Self Management of Asthma

Dr. Md. Khairul Hassan JessyAssociate Professor

Respiratory Medicine

NIDCH,Mohakhali,Dhaka

Self Management of Asthma

Introduction

To define the self management plan

To highlight the importance

To discuss the detailed procedure

Conclusion

In the last few years there have been

remarkable progress and

outstanding improvement

in the management of Asthma

But sadly, many patients of

developing countries are getting

unplanned

&

unscientific management

With

education, caution & medication most cases of

asthma can be effectively managed

History

Asthma was first recognized in

ancient Egypt &

treatment was

inhalation of frankincense

Source : Wikipedia

History…..

It was first recognized as a specific respiratory problem &

named by

Hippocrates

History…..

History…

The most recent advancement is

Combination of ICS & LABA with

Adjustable Maintenance Dose (AMD)or

Single Maintenance And Reliever Therapy (SMART)

Asthma is a

chronic inflammatory disease affecting

the airways with typical symptoms of

cough, wheezing, breathlessness

& chest tightness

Unified definition

Asthma is a chronic inflammatory disorder causing hyper-responsiveness of the airways to certain

stimuli resulting in recurrent variable airflow limitation at least partially reversible with treatment or spontaneously

manifested as shortness of breath, wheeze, cough and

chest tightness

It is not a curable diseaseBut to a large extent

It is

controllable like Diabetes & Hypertension

Use of

anti- inflammatory preventive drugsfor 2-5 years may lead to

Complete Remission in60 – 80 % of Childhood asthma

20 – 30 % of Adult asthma

But many serious episodes can

be avoided by

proper education and

care at home

Pharmacological management& Medicines of Asthma

Pharmacological management of Asthma…

The mainstay of asthma therapy is the

use of inhaled drugs

the advantages of this method are that drugs are

delivered direct to the airways and

avoid passage to the liver

Pharmacological management of Asthma…

thus lower doses are necessary and systemic

unwanted effect are minimized

The drugs used in asthma should be given in a

stepwise fashion according to the severity and

frequency of the attacks

Medicines of Asthma:

Medicine used to treat asthma are basically three

types

A) Relievers

B) Preventers

C) Protectors

A) Relievers

These medicines relax smooth muscles that

have tightened around the airways.

They relieve asthma symptoms.

A) Relievers (Bronchodilators)…

1. Short acting β2-agonists (SABA)

SalbutamolTerbutaline

2. Short acting Xanthenes' derivatives

TheophyllineAminophylline

3. Anticholinergics Ipratropium bromideOxitropium bromideTiotropium

B) ProtectorsThese medicines are long acting bronchodilator

medicines which prevent the recurrence of attacks

particularly nocturnal symptoms.

B) Protectors (Symptom controllers)

1) Long acting β2 agonist (LABA)

Salmeterol Formoterol

2) Long acting Xanthene derivatives

TheophyllineAminophylline

3) Sustained released Salbutamol

C) Preventers

medicines reduce or reverse the swelling in the airways

These medicines also prevent the initiation of inflammation after exposure to trigger factors

Thereby they prevent asthma episodes

C) Preventers (Anti-inflammatory medicines)

I)Corticosteroids •Inhaled•Oral

II) Cromones •Nedocromil sodium•Sodium Cromoglycate

III) Xanthene derivatives •Aminophylline and •Theophylline

IV) Antileukotrienes •CysLT-1 receptor inhibitor: •Montelukast and •Zafirlukast •Enzyme inhibitor: Zileuton

Newer and Disease modifying Drugs

Newer Drugs

Omalizumab (Xoliar)

