Diagnosis and treatment of asthma

Rafał Dobek
2nd Department of Respiratory Medicine
Institute of Tuberculosis and Lung Diseases
 Definition of asthma

Asthma is a heterogeneous disease, usually characterised by chronic

airway inflammation.

It is defined by the history of respiratory symptoms such as wheeze,

shortness of breath, chest tightness and cough that vary over time
and in intensity, together with variable expiratory airflow limitation.
 Asthma is inflammatory disease
Healthy vs Exacerbation of asthma Mechanisms of inflammation in asthma

Inflammation

Mucus hypersecretion

Thickening of smooth
muscles

Holgate et al., Nature Reviews Disease Primers volume 1, Article number: 15025 (2015), www.ginasthma.org. Accessed March 31, 2018; 2. Asthma.
http://www.physio-pedia.com/Asthma. Accessed July 30, 2018; 3. Brusselle GG et al. Nat Med 2013; 19(8): 977-9.
 Phenotypes of asthma

• allergic - onset often in childhood, coexistence of other allergic diseases, family history,
positive skin prick tests and/or specific IgE to inhaled allergens, sputum and blood
eosinophilia, efficacy of inhaled glucocorticosteroids (ICS)

• niealergiczna - onset often in adults, skin prick tests and sIgE negative, poor efficacy of
ICS

• late onset asthma

• asthma with remodelling (non-reversible bronchial obstruction)
• asthma with obesity

• Inflammatory phenotypes:
• eosinophilic,
• neutrophilic,
• paucigranulocytic asthma
 Epidemiology of astmy

• Asthma is one of the most frequent chronic diseases - number of

patients is above 300 millions in the world

• Prevalence of asthma in Poland among children is 8-10% and

5-6% among adults

• Health care expenditure on asthma is very high. Developed

economies might expect to spend 1-2 percent of total health
care expenditures on asthma.
 The most important features of asthma

• Asthma is common and potentially serious chronic disease that can be controlled
but not cured

• Asthma causes symptoms such as wheezing, shortness of breath, chest tightness

and cough that vary over time in their occurrence, frequency and intensity

• Symptoms are associated with variable expiratory airflow, 


i.e. difficulty breathing air out of the lungs due to

• Bronchoconstriction (airway narrowing)

• Airway wall thickening

• Increased mucus

• Symptoms may be triggered or worsened by factors such as viral infections,

allergens, tobacco smoke, exercise and stress
 Criteria of asthma control

• Asthma can be effectively treated

• When asthma is well-controlled, patients can

• Avoid troublesome symptoms during the day and night

• Need little or no reliever medication

• Have productive, physically active lives

• Have normal or near-normal lung function

• Avoid serious asthma flare-ups (also called exacerbations,

or severe attacks)
 Criteria of asthma control

Basing on the last four weeks period we can differentiate:

a) well controlled asthma – day symptoms ≤2 in a week, no nocturnal

symptoms, administration of relievers ≤2 in a week (protective inhalation
before exercise excluded) and no activity limitation

b) partially controlled asthma – 2 or 3 from above criteria fulfilled

c) uncontrolled asthma – ≤1 from above criteria fulfilled

ACT asthma control test
 Diagnosis of asthma

• Characteristic symptoms in history and signs in physical

examination

• Confirmation of variable airflow limitation based on spirometry,

reversibility test or diurnal variability of peak expiratory flow
(PEF)

• Confirmation of diagnosis may be difficult when treatment has

been started
 The diagnosis of asthma should be based on:

• A history of characteristic symptom patterns

• Evidence of variable airflow limitation, from bronchodilator reversibility

testing or other tests

• Document evidence for the diagnosis in the patient’s notes, preferably before
starting controller treatment

• It is often more difficult to confirm the diagnosis after treatment has been
started

• Asthma is usually characterized by airway inflammation and airway

hyperresponsiveness, but these are not necessary or sufficient to make the
diagnosis of asthma.
 Typical symptoms:

• attacks of dyspnoe

• chest tightness

• wheezing

• dry cough

• symptoms of other allergic diseases in patients with allergic

asthma (ie. allergic rhinitis)

When astma is well controlled - patient is asymptomatic

• Increased probability that symptoms are due to asthma if:
• More than one type of symptom (wheeze, shortness of breath, cough, chest
tightness)

• Symptoms often worse at night or in the early morning

• Symptoms vary over time and in intensity

• Symptoms are triggered by viral infections, exercise, allergen exposure,

changes in weather, laughter, irritants such as car exhaust fumes, smoke, or
strong smells

