Bronchial Asthma OS 216 Immuno

Jenifer R. Otadoy-Agustin-MD Exam 02

20 Jan 2020 Trans 09B

OUTLINE B. PATHOPHYSIOLOGY
I. Introduction V. Asthma Flare-Ups  In the acute phase, the mast cell recognizes an allergen, and
II. Asthma (Exacerbations) releases inflammatory mediators (Figure 1)
A. Definition A. Management of Worsening  In the chronic phase, the T-helper 2 cells and the macrophages
B. Pathophysiology Asthma as a Continuum are activated, and recruit eosinophils, and their degranulation
C. Diagnosis B. Written Asthma Action (Figure 1)
III. Assessment of Control and Plans  This leads to airway remodeling which is responsible for the
Severity C. Identifying Patients at Risk changes seen in an asthmatic airway (Figure 2):
A. Asthma Control of Asthma-related Death → Narrowing of the lumen
B. Assessment of Risk Factors D. Managing Exacerbations in → Bronchoconstriction
for Poor Asthma Outcomes Primary or Acute Care → Subepithelial membrane thickening
C. Asthma Severity E. Follow-up After an → Hyperplasia of smooth muscles
IV. Treatment Exacerbation → Angiogenesis
A. Goals of Treatment VI. Primary Prevention → Increased mucus production
B. Asthma Treatment Options
C. The Control-Based Asthma
Managements Cycle
D. Asthma Treatment Strategy
E. Reviewing Response and
Adjusting Treatment
Note from TG: Based on the lecture, recording, 2022 trans, and
GINA Guidelines 2019. Multiple parts of this trans were rearranged
and paraphrased for easier understanding. Parts not discussed in
previous transes were removed as the exam will be lecture-based.
I. INTRODUCTION
 January 2020 – Taal Volcano Eruption
→ Potential hazard for asthmatic patients
 Global Initiative for Asthma (GINA) Assembly
→ Came up with recommendations to treat asthma
→ Philippines participated in this GINA Assembly
→ Important because they found out that the prevalence of
asthma continues to increase
 339 million people worldwide suffer from asthma
 The National Nutritional Health Survey of 2008 found that there
was a 14.3% prevalence of asthma in the Philippines
→ Not as high as allergic rhinitis
 Even though asthma is treated, it is still a significant cause of
mortality
→ In the Philippines, 2.7% of all deaths are by asthma
→ Worldwide, we have the second highest mortality in the
world for patients 5-35 years old, and also across all ages.
 In 2018, PhilHealth found that asthma was the sixth most used
reason for admission to hospitals
 It is also one of the top 10 causes of death in the Philippines
→ All other respiratory diseases are decreasing in prevalence,
but asthma and COPD are increasing
II. ASTHMA
A. DEFINITION
 Asthma is a disease characterized by chronic airway
inflammation
 It is accompanied by four respiratory symptoms:
→ Wheezing Figure 1. Mast cells degranulate upon contact of allergen with the
surface IgE. This releases inflammatory mediators, and in the chronic
→ Shortness of breath
phase, leads to stimulation of the Th2 response and recruitment of
→ Cough macrophages, and eosinophils. This causes airway
→ Chest tightness damage/inflammation. Chronic inflammation leads to mucus gland
 It is also accompanied by a variable expiratory airflow limitation. hyperplasia, collagen deposition, smooth muscle hyperplasia and
hypertrophy (remodeling phase).
Asthma is characterized by chronic airway inflammation,
respiratory symptoms (wheezing, shortness of breath, cough,
and chest tightness), and a variable expiratory airflow
limitation.

TG B3: Medina, M., Medina, P., Mendoza, J. [Salvan] 1 of 11

OS 216 Immuno: Bronchial Asthma Exam 02 - Trans 09B

Spirometry/Lung Function Tests

 Review:
→ FEV1 (forced expiratory volume in 1 second) is the amount
of air you can forcefully expire from your lungs in one
second, measured using spirometry
→ FVC (forced vital capacity) is the total amount of air expired
during the spirometry test
 In asthma, we must confirm the presence of airflow limitation
(memorize):
There is airflow limitation when:
FEV1/FVC < 0.75 in adults
FEV1/FVC < 0.9 in children
 In asthmatic patients, FEV1 is lower than normal, but increases
upon administration of a bronchodilator (Figure 3)