Magnesium Sulfate

Frusemide

Ciclesonide

Newer and Disease modifying Drugs…

Disease modifying agents

Methotraxte,

Cyclosporin-A &

Gold-salts

OMALIZUMAB (XOLIAR) Considerations for IgE blocker Therapy

Monoclonal anti-IgE ab preparation

Inhibit binding of IgE to mast cell – does not

provoke mast cell degranulation

OMALIZUMAB (XOLIAR) Considerations for IgE blocker Therapy…

Patient at least 12 years of age Evidence of reversible disease (such as 12% or

greater improvement in FEV1 with at least a 200-ml increase

or 20% or greater improvement in PEF) IgE level ≥ 30 IU/ml


Systemic corticosteroids or high-dose inhaled

corticosteroids required to maintain adequate control

As directly observable therapy in patients who are not

adherent to prescribed therapy

An overview of asthma triggers

Asthma Triggers…

A trigger is anything that irritates the airways

and causes the symptoms of asthma

Normal healthy person is not bothered by those

triggers

Asthma Triggers…

Everyone's asthma is different and you may have

several triggers

An important aspect of controlling your asthma is

avoiding your triggers

It may be impossible to avoid all of your triggers

Asthma Triggers…

but once you've identified them

there are things you can do to help you to reduce

unnecessary symptoms and

better control of your asthma

Unhealthy indoor environment for asthma patient

Asthma Triggers…

Why To identify asthma triggers?To prevent some asthma attacks

To reduce the frequency and severity of some attacks

The patient is trying to control his asthma without removing

trigger factor

Asthma Triggers…

Detection of trigger by monitoring the lung function

To control asthma, PEP (Positive Expiratory Pressure) is so important that if they are

educated properly, then-73% of hospital admission from acute attack

of asthma can be reduced and80% of death from asthma can be prevented

Effortless easy breathing- is our goal24 hours a day

30 days a month

12 months a year

-with an intention for full remission

Non- Pharmacological

- Education- CautionPharmacological

- Medications used in management

We should educate our people

in their own languageBased on

- our scientific knowledge- less scientific terminology- less comprehensive patho-physiology

GINA aimsGINA guidelines

published

Implementation GINA guidelines

How are we doing?

Patients? Physicians?

Healthcare system?

Asthma control

Who is responsible for asthma control?

Researchers?

41.1

14.5

35.4

Asia PacificEuropeUSA

% of patients100

0

80

60

20

40

Rabe et al. Eur Respir J 2000;www.asthmainamerica.com;

Lai et al. J Allergy Clin Immunol 2003

Patients with persistent asthma receiving controller therapy

Asthma control in practice was poor

Doctors didn't follow

guidelines,

underestimate severity and

may confuse severity with control

Patients underestimate

the severity of their own disease

Guidelines were complex and can be difficult

to follow

Only 5% of patients achieved GINA-defined

control

Control of asthma means, patient-

is almost asymtomatic

can perform normal daily activities

requires reliever bronchodilator(sulbutamol

inhalation)<1 time a day

is free of nocturnal symptoms; if occurs , less

than two times per month

has PEFR reading >80% of personal best result

has <10% diurnal variability in Peak Flow Chart,

if available

has no history of emergency visit to doctors

or hospitals

has no or minimal side effects of medication

If we educate our patient properly

Then patient will cautiously avoid allergens

to control bronchial asthma

They will use their medications with an

intension to get remission

Includes –

Home Management

- of stable asthma

Emergency Management

-Loss of control of asthma

-Difficult to treat asthma

Asthma is a chronic disease and it should be

managed at home, except severe acute asthma

If home management plan is applied intelligently

and skillfully most asthmatics can lead a

symptom-free near-normal life

They may avoid hospitalization thereby

decreasing the financial expenditure significantly

There are two types of plans without self-management plan

with guided self-management plan

The patient is educated

Appropriate precautionary measures

are advised

“Step care management’’ is employed

The prescription is quite inflexible whatever be the condition

patient will not increase the drugs except β 2 agonist ( salbutamol ) inhaler

Salbutamol inhaler may be taken as per need upto 4-6 times / day

Development of a guide on the basis of best Peak Flow is known as guided self management plan. Patient will measure his lung function with the help of a peak flow meter and on the basis of best peak flow results, patients will modify their treatment.

