ACFrOgB tjlS-2fganV4ROSOsyPBAbjL23xINYkZApMmBRZdMu4jEyfdit8DWUYzmUtDtmVTY1bAINxDdwqsefvyAG0F0EruOHD86C53Y381pMVzRbMD0CFiFgUZaakoOZK4ZZSslpB32WFwxTtz

®
©
Program Certificate of Excellence in Family Medicine
Course Pulmonology
Module Obstructive & Restrictive Lung Diseases
Topic Asthma
Credit Hours 2 CME Credit Hours

Total
Educational 4 Educational Hours
Hours
MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | Asthma
®
©
Prof. Nasir Shah

MCPS, FCPS, MRCGP [INT], FRCGP [INT]
Professor and Head, Department of Family Medicine

University of Health Sciences Lahore
Dean Family Medicine Faculty, College of Physicians

and Surgeons Pakistan
Convener National Family Medicine Committee of

Pakistan
1
OBSTRUCTIVE & RESTRICTIVE DISEASES ®
©
OBSTRUCTIVE & RESTRICTIVE DISEASES ®

©
2
OBSTRUCTIVE & RESTRICTIVE DISEASE ®
©
OBSTRUCTIVE LUNG DISEASES RESTRICTIVE LUNG DISEASES

• Asthma • Sarcoidosis
• COPD • Pneumoconiosis
- Emphysema • Pulmonary fibrosis
- Chronic bronchitis • Interstitial lung disease
• Cystic fibrosis • Idiopathic pulmonary fibrosis
®
©
3
PATHOPHYSIOLOGY OF ASTHMA ®
©
1. Inflamed and thickened bronchial wall
2. Bronchospasm
3. Increased secretions
4. Air trapped in alveoli
DEFINITION (WHO – 2021) ®

©
Inflammation and narrowing/tightening of the muscles around
small airways, causing symptoms of:
• Cough and/or Intermittent

• Wheeze and/or
• Chest tightness and/or
• Shortness of breath Worse at night
EXPIRATORY
POLYPHONIC
WHEEZE
4
DEFINITION (OHGP – 2020) ®
©
Reversible & Obstructive Airway Disease
• 3 characteristic features:
1. Airflow limitation - reversible (spontaneously or with
treatment)
2. Airway hyper-responsiveness to a wide range of stimuli
3. Inflammation of the bronchi
EXPIRATORY
POLYPHONIC
WHEEZE
DEFINITION (OHGP – 2020) ®

©
Pathophysiology of Asthma is the guide for its treatment
• 3 characteristic features:
1. Bronchospasm (Reliever)
2. Hyper-responsiveness to stimuli (Control Triggers)
3. Inflammation (Inhaled Steroids)
5
GOLDEN WORDS ®
©
All that wheeze is NOT asthma and all asthmatics do not wheeze
IMPACT ON DAILY LIFE ®

©
PERSONAL
• Poor sleep
• Poor concentration
• Tiredness (especially during day time)
COMMUNITY/MASS LEVEL
• Absenteeism (School & Work)
• Financial loss (for families)
• Increased emergency cases at hospitals
6
ORGANIZATIONS / GUIDELINES ®
©
NICE (National Institute for Health and Care Excellence)
2021
GINA (Global Initiative for Asthma)
2017, 2018, 2019, 2020
SIGN (Scottish Intercollegiate Guideline Network)
2020
NAEPP (National Asthma Education and Prevention Program)
2007
MEDSCAPE ®
©
• Conflicting or complex regimens from multiple sources result in
confusion and lack of clear guidelines realistically applicable in
the primary care setting
7
CLASSIFICATION ®
©
NICE & SIGN/BTS Guidelines
1. Acute
2. Chronic
GINA Guidelines
1. Mild
2. Moderate
3. Severe
CLASSIFICATION ®
©
NAEPP (National Asthma Education and Prevention Program) 2007
1. Intermittent asthma
2. Mild persistent asthma
3. Moderate persistent asthma
4. Severe persistent asthma
8
DIAGNOSIS ®
©
Clinical diagnosis
• No single diagnostic test for asthma
• Both Clinical assessment and Objective tests have significant
false positive and false negative rates
• Asthma status and Outcome of diagnostic tests vary over time
DIAGNOSIS l STRUCTURED CLINICAL ASSESSMENT ®

