish patients’ current treatment regimen– Adherence to the current regimen– Level of asthma control

b) TREATING TO ACHIEVE CONTROL– Reliever and controller medications

c) MONITORING TO MAINTAIN CONTROL– Controlled STEP DOWN– Loss of control STEP UP

3. ASSESS, TREAT & MONITOR ASTHMA

Three or more

features of partly

controlled asthma

present in any week

a) Level of asthma control

c) Monitoring to maintain controlo Frequency of health care visit:

1-3/12 after initial visit (dx) every 3/12 thereafter following exacerbation follow up 2/52 to 1/12

o Stepping down: low dose ICS as controller switched to OD dose medium/high dose ICS ↓ 50% within 3/12 ICS + LABA ↓ ICS by 50% + continue LABA. Once control is

maintained ↓ ICS to low dose + stop LABA ICS + controller other than LABA ↓ ICS by 50% or low dose +

stop the combination

o Stepping up: short acting B2 agonist / LABA ICS combination: ICS + rapid and long acting B2 agonist

o Difficult-to-treat asthma: definition: not reaching acceptable control at step 4 confirm diagnosis ensure compliance proper technique of using inhalation devices smoking comorbidities: obesity / OSA / chronic sinusitis / GERD /

psychological disorders consider referral to respiratory physician

4. MANAGE EXACERBATION

• Aim of management: To prevent death To relieve respiratory distress To restore patient’s lung function to the best

possible level as soon as possible To prevent early relapse

• Assessment of severity of attack: Hx taking & physical examination PEF measurement

FEATURES MILD MODERATE SEVERE / LIFETHREATENING

ALTERED CONSCIOUSNESS NO NO YES

PHYSICAL EXAMINATION NO NO YES

SPEECH SENTENCES PHRASES WORD(S)

PULSE RATE < 100 bpm 100-120 bpm > 10 bpm

PULSUS PARADOXUS

ABSENT( < 10 mmHg)

MAYBE PRESENT(10-25 mmHg)

OFTEN PRESENT( > 25 mmHg)

WHEEZING INTENSITY MODERATE LOUD OFTEN QUITE

USE OF ACCESSORY MUSCLE ABSENT MODERATE MARKED

CENTRAL CYANOSIS ABSENT ABSENT PRESENT

ASSESSMENT OF SEVERITY OF ASTHMA EXACERBATION

FEATURES MILD MODERATE SEVERE / LIFE THREATENING

PEFR• after initial use of bronchodilator or % predicted or % personal best

> 80 % 60-80 % < 60 %

O2 SATURATION > 95 % 91-95 % < 90 %

ARTERIAL PO2NO NEED TO DO

ABG > 60 mmHg < 60 mmHg

ARTERIAL PCO2NO NEED TO DO

ABG < 45 mmHg > 45 mmHg

CONTINUE..

b) Pharmacology revisited..

BRONCHIALTONE

BRONCHOCONSTRICTION

BRONCHODILATION

ATP

AC

cAMP

PDE

AMPADENOSINEACETYLCHOLINE

b) Pharmacological treatment

BRONCHIALTONE

BRONCHOCONSTRICTION

BRONCHODILATION

ATP

AC

cAMP

PDE

AMP

B 2 AGONIST

THEOPHYLLINE

ADENOSINEACETYLCHOLINE

THEOPHYLLINEANTI

CHOLINERGIC