Peak Flow Meter

lead a symptom free near normal life

avoid many serious episodes of acute

asthma &

Chances of mortality and morbidity is

reduced considerably

Time consuming

More laborious

Needs patient compliance

Flow meters are devices to measure

the strength of airways (force of

inspiration and expiration)

Types of flow meters are

Peak expiratory flow meter ( peak flow

meter)

Incentive Spirometer

Peak inspiratory flow meter ( PIF )

The measurement of peak expiratory

flow was pioneered by Martin Wright

who produced the first meter to

measure lung function

The original design of instrument was

introduced in the late 1950s

and the subsequent development of a more

portable, lower cost version is the "Mini-

Wright" peak flow meter

Who Should Use a Peak Flow Meter?

People with moderate-to-severe asthma should have a

peak flow meter at home.

Even Peak flow meters are very helpful if a child have

moderate to severe asthma and require daily asthma

medications.

Most children ages 6 and up may be able to use a

peak flow meter.

PEF(Peak expiratory flow):

It is the highest flow one can achieve

during forceful expiration

The peak flow meter measures how fast air comes out of

the lungs when a person exhale forcefully after inhaling fully

Inexpensive, portable & handy device.Only measures the amount of airflow out of the large

airways of the lungs.Small airways (which also occur with asthma) will not

be detected by a peak flow meter.

Depends on a patient's sex, age and height.

Move the marker to the bottom of the numbered scale.

Stand up if you're able.

Take a deep breath, filling your lungs completely.

Place your lips tightly around the mouthpiece.

Blow as hard and as fast as you can with a single breath.

Note the final position of the marker. This is your peak flow rate.

Follow the steps above then blow into the peak

flow meter two more times.

Best of 3 blows is recorded.

To recognize early changes that may be signs of

worsening asthma and thus preventing asthma attack.

During an asthma attack, the muscles in the airways

tighten and cause the airways to narrow.

The peak flow meter alerts you to the tightening of

the airways often hours or even days before the

development of asthma symptoms.

By following the steps in asthma action plan,

patient may be able to

stop the narrowing of the airways

quickly and

avoid a severe asthma emergency

Mainly Used to find out early asthma attack (long before the

onset of symptoms) & by doubling the medicine a

serious episode can be avoided Used as a short term monitoring tool at

Doctor’s chamber & emergency room during exacerbations

Long term monitoring of asthma at patient’s home

by maintaining peak flow chart essential for constructing self

management plan

Can also be used to see whether the management plan is working or not to decide when to add or stop medicine to decide when the patient seeks emergency care to identify triggers

By using own PEF with his/her asthma action

plan, he/she will know when to take his/her

rescue asthma inhaler or other asthma

medicine.

Diurnal variability = (highest PEF – lowest PEF)X100 highest PEF

How to take care of Peak Flow Meter?

Most peak flow meters require weekly cleaning with warm water and a mild detergent.

PEF varies throughout the day.

In a person who does not have asthma, it may

vary between 10% and 15%.

In a person who has poorly controlled asthma,

it may vary more than 20%.

Peak Flow Chart

The highest peak flow measurement of a patient

achieved over a two week period when patient’s

asthma is totally/ well controlled

“Self management plan” needs to be constructed

depending on his own personal best peak flow value

A person's personal best is his or her highest peak flow.

Determine by taking readings over 2 weeks

when the asthma is under control.

Should be recorded at least twice daily.

Best is usually reached in the evening.

Never measured during an asthma attack.

Patient will-Record his personal best peak flow result in the prescribed peak flow diary or chart3 zones will be demarcated in the diaryTake peak flow reading every morning on waking up and night at bedtimePeak flow readings should be taken at the same time each dayThey will also write down if they were exposed to any trigger factor’s initiating an attack.