©
• Recurrent episodes of symptoms
• Symptom variability
• Absence of symptoms of alternative diagnosis
• Recorded observation of wheeze
• Personal history of atopy
• Historical record of variable PEF or FEV1
9
INVESTIGATIONS ®
©
1. Chest X-ray
I. Not done for confirmation, but;
i. In case of severe disease
ii. Rule out other causes/clinical suspicion of other
condition
2. Spirometry
I. Assess the integrated mechanical function of the lungs,
chest wall, respiratory muscles and airways
3. PEFR (Peak Expiratory Flow Rate)
I. Easy and Cheap
II. Monitor progress of disease and Effects of treatment
DIAGNOSIS OF ASTHMA l THE DON’TS ®

©
DO NOT offer these tests TO ESTABLISH a diagnosis of Asthma:
1. IgE levels
2. Eosinophil count
3. Skin prick tests to aeroallergens
4. Exercise challenge (adults aged 17 and over)
1 & 3 are used to identify triggers once diagnosis of Asthma is

confirmed
10
DIAGNOSIS OF ASTHMA ®
©
Clinical features that decrease the probability of Asthma:
1. Normal chest examination and/or
2. Normal PEFR or spirometry when symptomatic
3. Chronic productive cough without wheeze or breathlessness
4. Prominent dizziness, light- headedness & peripheral tingling
5. Voice disturbance
6. Symptoms with colds only Normal Spirometry
7. Smoking history (>20 pack years) When Asymptomatic
Does not Exclude Asthma
8. Cardiac disease
SPIROMETRY l PROCEDURE ®
©
11
SPIROMETRY ®
©
• Improvement in FEV1 of 12% or more and increase in volume of
200 ml or more is suggestive of asthma
SPIROMETRY: FEV1/FEV RATIO ®

©
• Normal FEV1/FVC ratio is 80%
• Obstructive defect (Asthma/COPD)

- FEV1 reduced more than FVC and ratio is <80%
• Restrictive defect ( Lung fibrosis)

- FVC reduced and FEV1/FVC ratio > 80%
12
OBSTRUCTIVE LUNG DISEASE ®
(FLOW VOLUME CURVE) ©
Not related to time
VOLUME TIME CURVE ®

©
13
PEAK EXPIRATORY FLOW ®
©
Variability over 20% is

suggestive of ASTHMA
®
©
MANAGEMENT OF ASTHMA
14
AIMS OF TREATMENT ®
©
1. Decrease daytime symptoms and night-time waking due to
asthma
2. Minimize the need for reliever medication
3. Decrease impact on lifestyle, e.g. absences from work/school,
exercise
4. Prevent severe attacks/exacerbations
5. Have normal lung function (FEV1 and/or PEF >80% predicted
or best)
6. Decrease side effects from medications
PRINCIPLES OF TREATMENT ®
©
• After starting or adjusting medicines for asthma, review the
response to treatment in 4 to 8 weeks
• Ensure that a person with asthma can use their inhaler device;
- At any asthma review, either routine or unscheduled
- Whenever a new type of device is supplied
15
HOW TO USE AN INHALER ®
©
APPROACH TO MANAGEMENT ®
©
• Start treatment as per severity level
• Achieve early control
• Maintain control by:
- Increasing treatment as necessary
- Decreasing treatment when control is good
16
ASTHMA CONTROL-GINA-2019 ®
©
• In the past 4 weeks
1. Day time symptoms more than twice per week

2. Use of reliever twice a week
3. Night time wakening because of asthma
4. Any activity limitation
5. Well control: 0 symptom

