ma7384@cgmh.org.

tw
2015-11-01

Asthma: heterogeneous disease

chronic airway
inflammation
respiratory symptoms vary
over time and in intensity
variable expiratory airflow
limitation
GINA guideline

CMAJ 2008;179(11):1121-31

30% patients
have no
reversible
airflow
obstruction or
airway
hyperreactivity
CMAJ 2008;179(11):1121-31

2
3

GINA guideline

cough
wheeze

short of
breath
chest tightness

Isolated cough seldom asthma

Mincheva et al. Respiratory Research 2014, 15:79

2 History and Physical

examination
Increase the probabilities of asthma
History of allergic rhinitis or eczema
Family history of asthma or allergy

GINA guideline

2 History and Physical

examination
Physical examination: often normal
Wheeze also noted when upper airway
obstruction, tracheomalacia, inhaled
foreign body, vocal cord dysfunction,
COPD, bronchiectasis, heart failure,
pulmonary embolism

GINA guideline

3 Airflow limitation
In all patients >5 years of age, use
spirometry to determine that airway
obstruction is at least partially reversible
FEV1 from spirometry is more reliable
than peak expiratory flow
()
GINA guideline

<50% patients with physician

diagnosed asthma received PFT

CHEST 2012; 141(5):11901196


1. FEV1 () <80%
predicted
+ FEV1/FVC <75%
2. Bronchodilator reversibility tests

Increase FEV1>12% and >200mL from

baseline, 10-15 minutes after 200400mcg albuterol

FEV1 baseline
12% and
200mL after
bronchodilator

CHEST 2011; 140(4):10551063

Bronchodilator reversibility tests

COPD or asthma
In COPD patients

CHEST 2011; 140(4):10551063

Peak flow meter

Average daily diurnal PEF variability >
10%
Cheap, Easy to use
Less reliable

FEV1peak expiratory flow

CHEST 2006; 130:14541461

Methacholine challenge test

Am J Respir Crit Care Med Vol 161. pp 309-329, 2000

Pre

Test

Fall in FEV1 from baseline of >=20% with

standard dose of methacoline

Methacholine challenge test

(PC20)
High sensitivity but less specific
Airway hyperresponsiveness could be
described in cystic fibrosis, allergic
rhinitis, COPD

Negative result in patient not taking ICS

can help exclude asthma
GINA guideline

Allergy tests
Specific immunoglobulin E : expansive

(CGMH)
60

D. pteronyssinus

50

D. farinae

40

30

20

10

0
Specific IgE

Chih-Hao Chang, Horng-Chyuan Lin, et al

2012; 27: 1-12

FENO (exhaled nitric oxide)

Not widely use
Wide normal range
Decrease in smoker and during
bronchoconstriction
Use in asthma step down or adherence
monitor

FENO vs PEFR

FENO use in asthma step down

J Asthma, 2013; 50(7): 718721

High FENO
poor adherence

Clinical and Translational Allergy 2013, 3:37

Bronchoscpic biopsy

CHEST 2012; 141(3):599606

Diagnosis of asthma
1. No single method (including
history, PE, bronchodilator reversibility
tests, PC20)

2. Spirometer is useful for

diagnosing asthma
3. Not all wheeze is asthma
(differential diagnosis)

Assessment of asthma
1

1 Asthma symptom control

Daytime asthma symptoms more than
twice/week ?
Any night waking due to asthma ?
Reliever needed for symptoms more than
twice/week ?
Any activity limitation due to asthma ?
0: Well controlled ; 1-2 partly controlled; 3-4
uncontrolled
GINA guideline

Asthma control test

1
2
3
4
5
http://www.gsk.tw/YourHealth/health-8-1.shtml

Asthma control test

1
2
3
4
5

http://www.gsk.tw/YourHealth/health-8-1.shtml

Asthma control test

()

5
http://www.gsk.tw/YourHealth/health-8-1.shtml

Asthma control test

(Albuterol()
Ventolin()Berotec(
Bricanyl())
1

5
http://www.gsk.tw/YourHealth/health-8-1.shtml

Asthma control test

1
2
3
4
5
http://www.gsk.tw/YourHealth/health-8-1.shtml

Asthma control test

1
2
3
4
5
http://www.gsk.tw/YourHealth/health-8-1.shtml

Mincheva et al. Respiratory Research 2014, 15:79

Asthma severity
Mild asthma: well controlled with step 1
or step 2 treatment

Moderate asthma: well controlled with

step 3 treatment (low dose ICS/LABA)
Severe asthma: requires step 4 or 5
treament

Asthma control and severity

Eur Respir J 2008; 32: 545554

Lung function in asthma

Nonsmoking
with asthma

Smoking with
asthma

Current Opinion in Pulmonary Medicine 2009, 15:3945

Variability of Peak Expiratory Flow

GINA guideline

2
Question the patient
I realize that it is difficult to take your asthma
medication twice a day, every day. In 4 weeks
you would need to use your inhaler 28 times.
Most of my patients take their medicine 60%
to 70% of the time. How do you do?

Pharmacy prescription refill databases

Data assessed is only as accurate as the data that
was input
Assume that the patient was in possession of
the medication no guarantees that medications
were taken
Patterns of no drug therapy may not indicate
non-adherence
Doctor may have discontinued or verbally
informed patient to change daily regimen (e.g.,
BID to QD or cut pills in half)
Patient may have been given samples

http://dx.doi.org/10.5415/apallergy.2012.2.1.67

3 cormobidities: GERD

Curr Opin Pulm Med 2013, 19:4248

Weight reduction
better asthma control

Eur Respir J. 2014 May;43(5):1368-77

Assessment of asthma
1. Do asthma control test
2. Follow up lung function
(spirometry)

3. Assess inhaler technique,

adherence, and cormobidities
(especially poor controlled asthma)

Thanks for your

Thanks
for your attention
attention