Patient will- Peak expiratory flow is lowest in the early

morning and highest in the afternoon. If patient wants to take the test only one time

during the day, they should take it first in the morning, before using a bronchodilator medicine.

note how many times they took extra reliever asthma medicine to stop their symptoms every day

( 3 basic steps )( 3 basic steps )Step 1Step 1

Patient will measure the lung function with peak flow meter & maintain a

peak flow chart

( 3 basic steps )Step 2

With this chart - patient’s personal best peak flow result is

determinedOn that basis readings are recorded in a

chart with 3 color zones :Green,Yellow, Red

Peak Flow Chart

( 3 basic steps )Step 3

Physician will develop one prescription for each zone

Patient is educated to modify drugs up to a certain limit

Peak Flow Zone System

3 traffic light colors are used to measure the control of asthma

Green

Yellow

Red

Green zone indicates

well controlled asthma

Green zone ( safety zone ) peak flow 100 - 80 % of personal best

no/minimal symptoms maintenance therapy continuesinhaled β 2 agonists may be used in some specific

situations

( before exercise / mild symptoms)

Yellow zone ( zone of alert )

- PEF is < 80 –> 60 % of personal best

o Asthma symptoms –

cough ( nocturnal )

breathlessness

wheezing may be present

Yellow zone ( zone of alert )…suggestive of – Acute exacerbation or gradual deterioration of

severity of asthma Consultation with physician is needed . Patient will double his preventer drug and take one or

two oral protector drugs.

Red zone ( zone of emergency ) This signals a medical alert

o PEF is < 60 % of personal bestoAsthma symptoms are present at rest and

interferes activityo β 2 agonist should be taken immediatelyo patient will start rescue oral steroid &o should contact the physician ( may need

hospitalization )

Red Zone means

Along with prescription of yellow Zone

patient will start rescue oral steroid and

should contact a physician immediately

Scenario 1: Mr. X , 45 years - known case of bronchial

Asthma & Allergic Rhinitis Personal best peak flow result =500L/min Present PEFR = 420 l/min

Questions: 1.PEF Zone? 2.What treatment to be given?

Ans. 1. Green Zone 2.Rx

Inhaler Fluticasone/Salmaterol (125/25)2 puffs 12 hourly (contd) (gargle after use)

Inhaler Salbutamol 2 puffs SOS

Tab. Montelukast 10 mg 0+0+1(contd)

Tab. Fexofenadine 120/Rupatidine 100+0+1 SOS

Fluticasone nasal spray2 puffs once daily in the morning (sos)

Scenario 2:Mr. X , 45 years - known case of bronchial Asthma & Allergic Rhinitis

Personal best peak flow result=500L/minPresent PEFR = 350 l/min

Questions: 1.PEF Zone? 2.What treatment to be given?

Ans. 1.Yellow Zone 2.Rx:

Inhaler Fluticasone/Salmaterol(250/25)2 puffs 12 hourly (contd)(gargle after use)

Inhaler Salbutamol 2 puffs sos

Tab. Montelukast 10 mg 0+0+1(contd)

Tab. Fexofenadine 120/Rupatidine 10 0+0+1 sosTheophylline S.R.(200 mg)

0+0+1 (contd)Fluticasone nasal spray 2 puffs once daily in the morning (contd)

Scenario 3:

Mr. X , 45 years - known case of bronchial

Asthma & Allergic Rhinitis

Personal best peak flow result = 500 L/min

Present PEFR = 150 l/min

Questions:

1.PEF Zone?

2.What treatment to be given?

Ans. 1.Red Zone

2.RxTab. Prednisolone (20 mg)

2+0+0 (after meal) 7 days

Tab. Esomoprazole (20 mg)

1+0+1

+treatment of yellow zone(to contact physician immediately)

Asthma is not a curable disease But total/well control is possible in almost all

cases by

oproper Educationotaking Caution ( regarding

environmental control )&

oNeed for Medication.

Asthma is a chronic disease and it

should be managed at home except

severe acute asthma

THANK THANK YOU !YOU !

Self Management of Asthma

Education

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