Www.sinagroup.org January 2013 The Saudi Initiative for Asthma Guidelines for the Diagnosis and...

www.sinagroup.org January 2013

The Saudi Initiative for AsthmaGuidelines for the Diagnosis and Management of

Asthma in Adults and Children2013 update

On behalf of the SINA panelMohamed S. Al-Moamary, FRCP (Edin) FCCP

Dep. of Medicine, King Abdulaziz Medical City-RiyadhKing Saud bin Abdulaziz University for Health Sciences


Enter presenter nameEnter the presenter’s institute


SINA is developed by a task force originated from the Saudi Initiative for Asthma Group under the umbrella of the Saudi Thoracic Society

SINA is a practical approach for a comprehensive management of asthma in adults and children and when to refer to a specialist.

International recommendations were customized to the local setting for asthma diagnosis and management

Directed to HCW dealing with asthma who are not specialists in the field.

What is SINA?


Purpose of SINA

To provide a document that is easy to follow, simple to understand yet totally updated and carefully prepared for use by non-asthma specialist including primary care doctors and general practice physicians


Where do you find SINA?

The SINA guideline was published in the Annals of Thoracic Medicine (www.thoracicmedicine.org): Al-Moamary MS, Alhaider SA, Al-Hajjaj MS, Al-Ghobain MO, Idrees MM, Zeitouni MO, Al-Harbi AS, Al Dabbagh MM, Al-Matar H, Alorainy HS. The Saudi initiative for asthma - 2012 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2012;7:175-204

The SINA guidelines booklet is available at: www.sinagroup.org


Saudi Thoracic Society commitment

The STS is committed to improve the care of asthma by a long term plan:

Periodic scientific meetings Annual asthma meeting (since 2001) Frequent asthma courses Educational brochures Publishing new and updated asthma guidelines


What is new in SINA-2012

Comprehensive revision with the addition of new 125 referencesAddition of charts and algorithms for asthma diagnosis and managementUpdating asthma management Rewritten “asthma in children” section New section on “difficult to treat asthma”


SINA Panel

Mohamed S. Al-Moamary (Chairman), King Saud bin Abdulaziz University for Health Sciences, RiyadhSami Alhaider, King Faisal Specialist Hospital and Research Center, RiyadhMohamed S. Al-Hajjaj, King Saud University, RiyadhMohammed O. AlGhobain, King Saud bin Abdulaziz University for Health Sciences, RiyadhMajdy M. Idrees, Military Hospital, RiyadhMohamed O. Zeitouni, King Faisal Specialist Hospital and Research Center, RiyadhAdel S. Alharbi, Military Hospital, Riyadh Hussain Al-Matar, Imam Abdulrahman Al Faisal, DammamMaha M. Al Dabbagh, King Fahd Armed Forces Hospital, Jeddah Hassan S Alorainy, King Faisal Specialist Hospital and Research Center, Riyadh


Acknowledgment

The SINA panel would like to thank the following reviewers : • Prof. J. Mark FitzGerald from the University of British Columbia,

Vancouver, BC, Canada• Prof. Qutayba Hamid from the Meakins-Christie Laboratories, and the

Montreal Chest Research Institute• Prof. Sheldon Spier, the University of British Columbia, Vancouver,

Canada• Prof. Eric Bateman from the University of Cape Town Lung Institute,

Cape Town, South Africa (SINA 2009)• Prof. Ronald Olivenstein from the Meakins-Christie Laboratories and

the Montreal Chest Research Institute, Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada. (SINA 2009)


SINA Documents

Published manuscript BookletElectronic versionSlides kitFlyersWebsite: www.sinagroup.org


EpidemiologyPathophysiologyDiagnosisMedicationsApproach to ManagementTreatment StepsSpecial SituationsAcute Asthma

Sections of SINA – update cover


Prevalence

Prevalence of asthma has increased between 1986 – 1995

Alfrayyah et al. Ann Allergy Asthma Immunol 2001;86:292–296


Burden of Asthma

Asthma is among the most common chronic illnesses in Saudi Arabia

53% had missed school or work (AIRKSA-2007)

35% attempted Unconventional therapy (Al Moamary, ATM 2008)

46% were controlled in Riyadh (AIRKSA-2007)

36% were controlled in 5 tertiary care centers in Riyadh (Aljahdali SMJ-2008)

48% were controlled in one center (Al Moamary, ATM 2008)


AIRKSA report (Ministry of Health)

78 % of adults & 84% of kids reported acute asthma over 12 months (AIRKSA)

54 % of adults & 80% of kids reported ER over 12 months (AIRKSA)

45-68% of adults & 37-56% of kids reported limitation of activity over 12 months (AIRKSA)

76 % of adults & 78% of kids never had spirometry(AIRKSA)


The prevalence of wheeze and associated symptoms in the study group

Al-Ghobain et al, NBC Pulm Med 2012;12:39


Pattern of asthma treatment

Al-Shimemeri, Ann Thorac Med 2006;1:20-5


Pathology of Asthma

Inflammation

Airway Hyper-responsiveness Airway Obstruction

Symptoms of Asthma


Pathophysiology


Inflammation Remodeling

InflammationAirway HypersecretionSubepithelial fibrosisAngiogenesis


Diagnosis - History

Episodic attacks:

Cough

Breathlessness

Wheezing

Nocturnal symptoms

Patient could be asymptomatic between attacks

co-existent conditions: GERD, rhinosinusitis.


Relevant Questions

Does the patient or his/her family have a history of asthma or other atopic conditions, such as eczema or allergic rhinitis?

Does the patient have recurrent attacks of wheezing?

Does the patient have a troublesome cough at night?

Does the patient wheeze or cough after exercise?