Figure 2. Histology of a normal bronchiole vs. a bronchiole of an asthmatic

patient. Notice that there is an evident decrease in lumen size because of
subepithelial membrane thickening, airway smooth muscle hyperplasia, and
angiogenesis. Increased mucus production also contributes to
bronchoconstriction. (BV – blood vessel, Ep – epithelium, Sm – smooth
muscle, Bm – basement membrane)

 The increased mucus production in asthma also contributes to

inflammation in the airway
 Air trapping in the alveoli also produces more mucus and
smooth muscle constriction
 This contributes to bronchoconstriction (and thus, the symptoms
felt by the patient such as cough and shortness of breath) on top
of the airway remodeling
 All these contribute to the four symptoms mentioned earlier and
also the variable expiratory airflow limitation experienced by
asthmatic patients.
C. DIAGNOSIS Figure 3. Typical spirometric tracings. FEV1 is lower than normal in
asthmatic patients but this increases upon administration of a
History of Present Illness bronchodilator.
 Diagnosis is clinical
 Respiratory symptoms are typical of asthma (wheezing,  In the clinics, upon ordering a spirometry test, we might be
shortness of breath, cough, and chest tightness) shown a complicated form listing the results of our patient, but
→ Diagnosis increases in probability if: do not worry as all the pertinent info has already been calculated
 The patient has more than one of these symptoms and summarized for us to interpret:
 Varies in intensity over time
 Worse at night or in the early morning Table 1. Pertinent Spirometry Results
 There is a perceived trigger (allergen, viral infections, PRE %PRED POST %CHg
Commented [MRAS1]: Ano meaning ng headers?
exercise, laughing, exposure to car exhaust fumes, FVC 4.59 97 4.53 -1
smoke, or strong smells) FEV1 3.85 93 4 4
→ Diagnosis decreases in probability if there is: FEV1% 83.9 96 88.3 5
 An isolated chronic cough with no other symptoms  Column meanings:
 Chronic production of sputum → Column 2: pre-bronchodilator
 Shortness of breath associated with dizziness, light- → Column 3: % predicted value
headedness, or peripheral tingling → Column 4: post-bronchodilator
 Chest pain → Column 5: percent change
 Exercise-induced dyspnea with noisy inspiration (stridor)  FEV1/FVC = FEV1%
Asthma is ruled in if symptoms include wheezing, shortness  In the example given (Table 1), since FEV1% is 83.9% or 0.839,
of breath, cough, or chest tightness, varying in intensity over this does not qualify as airflow limitation if the patient is an adult
time, worsening at night or in the early morning, and with a  Airflow limitation caused by asthma must also be significantly
perceived trigger. improved by administration of a bronchodilator
→ Variability refers to improvement or deterioration in
Physical Examination Findings symptoms and lung function over a period of time, or through
 Normal, or may include wheezing upon auscultation a reversibility test using a rapid-acting bronchodilator
→ Wheezing is also found in other conditions (DDx: respiratory Significant bronchodilator reversibility:
infections, COPD, upper airway dysfunction, endobronchial
obstruction, aspiration of foreign bodies) Adults: % increase in FEV1 >12% and >200mL increase
→ Wheezing may also be absent during severe asthma Children: % increase >12% predicted
exacerbations (‘silent chest’)  In the example given (Table 1), the percent change in FEV1 was
just 4% (last column)
→ Bronchodilator reversibility = (4-3.85)/3.85 = 0.04 = 4%

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OS 216 Immuno: Bronchial Asthma Exam 02 - Trans 09B