6. Partial control: 1-2 symptoms
7. Poor control: 3-4 symptoms
SELF-MANAGEMENT ®
©
• All patients should receive self-management education
• Brief, simple education
• Include information about:
- Nature of disease
- Nature of the treatment and how to use it
- Self-monitoring
- Recognition of acute exacerbations
- Allergen/trigger avoidance
17
NON-PHARMACOLOGICAL MEASURES ®
©
• Patient education
• Avoidance of allergens/triggers
• Avoid smoking
• Graded exercise training
• Psychological treatment
• Yoga
ENVIRONMENT ®
©
• Pollen
• Birds
• Mold
• Animals
• Cockroaches
• House dust mite
• Perfumes/sprays
• Bed sheets/ pillow covers
18
®
©
PHARMACOLOGICAL TREATMENT ®
©
• Intermittent Reliever Therapy (Reliever medicines)
• Short Acting Beta2 Agonists (SABA)
• Regular Preventer Therapy (Controller medicines)

• Inhaled Corticosteroids (ICS)
• Long Acting Beta Agonists (LABA)
• Anticholinergics
• Leukotriene Receptor Antagonists (LTRA)
• Theophylline
19
KEEP IT SIMPLE ®
©
• Relief of symptoms (bronchospasm) Salbutamol
• Control of inflammation ICS
• Add on therapy
- LABA
- Increase ICS
- LRTA
- Theophylline
• Oral steroids
TREATMENT TERMINOLOGIES ®
©
• SABA Short Acting Beta2 Agonist
Salbutamol, Terbutaline
• 1-2 puffs PRN (100 mcg per puff)
• Duration of action 3-5 hours
• LABA Long Acting Beta2 Agonist

Salmeterol, Formoterol
• 50-100 mcg BD
• Duration of action 12 hours
• Adjunct therapy (MART – Combination with ICS)
20
TREATMENT TERMINOLOGIES ®
©
• ICS Inhaled Corticosteroids
Beclomethasone, Fluticasone
• Use regularly
• Alleviation of symptoms after 3-7 days
• If cough  Use SABA before ICS
• If candidiasis  use via Large volume Spacer or
Mouthwash (after ICS use)
• MART Maintenance And Reliever Therapy

(combined ICS and fast-acting LABA in a single
inhaler, used daily, as required)
®
©
Becotide
Ventide
21
®
©
®
©
22
®
©
®
©
23
LTRA ®
©
DRUGS FOR EXCERBATIONS ®

©
24
®
©
®
©
25
®
©
®
©
ADULTS
26
STEP LADDER APPROACH IN ASTHMA-ADULTS ®
©
Step 1 Step 2 Step 3 Step 4
Salbutamol Yes Yes Yes Yes
ICS Yes Yes Yes Yes
LABA Yes Yes Yes
Increase ICS Yes Yes
LTRA Yes Yes
Refer Yes
®
©
CHILDREN
27
STEP LADDER APPROACH IN ASTHMA-CHILDREN ®
©
Step 1 Step 2 Step 3 Step 4
Salbutamol Yes Yes Yes Yes
Very low dose ICS Yes Yes Yes Yes
LTRA Yes (<5y) Yes (<5y) Yes Yes
LABA Yes Yes Yes
Low dose ICS Yes Yes
Refer Yes
ICS DOSES FOR AGES 17 & ABOVE ®

©
• Low Dose
≤ 400 mcg budesonide or equivalent (Beclomethasone ≤ 200mcg,
Fluticasone ≤ 250 mcg)
• Moderate Dose
>400 up to 800 mcg budesonide or equivalent. (Beclomethasone
>200-400mcg, Fluticasone >250 up to 500 mcg)
• High Dose
> 800 mcg budesonide or equivalent (Beclomethasone >400mcg,
Fluticasone >500 mcg)
28
ICS DOSES FOR AGES 16 & BELOW ®
©
• Low Dose
≤ 200 mcg budesonide or equivalent (Beclomethasone ≤ 100mcg,
Fluticasone ≤ 125 mcg)
• Moderate Dose
>200 up to 400 mcg budesonide or equivalent. (Beclomethasone
>100-200mcg, Fluticasone >125 up to 250 mcg)
• High Dose
> 400 mcg budesonide or equivalent (Beclomethasone > 400mcg,
Fluticasone >250 mcg)
STEPPING DOWN ®
©
• Review and consider stepping down at intervals ≤3 months
• Maintain on the lowest dose of inhaled steroid controlling