• Decreased probability that symptoms are due to asthma if:

• Isolated cough with no other respiratory 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)

 Physical examination

• wheezes and prolonged expiration

• increased heart rate

• in sever asthma attacks - „silent chest”

When astma is well controlled - no symptoms at all

• Physical examination in people with asthma
• Often normal

• The most frequent finding is wheezing on auscultation, especially

on forced expiration

• Wheezing is also found in other conditions, for example:

• Respiratory infections

• COPD

• Upper airway dysfunction

• Endobronchial obstruction

• Inhaled foreign body

• Wheezing may be absent during severe asthma exacerbations

(‘silent chest’)
 Confirm presence of airflow limitation

• Document that FEV1/FVC is reduced (at least once, when FEV1 is low)

• FEV1/ FVC ratio is normally >0.75 – 0.80 in healthy adults, and 


>0.90 in children

• Confirm variation in lung function is greater than in healthy individuals

• The greater the variation, or the more times variation is seen, the greater
probability that the diagnosis is asthma

• Excessive bronchodilator reversibility (adults: increase in FEV1 >12% and

>200mL; children: increase >12% predicted)

• Excessive diurnal variability from 1-2 weeks’ twice-daily PEF monitoring

(daily amplitude x 100/daily mean, averaged)

• Significant increase in FEV1 or PEF after 4 weeks of controller treatment

• If initial testing is negative:

• Repeat when patient is symptomatic, or after withholding bronchodilators

• Refer for additional tests (especially children ≤5 years, or the elderly)

Example of spirometry with bronchial obstruction

FEV1 67,1% w.n.

FVC 84,6% w.n.
FEV1/FVC - 0,64
 Typical spirometric tracings

Volume Flow
Normal

FEV1
Asthma 

(after BD)
Normal
Asthma 

(before BD) Asthma 

(after BD)

Asthma 

(before BD)

1 2 3 4 5 6 Volume
Time (seconds)

Note: Each FEV1 represents the highest of

three reproducible measurements

GINA 2017
Triggers of attacks and exacerbations of asthma:

• allergens (in patients with allergic asthma)

• respiratory infections (mainly viral)

• air pollutants (including tobacco smoke)

• physical exercise

• medications (β-blockers, ASA, NSAID)

 Increased risk of asthma exacerbations:

• uncontrolled symptoms

• SABA overuse

• non-compliance with treatment plan and poor technique of inhalers use

• low FEV1 (<60% predicted)

• specific allergens exposure

• psychological problems

• tobacco smoke exposure

• concomitant diseases (obesity, chronic rhinitis and sinusitis, food allergy)

• high sputum and blood eosinophilia

• severe asthma exacerbation in recent year

 Non-pharmacological treatment
• education

• training in inhalers technique

• written treatment plan

• regular physical activity

• influenza vaccination

• body mass reduction

• quit smoking
 Medications in asthma:

• controllers – ICS, LABA, LAMA, LTRA

• relievers – SABA, SAMA,

• biologicals – omalizumab (anti-IgE), mepolizumab, reslizumab (anti-IL5),

benralizumab (anti IL-5R), dupilumab (anti-IL4/IL-13)

•
 Box 3-5A Confirmation of diagnosis if necessary
Symptom control & modifiable
Adults & adolescents 12+ years risk factors (including lung function)
Comorbidities
Inhaler technique & adherence
Patient goals
Personalized asthma management:

AS
EW I
Assess, Adjust, Review response

V
ES
Symptoms

ADJU

RE
Exacerbations
Side-effects

S
Lung function

ST
Patient satisfaction

S
Treatment of modifiable risk
factors & comorbidities STEP 5
Non-pharmacological strategies
Education & skills training Asthma High dose
ICS-LABA
Asthma medication options: medications
STEP 4 Refer for
Adjust treatment up and down for phenotypic
individual patient needs STEP 3 Medium dose assessment
± add-on
STEP 2 ICS-LABA
Low dose therapy,
PREFERRED STEP 1 e.g.tiotropium,
CONTROLLER Daily low dose inhaled corticosteroid (ICS), ICS-LABA anti-IgE,
to prevent exacerbations As-needed or as-needed low dose ICS-formoterol * anti-IL5/5R,
and control symptoms low dose anti-IL4R
ICS-formoterol *
Other Low dose ICS Leukotriene receptor antagonist (LTRA), or Medium dose High dose ICS, Add low dose
controller options add-on OCS, but
taken whenever low dose ICS taken whenever SABA taken † ICS, or low dose
tiotropium, or consider
SABA is taken † ICS+LTRA # add-on LTRA # side-effects