→ This is not a significant reversibility and does not rule in  High short-acting beta agonist (SABA) use
asthma → Comorbidities:
 Obesity
 Chronic rhinosinusitis
 Gastroesophageal reflux disease (GERD)
 Class example (Figure 4):  Confirmed food allergy
 Anxiety, depression
 Pregnancy
→ Exposures:
 Smoking
 Air pollution
 Allergen exposure
→ Setting:
 Major socioeconomic problems
→ Lung function:
 Low FEV1, especially <60% predicted
→ Other tests:
 Sputum/blood eosinophilia
 Elevated FENO in allergic adults on ICS Commented [MRAS4]: What does this mean?
C. ASTHMA SEVERITY
 Asthma severity is assessed retrospectively from the level of
treatment required to control symptoms and exacerbations
Figure 4. Pre-bronchodilator FEV1 was 2.3, and post-bronchodilator FEV1  Asthma severity is assessed after patient has been on controller
was 3.5. (3.5-2.3)/2.3 = 52.17%, and thus reversibility is significant, ruling in treatment for several months. Commented [MRAS2]: Walang higher res image?
asthma. Note that from the values given for FEV1, we can already see that  Severity is not static – it may change over months or years or as Ignore this comment na lang kung wala talaga.
there is a >200 mL change since the y-axis is in liters (1.2 liter change!). different treatments become available.
 Mild persistent asthma: well-controlled with Steps 1 or 2 Pwede rin i-crop ‘yung text on the right side of the
Through spirometry, asthma is ruled in if: figure since nasa caption naman na.
 Moderate persistent asthma: well-controlled with Steps 3/4
1.) There is airflow limitation:  Severe persistent asthma: requires Step 5 treatment, or
FEV1/FVC < 0.75 in adults remains uncontrolled even with treatment Commented [MRAS5]: The image below says Step 3
FEV1/FVC < 0.9 in children for moderate and Step 4 or 5 for Severe, though.
2.) There is significant reversibility upon administration of a
bronchodilator:
Adults: % increase in FEV1 >12% and >200mL increase
Children: % increase >12% predicted

III. ASSESSMENT OF CONTROL AND SEVERITY

A. ASTHMA CONTROL
 Two domains:
→ Symptom control over the last 4 weeks
→ Risk factors for poor outcomes, including low lung function

Figure 5. Level of Asthma Symptom Control (GINA, 2019). See Summary

part III for larger photo. MEMORIZE! Figure 6. Classification of Asthma Severity >12 Years of Age. See
Summary part III for complete larger photo. MEMORIZE!
B. ASSESSMENT OF RISK FACTORS FOR POOR
ASTHMA OUTCOMES IV. TREATMENT
See Appendix B for the complete GINA table. A. GOALS OF TREATMENT
 Long-term goals of asthma management: Commented [MRAS3]: Do you mean Summary? Or is
 Assess risk factors at diagnosis and periodically, at least every this a different table?
1-2 years, particularly for patients experiencing exacerbations. → Symptom control:
 Measure FEV1 at start of treatment, after 3-6 mos. of controller  Achieve good control of symptoms
treatment to record personal best lung function, then periodically  Maintain normal activity levels
for ongoing risk assessment → Risk reduction:
 Assess patient’s risks for:  Minimize future risk of exacerbations, fixed airflow
→ Exacerbations limitation, & medication side-effects
→ Fixed airflow limitation  Achieving these goals requires a partnership between patient
→ Medication side-effects and their health care providers
 Additional potentially modifiable risk factors for exacerbations, → Ask the patient about their own goals regarding their asthma
even in patients with few asthma symptoms, include: → Good communication strategies are essential
→ Medications:  Consider the health care system, medication availability, cultural
 Inhaled corticosteroids (ICS) not prescribed and personal preferences, and health literacy
 Poor adherence B. ASTHMA TREATMENT OPTIONS
 Incorrect inhaler technique