Does the patient experience wheezing, chest tightness, or cough after exposure to pollens, dust, feathered or furry animals, exercise, viral infection, or environmental smoke?


Relevant Questions

Does the patient experience worsening of symptoms after taking aspirin/nonsteroidal inflammatory medication or use of B-blockers?

Does the patient's cold “go to the chest” or take more than 10 days to clear up?

Are symptoms improved by appropriate asthma treatment?

Are there any features suggestive of occupational asthma


Normal between attacks

Bilateral expiratory wheezing

Examination of the upper airways

Other allergic manifestations: e.g., atopic dermatitis/eczema

Consider alternative Dx when there is localized wheeze, crackles, stridor, clubbing

Physical Examination


Investigations

Measurements of lung function:

Spirometry

Peak expiratory flow (PEF)

Normal Spirometry does not role out asthma

Spirometry is superior to PEF


Bronchodilator response

Proper instructions on how to perform the forced

expiratory maneuver must be given to patients, and

the highest value of three readings taken.

The degree of significant reversibility is defined as an

improvement in FEV1 ≥12% and ≥200 ml from the

pre-bronchodilator value.


Measurements of allergic status to identify risk factors (if indicated)Chest X-ray is not routinely recommendedRoutine blood tests are not routinely recommendedIgE measurement is indicated in severe cases

Clinical Assessment


Assessment of Asthma Control


Level of Control: Level of Control:

• Total: 25

• Control: 20-24

• Partial control: 16-19

• Uncontrolled: < 16

Asthma Control Test


Differential Diagnosis

Upper airway diseasesAllergic rhinitis and sinusitis

Obstructions involving large airwaysForeign body in trachea or bronchusVocal cord dysfunctionVascular rings or laryngeal websLaryngotracheomalacia, tracheal stenosis, or bronchostenosisEnlarged lymph nodes or tumor

Obstructions involving small airwaysViral bronchiolitis or obliterative bronchiolitisCystic fibrosisBronchopulmonary dysplasiaHeart disease

Other causesRecurrent cough not due to asthmaAspiration from swallowing mechanism dysfunction or GERD


Management of Acute Asthma


Acute Asthma in Adults

Most patients who present with an acute asthma exacerbation have chronic uncontrolled asthmaThe following should be carefully checked:

previous history of near fatal asthmapatient taking three or more medicationsheavy use of SABA and frequent ER visits

Patient should be assessed to determine the severity of acute attacks PEF and pulse oximetry measurements are complementary to history taking and physical examination


Levels of severity of acute asthma exacerbations in adults


Initial Assessment of Acute Asthma


Medications used in acute asthma

OxygenHigh concentration of inspired oxygen to correct hypoxemia (do not miss COPD)Pulse oximetry should be used to tailor oxygen therapyFailure to achieve oxygen saturations of more than 92% is a good predictor of the need for hospitalizationNormal or high PaCO2 is an indication of a severe attack, and need for specialist consultation


Bronchodilators

Inhaled salbutamol is the preferred choiceRepeated doses is recommended at 15–30 minute intervals. Alternatively, continuous nebulization (Salbutamol at 5–10 mg/hour) may be used for one hour if there is an inadequate response to initial treatment.


Bronchodilators

Patients who are able to use the inhaler devices, 6–12 puffs of MDI with a spacer are equivalent to 2.5 mg of Salbutamol by nebulizerIn moderate to severe acute asthma, combining ipratropium bromide with Salbutamol has some additional bronchodilation effects, in reducing hospitalizations and greater improvement in PEF or FEV1


Steroid therapy

Systemic steroids: reduce relapses and subsequent hospital admissionOral steroid = injected steroidsOral prednisolone: 40–60 mg dailySystemic steroids should be given for seven days for adults and three to five days for


Magnesium sulphate

A single dose of IV magnesium sulphate (1.2–2 gm IV infusion over 20 mins) is safe and effectiveRoutine use of IV magnesium sulphate in patients with acute asthma presenting to emergency department is not recommended.Its use should be limited to those with sever exacerbation who fail to respond to treatment after an hour


Intravenous aminophylline

In acute asthma, the use of intravenous aminophylline did not result in any additional bronchodilation compared to standard care with B2-agonists


Antibiotics

Viral infection is the usual cause of asthma exacerbationThe role of bacterial infection has been probably overestimated, and routine use of antibiotics is strongly discouragedThey should be used when there is associated pneumonia or bacterial bronchitis


Initial Management of Acute Asthma


If there is an adequate response


If there is a partial response


If there is a poor response


Referral to a specialist center

Status asthmaticsDeteriorating PEFPersisting or worsening hypoxiaHypercapnea, respiratory acidosis (pH <7.3)Severe exhaustionIncrease work of breathingDrowsinessConfusionComaRespiratory arrest


Criteria for admission

Patients whose peak flow is ≥ 60% best or predicted one hour after initial treatment can be discharged from the emergency departmentCriteria for admission:

Any feature of a life threatening, near fatal attackAny feature of a severe attack that persists after initial treatment. unless any of the following is present:still suffering from significant symptomsprevious history of near fatal or brittle asthmaconcerns about compliance and pregnancy


Asthma in children < 5 years

No tests can diagnose asthma with certainty.

Lung function testing is not very helpful

CXR may help to exclude structural abnormalities of the airway.

A trial of treatment with short-acting bronchodilators and inhaled corticosteroids (ICS) for at least 8 to 12 weeks may provide some guidance as to the presence of asthma.


Acute asthma in children < 5 years

Immediate medical attention should be taken in case of children less than two year who had a history of poor response to three doses of SABA within 1–2 hours, saturation less than 92%, or the child is acutely distressed.

In this age group, the risk of fatigue, respiratory compromise and dehydration is considerable

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