symptoms
• When reducing steroids, cut dose by 25–50% each time
29
®
©
ASTHMA EXACERBATIONS
ASTHMA EXACERBATIONS ®
©
• Assess and Record
− Symptoms and response to self-treatment
− Respiratory rate, amount of wheeze, and level of
breathlessness
− Peak expiratory flow rate (PEFR) (lungs)
− Peripheral oxygen saturation (SpO2) (circulation)
− Heart rate and Blood Pressure (CVS)
− Degree of agitation and conscious level (brain)
30
MODERATE EXACERBATION ®
©
Features:
• PEFR >50-75 % of predicted or best
• SpO2 ≥ 92% on room air
• Respiratory Rate < 25 breaths/min
• Heart Rate < 110 beats/min
• Normal speech
Treat at home or in clinic and assess treatment response!
SEVERE ASTHMA ®
©
• PEFR 33–50% predicted or best
• Oxygen saturation ≥92%
• Unable to talk in sentences
• Tachypnea (respiratory rate ≥25 breaths/min)
• Tachycardia (heart rate ≥110bpm)
31
LIFE THREATENING SIGNS ®
©
• PEFR < 33 % predicted or best
• Oxygen saturation < 92 %
• Poor respiratory efforts
• Silent chest
• Arrhythmias
• Hypotension
• Altered consciousness
• Cyanosis
• Exhaustion
PRE-HOSPITAL CARE IN ACUTE EXACERBATIONS ®

©
1. Metered Dose Inhalers (MDI)
2. Continuous nebulization
- Superior to MDI
- Dose of salbutamol is 10-15 mg in 70 mL of isotonic saline
- Paediatric dose of Salbutamol is 0.5 mg/kg/h
3. Intravenous/oral steroids
32
PRE-HOSPITAL CARE IN ACUTE EXACERBATIONS ®
©
1. Metered Dose Inhalers (MDI) with spacer
2. Continuous nebulization
- Salbutamol
- Ipratropium in life threatening
3. Intravenous/oral steroids
4. BRONCHODILATOR PLUS STEROID (NUT SHELL)
SIGNIFICANT AIRWAY OBSTRUCTION AND ICS? ®

©
• Inhaled steroids may not reach the bronchi because of
obstruction
• Treat with oral prednisolone 30 mg od for 2 weeks
33
®
©
MANAGEMENT OF EXACERBATIONS
IN CHILDREN < 2 YEARS
MANAGEMENT OF EXACERBATION IN CHILDREN < 2 Y ®

©
• Intermittent wheezing attacks are usually in response to viral
infection
• Response to bronchodilators is inconsistent
Mild – Moderate wheeze:
• Bronchodilator (MDI & Spacer with a Face mask)
• If positive response  Prednisolone 10mg PO for 3 days
• If No response  Consider Alternative diagnosis or Admit
Severe wheezing  ADMIT

Life threatening features  Admit Immediately
34
®
©
MANAGEMENT OF EXACERBATIONS
IN CHILDREN >2 YEARS
SUMMARY OF TREATMENT OF ACUTE ®

EXACERBATION > 2 years ©
Moderate Severe Life threatening

If no response in
Admission If poor response Immediate
15 minutes
Salbutamol neb Yes Yes Yes
Oral steroid Yes Yes Yes
Oxygen Yes Yes
Ipratropium neb Yes
35
ASTHMA l RISK FACTORS WITH POOR OUTCOME ®
©
1. Medications:
- ICS not prescribed
- Poor adherence
- Incorrect inhaler technique
- High SABA use (if > 1x200-dose canister/month)
2. Exposures
- Smoking
- Air pollution
- Allergen exposure if sensitized
Major socioeconomic problems