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 Patient Education (always indicated)
 Allergen Avoidance (when indicated)
 Pharmacotherapy
 Immunotherapy
 Non-pharmacologic Interventions:
→ Avoidance of tobacco smoke exposure
→ Physical activity
→ Occupational asthma
→ Avoid medications that worsen asthma
→ Remediation of dampness or mold in homes
→ Allergy work up
 Patient-MD partnership
C. THE CONTROL-BASED ASTHMA MANAGEMENT
CYCLE
Figure 7. Control-based Asthma Management Cycle (GINA, 2019). See
Summary part IV for larger photo.
D. ASTHMA TREATMENT STRATEGY (GINA, 2019)
See Summary part IV for GINA 2019 diagram on Stepwise Treatment
of Asthma.
STEP 1: AS-NEEDED LOW DOSE ICS-FORMOTEROL
(OFF-LABEL)
Initial Controller Treatment for Adults, Adolescents,
and Children 6-11 years old
 Controller medications – used daily for maintenance treatment
 For best outcomes, initiate controller treatment as early as
possible after making the diagnosis of asthma
 GINA no longer recommends SABA-only treatment of asthma in
adults or adolescents
 Preferred controller: as-needed low dose combination ICS-
formoterol (adults & adolescents)
→ All evidence for as-needed ICS-formoterol in mild asthma is
with low dose budesonide-formoterol, but BDP-formoterol
may also be suitable.
→ budesonide + formoterol = ICS + long-acting beta agonist
(LABA)
 Other controller option: Low dose ICS taken whenever SABA
is taken
→ May be an option if ICS-formoterol is unavailable or not
affordable
→ Helps reduce risk for severe exacerbations
→ A patient with infrequent symptoms (<2x/month) is more
likely to adhere to this regimen vs. a regular (e.g. daily) low-
dose ICS
 Therefore, regular low-dose ICS is no longer
recommended for this population of patients.
 Controller Options for Children 6-11 years:
→ Low dose ICS taken whenever SABA is taken
→ Regular ICS + as-needed SABA (less preferred due to
possibility of low adherence)
 Consider starting at a higher step if:
→ Troublesome asthma symptoms on most days
→ Waking from asthma once or more a week, especially if any
risk factors for exacerbations
Exam 02 - Trans 09B
 If initial asthma presentation is with an exacerbation:
→ Give a short course of oral steroids and start regular
controller treatment (e.g., high dose ICS or medium dose
ICS/LABA, then step down)
Low, Medium, and High Dose ICS for Adults and
Adolescents (>12 years)
Figure 8. Low, Medium, and High Dose ICS for Adults and Adolescents
(>12 years) (GINA, 2019). CFC – cholorofluorocarbon, HFA –
hydrofluoroalkane. MEMORIZE! Especially: Budesonide &
Fluticasone
 Budesonide, Beclometasone, and Fluticasone are all available in
the Philippines
STEP 2: LOW-DOSE CONTROLLER + AS NEEDED
INHALED RELIEVER
Controller Options (Choose 1)
 Preferred Step 2 Controller (adults, adolescents, & children):
Daily low dose ICS + as-needed SABA
→ ICS: most potent and most effective
 Preferred Step 2 Controller (adults & adolescents): as-needed
low dose ICS-formoterol
→ No need for SABA as reliever if using ICS-formoterol
 Other Step 2 Controller (adults & adolescents): Leukotriene
Receptor Antagonists (LRTA)
→ Less effective than ICS in terms of exacerbation reduction
→ May be used for px’s with both asthma and allergic rhinitis
→ Ex: Montelukast
Reliever: Short-acting Beta-Agonist (SABA)
 A reliever (used for acute exacerbations)
 For treatment of acute asthma exacerbations and episodes
→ Effective in 15 min, until 4-6 hrs
 Examples: Salbutamol (aka Albuterol in the US), Levalbuterol,
Terbutaline, Fenoterol
 No longer needed if using ICS-formoterol
STEP 3: CONTROLLER + AS-NEEDED INHALED
RELIEVER
 Preferred Step 3 Option (adults & adolescents): Low Dose
ICS-LABA maintenance + as-needed SABA
 Preferred Step 3 Option (adults & adolescents): Low Dose
ICS-formoterol as both maintenance & reliever treatment
 Other Step 3 Options (adults & adolescents):
→ Medium Dose ICS + as-needed reliever
→ Low Dose ICS + LTRA or Low Dose Sustained-release
Theophylline + as-needed reliever
 Less efficacious
STEP 4: CONTROLLER + AS-NEEDED INHALED
RELIEVER
 Preferred Step 4 Option (adults & adolescents): Low Dose
ICS-formoterol as both maintenance & reliever treatment
→ For adult & adolescent px with >1 exacerbation in previous
year
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OS 216 Immuno: Bronchial Asthma Exam 02 - Trans 09B