PREFERRED As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡

RELIEVER Other
As-needed short-acting β2 -agonist (SABA)
reliever option
* Off-label; data only with budesonide-formoterol (bud-form) ‡ Low-dose ICS-form is the reliever for patients prescribed bud-form
† Off-label; separate or combination ICS and SABA inhalers or BDP-form maintenance and reliever therapy
# Consider adding HDM SLIT for sensitized patients with allergic
rhinitis and FEV >70% predicted
© Global Initiative for Asthma, www.ginasthma.org 1
 Box 3-5A Confirmation of diagnosis if necessary
Symptom control & modifiable
Adults & adolescents 12+ years risk factors (including lung function)
Comorbidities
Inhaler technique & adherence
Patient goals
Personalized asthma management:

AS
EW I
Assess, Adjust, Review response

V
ES
Symptoms

ADJU

RE
Exacerbations
Side-effects

S
Lung function

ST
Patient satisfaction

S
Treatment of modifiable risk
factors & comorbidities STEP 5
Non-pharmacological strategies
Education & skills training Asthma High dose
ICS-LABA
Asthma medication options: medications
STEP 4 Refer for
Adjust treatment up and down for phenotypic
individual patient needs STEP 3 Medium dose assessment
± add-on
STEP 2 ICS-LABA
Low dose therapy,
PREFERRED STEP 1 e.g.tiotropium,
CONTROLLER Daily low dose inhaled corticosteroid (ICS), ICS-LABA anti-IgE,
to prevent exacerbations As-needed or as-needed low dose ICS-formoterol * anti-IL5/5R,
and control symptoms low dose anti-IL4R
ICS-formoterol *
Other Low dose ICS Leukotriene receptor antagonist (LTRA), or Medium dose High dose ICS, Add low dose
controller options add-on OCS, but
taken whenever low dose ICS taken whenever SABA taken † ICS, or low dose
tiotropium, or consider
SABA is taken † ICS+LTRA # add-on LTRA # side-effects

PREFERRED As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡

RELIEVER Other
As-needed short-acting β2 -agonist (SABA)
reliever option
* Off-label; data only with budesonide-formoterol (bud-form) ‡ Low-dose ICS-form is the reliever for patients prescribed bud-form
† Off-label; separate or combination ICS and SABA inhalers or BDP-form maintenance and reliever therapy
# Consider adding HDM SLIT for sensitized patients with allergic
rhinitis and FEV >70% predicted
© Global Initiative for Asthma, www.ginasthma.org 1
 Box 3-5A Confirmation of diagnosis if necessary
Symptom control & modifiable
Adults & adolescents 12+ years risk factors (including lung function)
Comorbidities
Inhaler technique & adherence
Patient goals
Personalized asthma management:

AS
EW I
Assess, Adjust, Review response

V
ES
Symptoms

ADJU

RE
‘Controller’ treatment Exacerbations
Side-effects
means the treatment

S
Lung function

ST
Patient satisfaction
taken to prevent

S
Treatment of modifiable risk
factors & comorbidities STEP 5
exacerbations Non-pharmacological strategies
Education & skills training Asthma High dose
ICS-LABA
Asthma medication options: medications
STEP 4 Refer for
Adjust treatment up and down for phenotypic
individual patient needs STEP 3 Medium dose assessment
± add-on
STEP 2 ICS-LABA
Low dose therapy,
PREFERRED STEP 1 e.g.tiotropium,
CONTROLLER Daily low dose inhaled corticosteroid (ICS), ICS-LABA anti-IgE,
to prevent exacerbations As-needed or as-needed low dose ICS-formoterol * anti-IL5/5R,
and control symptoms low dose anti-IL4R
ICS-formoterol *
Other Low dose ICS Leukotriene receptor antagonist (LTRA), or Medium dose High dose ICS, Add low dose
controller options add-on OCS, but
taken whenever low dose ICS taken whenever SABA taken † ICS, or low dose
tiotropium, or consider
SABA is taken † ICS+LTRA # add-on LTRA # side-effects

PREFERRED As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡

RELIEVER Other
As-needed short-acting β2 -agonist (SABA)
reliever option
* Off-label; data only with budesonide-formoterol (bud-form) ‡ Low-dose ICS-form is the reliever for patients prescribed bud-form
† Off-label; separate or combination ICS and SABA inhalers or BDP-form maintenance and reliever therapy
# Consider adding HDM SLIT for sensitized patients with allergic
rhinitis and FEV >70% predicted
© Global Initiative for Asthma, www.ginasthma.org 1