©
3. Co-morbidities
- Obesity
- Chronic Rhinosinusitis
- GERD
- Confirmed food allergy
- Anxiety & Depression
- Pregnancy
36
©
4. Lung Function
• Low FEV-1, especially if<60% predicted
5. Other Tests
• Sputum/blood Eosinophilia
6. Risk factors for flare-ups

• Ever being intubated or in ICU for Asthma
• ≥ 1 Severe exacerbation in last 12 months
VARIANTS OF ASTHMA ®
©
1. Adult onset Asthma
2. Allergic Asthma
3. Brittle Asthma
4. Childhood Asthma
5. Cough variant Asthma
6. Difficult Asthma
7. Exercise induced Asthma
8. Non-allergic Asthma
9. Occupational Asthma
10. Seasonal Asthma
37
ADULT ONSET ASTHMA ®
©
• Also known as “Late Onset Asthma”
Causes:
• Smoking
• Obesity
• Female Hormones
• Occupational asthma
ALLERGIC ASTHMA ®
©
• Also known as “Atopic Asthma”
• Triggered by Allergens, like Pollens, Pets and Dust mites
• 80% develop Hay fever, Eczema and Food allergies
Avoid the trigger!
38
NON-ALLERGIC ASTHMA ®
©
• Also known as “Non-Atopic Asthma”
• Not related to allergy triggers
• Less common than Allergic Asthma
• Often develops “Later in life”
Causes Not well understood!

Usually Severe!
CHILDHOOD ASTHMA ®
©
• Starts in Childhood
• Exacerbations usually precipitated by Viral infection
• May Improve or Disappear completely with Age
• Can return later in life, if moderate or severe
39
CHILDHOOD ASTHMA l PROGNOSTIC FACTORS ®
©
1. Earlier onset of wheeze – Better prognosis
2. Males: Risk factor for asthma in pre-puberty, however they
“grow-out” of asthma during adolescence
3. Co-existent or Family History of Atopy – Risk factor for
persistence of wheeze
4. Severe or persistent episodes in childhood usually persist in
adolescence as well.
BRITTLE ASTHMA ®
©
• Asthma that worsens Suddenly or Severely
Term is replaced by Severe Asthma!
40
DIFFICULT ASTHMA ®
©
Difficult to manage due to Underlying conditions, like Allergies
Features:
• Symptoms don’t go away despite high dose medications
• Use of Reliever inhaler ≥ 3 times per week
• Frequent asthma attacks
REFER!
EXERCISE INDUCED ASTHMA ®

©
• Asthma-like symptoms triggered by Exercise
- Athletes or doing strenuous exercise in very cold conditions
• Also known as EIB (Exercise Induced Bronchoconstriction)

- Tightening & narrowing of airways not caused by asthma
41
EXERECISE INDUCED ASTHMA l FEATURES ®
©
Signs that exercise is causing the asthma symptoms include:
1. Needing to use your reliever inhaler
2. Stopping to catch your breath
WHY IS EXERCISE A TRIGGER ®

©
Breathing is usually through mouth while exercising
 Air is usually colder and drier than normal
 May induce symptoms of asthma
Other triggers while exercising:

• Pollution and Pollens (Outdoor exercising)
• Dust (Indoor exercising)
• Chlorine (swimming pools)
42
EXERCISE INDUCED ASTHMA l RISK FACTORS ®
©
• Smoking
• Pre-existing severe asthma
• Non-compliance with medications (inhalers)
EXERCISE INDUCED ASTHMA l MANAGEMENT ®