→ More effective in reducing exacerbations than the same

dose of ICS-LABA or higher doses of ICS
→ Maintenance dose may be increased to medium, if
necessary
 Preferred Step 4 Option (adults, adolescents, & children):
Medium Dose ICS-LABA maintenance + as-needed SABA
 Other Step 3 Options (adults & adolescents):
→ Medium/High Dose ICS + LTRA or Low Dose Sustained-
release Theophylline + as-needed reliever
→ Add-on Tiotropium (long-acting muscarinic antagonist)
 For px aged >6 years
 Modestly improves lung function and modestly reduces
exacerbations
STEP 5: HIGHER LEVEL CARE AND/OR ADD-ON
TREATMENT
 Preferred Step 5 Option: Refer for phenotypic assessment &
consideration of add-on treatment
→ Add-on Tiotropium
 For px >6 yrs old whose asthma is not well-controlled with
ICS-LABA
→ Add-on Azithromycin
 For adult px with persistent symptomatic asthma despite
moderate-high dose ICS & LABA Figure 10. Mechanism of Action of Omalizumab.
 Macrolide antibiotic: can cause ototoxicity & cardiac
E. REVIEWING RESPONSE AND ADJUSTING
arrhythmia; widespread use may contribute to
antimicrobial resistance TREATMENT
→ Add-on Anti-IgE (Omalizumab)  How often should asthma be reviewed?
 For px >6 yrs old with moderate or severe allergic asthma → First review: 1-3 months after starting treatment
that is uncontrolled on Step 4-5 treatment → Every 3-12 months after the first review
→ Add-on IL-5/5R (subcutaneous mepolizumab or IV  Every 4-6 weeks during pregnancy
reslizumab) → After an exacerbation, within 1 week
→ Add-on IL-4R (subcutaneous dupilumab)  Stepping up asthma treatment
→ Add-on Low Dose Oral Corticosteroids → Sustained step-up (for at least 2-3 months): if asthma poorly
 May be effective for some adults with severe asthma, but controlled
often associated with substantial side-effects  Important before stepping up: first check for common
 Other Step 5 Option: Combination High Dose ICS-LABA causes (symptoms not due to asthma, incorrect inhaler
→ May be considered in adults & adolescents, but increase in technique, poor adherence)
ICS dose provides little additional benefit + increased risk of → Short-term step-up (for 1-2 weeks), e.g., with viral infection
side-effects (e.g., adrenal suppression) or allergen exposure
 May be initiated by clinician or by patient with written
Omalizumab (Add-on Anti-IgE) asthma action plan
 Stepping down asthma treatment
→ Consider step-down after good control maintained for 3
months
→ Find each patient’s minimum effective dose, that controls
both symptoms and exacerbations
 Proper use of inhalers (Figure 11)

Figure 9. Mechanism of Action of Omalizumab.

 Omalizumab prevents the binding of the allergen to the IgE, thus

inhibiting the release of allergic reaction mediators (histamine &
leukotrienes)
 Inhibits inflammation and constriction of the airways
 Bound IgE cannot complex with mast cells, preventing
degranulation and resulting in decrease in symptoms.
 Omalizumab
→ Binds to circulating IgE, decreasing cell-bound IgE
→ Downregulates the expression of high affinity receptors
 Result: decreased tissue infiltration of eosinophils & decreased
mediator release = decreased asthma symptoms and
exacerbations

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C. IDENTIFYING PATIENTS AT RISK OF ASTHMA-

RELATED DEATH
 Patients at increased risk of asthma-related death should be
identified
→ Any history of near-fatal asthma requiring intubation and
ventilation
→ Hospitalization or emergency care for asthma in last 12
months
→ Not currently using ICS, or poor adherence with ICS
→ Currently using or recently stopped using OCS
 (indicating the severity of recent events)
→ Over-use of SABAs, especially if more than 1 canister/month
→ Lack of a written asthma action plan
→ History of psychiatric disease or psychosocial problems
→ Confirmed food allergy in a patient with asthma
 Flag these patients for more frequent review
D. MANAGING EXACERBATIONS IN PRIMARY OR
ACUTE CARE
Figure 11. Proper use of inhalers. (Top row: metered dose type; 2nd from
top row: dry powder type; 8-numbered rows: dry turbo type).

Figure 12. Hands-on inhaler training guide.

V. ASTHMA FLARE-UPS (EXACERBATIONS)

 Acute or sub-acute events where symptoms and lung function
worsen from the patient’s usual status
 Occasionally, the initial presentation of asthma
A. MANAGEMENT OF WORSENING ASTHMA AS A
CONTINUUM
 Self-management within a written asthma action plan
 Management in primary care
 Management in the emergency department and hospital
 Follow-up after any exacerbation
Figure 14. Management of exacerbations. See Summary part V for larger
B. WRITTEN ASTHMA ACTION PLANS photo.
 All patients should be provided with this.
→ It should be appropriate for their level of asthma control and E. FOLLOW-UP AFTER AN EXACERBATION
health literacy  Follow-up all patients regularly after an exacerbation until
 It should include: symptoms and lung function return to normal
→ Patient’s usual asthma medications → Patients are at increased risk during recovery from an
→ When and how to increase medications, and start OCS exacerbation
Commented [MRAS6]: Is this oral corticosteroids?
→ How to access medical care if symptoms fail to respond  Exacerbations often represent failures in chronic asthma care,
and they provide opportunities to review the patient’s asthma
management
 At follow-up visit(s), check:
→ The patient’s understanding of the cause of the flare-up
→ Modifiable risk factors, e.g. smoking
→ Adherence with medications, and understanding of their
purpose
→ Inhaler technique skills
→ Written asthma action plan

Figure 13. Self-management with a written action plan.

