The Inhalers

Short-acting bronchodilators (SABA or SAMA)

Ventolin
Salbutamol

Lung function

Atrovent
Ipratropium bromide

Quality of life

Berodual
4-6h Exacerbations

Fenoterol/Ipratropium
Safety
Long-acting bronchodilators (LAMA or LABA)
LAMA LABA

Spiriva™ Striverdi™
Tiotropium Olodaterol

Lung function

Seebri™ Onbrez™
Glycopyrronium Indacaterol

Quality of life

Incruse™ 24 h Exacerbations

Umeclidinium
Safety
Dual long acting bronchodilators (LABA/LAMA)
Ultibro™
Indacaterol/Glycopyrronium

Lung function

Spiolto™
Tiotropium/Olodaterol

Quality of life

Anoro™ 24 h Exacerbations

Umeclidinium/Vilanterol
Safety
Combination steroid inhalers (LABA/ICS)
Seretide™
Salmeterol/Fluticasone
diproprionate

Symbicort™ Lung function

Fomoterol/Budesonide

Quality of life

Relvar™
Vilanterol/Fluticasone furorate Exacerbations

Safety
Triple therapy (LABA/LAMA/ICS)
Seretide™
Salmeterol/Fluticasone
dipropionate + Spiriva™
Tiotropium

Symbicort™
Fomoterol/Budesonide + Spiriva™
Tiotropium
Lung function

Quality of life

Exacerbations

Safety
Asthma
Case
• 40/M
• Known asthma since 20s
• Rx Salbutamol & Beclometasone
• ↑ SOB & wheeze x 3/12
• Rhinitis daily
• Triggers dust, URTI
• Smoker 6/day
• Cat x 1
Asthma diagnosis
1. Cough, SOB, wheeze, chest tightness

PLUS

2. Variable airflow obstruction

• FEV1/FVC < 0.7
• ∆FEV1 >12% and 200 ml
• PEF variability >10%
Asthma mimics
• Vocal cord dysfunction
• Central airway obstruction
• Recurrent aspiration
• Bronchiolitis
• Gastro oesophageal reflux disease
• Psychogenic hyperventilation
• Chronic obstructive pulmonary disease
• Heart failure
• Drug side effects (e.g. ACE inhibitor-induced cough)
• Pulmonary embolism
Non-pharmacological treatment
• Asthma education
• Written asthma action plan
• Self-monitoring
• Inhaler technique
• Adherence to treatment
Modifying risk factors or co-morbidities
• Allergic rhinitis
• GERD
• Obesity
• Anxiety/depression
• Food allergy
• Aspirin and NSAIDs
• Allergen avoidance
• Cigarette smoking
Uncontrolled versus severe asthma
• Uncontrolled asthma = can regain their control after properly
addressing issues of diagnosis, adherence and technique of
medications, co-morbidities and triggers

• Severe asthma = only those with uncontrolled asthma despite doing

everything right
ATS/ERS definition of severe asthma

• During treatment with:

• High-dose ICS + at least one additional controller
• Oral corticosteroids >6 months/year
• At least one of the following occurs or would occur if treatment is
reduced:
• ACT <20 or ACQ >1.5
• At least 2 exacerbations in the last 12 months
• At least 1 exacerbation treated in hospital or requiring mechanical ventilation
in the last 12 months
• FEV1 <80% (if FEV1/FVC below the lower limit of normal)
Factors associated with uncontrolled asthma
• No ICS, poor adherence, incorrect technique
• High SABA use
• FEV1 <60%
• High bronchodilator reversibility
• Psychological or socio-economic issues
• Smoking, allergen exposure
• Chronic sinusitis, obesity
• Eosinophilia
• Prior ICU care
• Frequent exacerbators
Conclusions
1. Asthma is a heterogeneous disease characterized by variable
respiratory symptoms and airflow obstruction
2. Spirometry is helpful but not required for diagnosis
3. Beware of conditions that mimic asthma
4. Management aims are symptom control and reduction of future
risk
5. Uncontrolled asthma not the same as severe asthma
6. ICS is the mainstay of treatment
COPD
Case
• 65/M
• 20 cigarettes/day x 54 years
• SOB, cough, wheeze x 14 years
• No nocturnal symptoms
• No triggers
• Eosinophil 0.93
• Rx Salbutamol & Tiotropium
Goals for the treatment of stable COPD
• Relieve symptoms
• Improve exercise tolerance REDUCE SYMPTOMS
• Improve health status

• Prevent disease progression

• Prevent and treat exacerbation REDUCE RISK
• Reduce mortality

Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2018

Appropriate Care Guide 2018, Agency for Care Effectiveness, MOH, Singapore
Combined ABCD assessment tool
• Symptoms and future risk of exacerbations be assessed as a basis for
pharmacological management of stable COPD
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2018
Jones PW et al. ERJ 2009; 34: 648-654
Consider if
eosinophils > 300
and frequent
exacerbator
Appropriate Care Guide 2018, Agency for Care Effectiveness, MOH, Singapore
Conclusions
1. The goals of COPD treatment is to reduce symptoms and reduce risk
of further exacerbations
2. GOLD ABCD classification is used to determine initial treatment
3. Subsequent treatment depends on whether the patient problem is
dyspnea or exacerbations
4. LABA/LAMA (may) reduce exacerbation versus LABA/ICS
5. LABA/ICS associated with increased pneumonia risk
6. Blood eosinophils may predict the need for ICS
7. Stepping down of ICS may be appropriate in selected patients