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VI. PRIMARY PREVENTION

 The development and persistence of asthma are driven by gene-
environment interactions
 For children, a ‘window of opportunity’ exists in utero and in
early life, but intervention studies are limited
 For intervention strategies including allergen avoidance
→ Strategies directed at a single allergen have not been
effective
→ Multifaceted strategies may be effective, but the essential
components have not been identified
 Current recommendations are
→ Avoid exposure to tobacco smoke in pregnancy and early life
→ Encourage vaginal delivery
→ Advise breast-feeding for its general health benefits
→ Where possible, avoid use of paracetamol (acetaminophen)
and broad-spectrum antibiotics in the first year of life

END OF TRANS

REFERENCES
Lecture and recording
2022 Trans
GINA 2019

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OS 216 Immuno: Bronchial Asthma
SUMMARY
I. INTRODUCTION
 Global Initiative for Asthma (GINA) Assembly
→ Came up with recommendations to treat asthma
→ Philippines participated in this GINA Assembly
→ Important because they found out that the prevalence of
asthma continues to increase
 339 Million people worldwide suffer from asthma
 The National Nutritional Health Survey of 2008 found that there
was a 14.3% prevalence of asthma in the Philippines
 Even though asthma is treated, it is still a significant cause of
mortality
→ In the Philippines, 2.7% of all deaths are by asthma
→ Worldwide, we have the second highest mortality in the
world for patients 5-35 years old, and also across all ages.
 In 2018, PhilHealth found that asthma was the sixth most used
reason for admission to hospitals
 It is also one of the top 10 causes of death in the Philippines
→ All other respiratory diseases are decreasing in prevalence,
but asthma and COPD are increasing
II. ASTHMA
A. DEFINITION
 Asthma is characterized by chronic airway inflammation,
respiratory symptoms (wheezing, shortness of breath, cough
and chest tightness), and a variable expiratory airflow
limitation.
B. PATHOPHYSIOLOGY
 In the acute phase, the mast cell recognizes an allergen, and
releases inflammatory mediators
III. ASSESSMENT OF ASTHMA CONTROL & SEVERITY
Exam 02 - Trans 09B
 In the chronic phase, the T-helper 2 cells and the macrophages Commented [MRAS7]: Kaya bang higher res images
are activated, recruiting eosinophils and stimulating their for the figures to memorize? Can you access the latest
degranulation
GINA guidelines?
 This leads to airway remodeling which is responsible for the
changes seen in an asthmatic airway:
→ Narrowing of the lumen
→ Bronchoconstriction
→ Subepithelial membrane thickening
→ Hyperplasia of smooth muscles
→ Angiogenesis
→ Increased mucus production
C. DIAGNOSIS
 Asthma is ruled in if symptoms include wheezing, shortness of
breath, cough, or chest tightness, varying in intensity over
time, worsening at night or in the early morning, and with a
perceived trigger. Physical examination findings may be normal
or may include wheezing on auscultation.
→ Diagnosis of asthma decreases in probability if there is:
 An isolated chronic cough with no other symptoms
 Chronic production of sputum
 Shortness of breath associated with dizziness, light-
headedness or peripheral tingling
 Chest pain
 Exercise-induced dyspnea with noisy inspiration (stridor)
 Through spirometry, asthma is also ruled in if:
1. There is airflow limitation:
 FEV1/FVC < 0.75 in adults
 FEV1/FVC < 0.9 in children
2. There is significant reversibility upon administration of a
bronchodilator:
 Adults: % increase in FEV1 >12% and >200mL increase
 Children: % increase >12% predicted
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IV. ASTHMA TREATMENT STRATEGY (GINA, 2019)

Low, Medium, and High Daily Doses of Inhaled Corticosteroids.

V. ASTHMA FLARE-UPS (EXACERBATIONS)

A. SELF-MANAGEMENT WITH A WRITTEN ACTION PLAN

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B. MANAGING EXACERBATIONS IN PRIMARY OR ACUTE CARE

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