©
1. Activity is good for asthma
i. Increases Stamina
ii. Boosts immunity and fight against cold and viruses
iii. Releases Endorphins and lessens stress (trigger for asthma)
2. Change the activity (do walk and yoga etc.)
43
EXERCISE INDUCED ASTHMA l MANAGEMENT ®
©
3. Reduce fear/anxiety of having an attack by:
i. Exercise with a friend (tell him about your asthma)
ii. Do warm-up before starting a vigorous exercise
iii. CBT
4. Preventive inhalers (as prescribed)
Immediately prior to exercise, Inhaled short-acting β₂

agonists (SABA) are the drug of choice
OCCUPATIONAL ASTHMA ®
©
• A type of Allergic Asthma, directly related to work/workplace
• Symptoms improve on the day(s) a person is not at work
44
OCCUPATIONAL ASTHMA ®
©
OCCUPATIONAL ASTHMA l SPECIFIC TESTS ®

©
After establishing the diagnosis of Asthma, certain tests can be
ordered for Occupational Asthma:
1. Allergy skin tests
2. Challenge test
3. High risk jobs perform PFTs before recruitment
45
SEASONAL ASTHMA ®
©
Exacerbation or triggering of Asthma in certain times of year:
• Hay fever season (Spring – Pollen allergies)
• Winter
Types of Pollens:
Tree pollen (March – Mid May)
Grass pollen (Mid May – July)
Weed pollen (End of June – September)
COUGH VARIANT ASTHMA ®

©
• Type of Asthma, WITHOUT having typical features of Asthma,
like wheezing and shortness of breath etc.
• Triggering factors are the same as that of Classic Asthma
• Main Feature is Dry (Non-productive) Cough
• Typically responds to INHALER(s)
46
ASTHMA IN PREGNANCY l MANAGEMENT ®
©
The following drugs should be used as normal during pregnancy:
• Short-acting β₂ agonists (SABA)
• Long-acting β₂ agonsits (LABA)
• Inhaled corticosteroids (ICS)
• Oral and intravenous Theophylline
BTS/SIGN Asthma Guidelines 2019
ASTHMA IN LABOUR & BREASTFEEDING ®

©
Breastfeeding
• Encourage breastfeeding
• Continue usual medications
Labour:
• Continue usual Asthma medications, or
• If receiving Prednisolone > 7.5mg/day > 2weeks prior to
delivery;
 IV Hydrocortisone 100mg 6-8 hourly during labour
BTS/SIGN Asthma Guidelines 2019
47
ASTHMA vs. COPD ®
©
ASTHMA COPD
• Onset before 20 years • Onset after 40 years
• Variable pattern • Persistent pattern
• Day and night variation • Good and Bad days
• Related to triggers • Related to smoking
• Reversible airflow obstruction • Irreversible airflow obstruction
• PFT normal between attack • PFT abnormal between attacks
ASTHMA vs. COPD ®

©
ASTHMA COPD
• Worsened by smoking • Caused by smoking
• Family history of asthma and • Not related to family history
allergies present • Deterioration over time
• No deterioration over time • Limited response to SABA
• Good response to SABA • Hyperinflation on CXR
• Chest X-ray normal
48
ASTHMA vs. REACTIVE AIRWAY DISEASE ®
©
• A diagnosis made in children ≤ 5 years with signs of asthma but
are too young to have lung function tests to confirm the
diagnosis of asthma
• Usually in children under 5 years
• Term is used when Asthma is suspected,

but not confirmed
REFERENCES ®
©
• https://www.nice.org.uk/guidance
• https://www.sehat.com.pk (for pictures of drugs)
• Oxford handbook of General Practice, 5th edition
• BTS/SIGN Guidelines 2019
• GINA Guidelines 2020
49
®
©
50

ACFrOgB tjlS-2fganV4ROSOsyPBAbjL23xINYkZApMmBRZdMu4jEyfdit8DWUYzmUtDtmVTY1bAINxDdwqsefvyAG0F0EruOHD86C53Y381pMVzRbMD0CFiFgUZaakoOZK4ZZSslpB32WFwxTtz

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

ACFrOgB tjlS-2fganV4ROSOsyPBAbjL23xINYkZApMmBRZdMu4jEyfdit8DWUYzmUtDtmVTY1bAINxDdwqsefvyAG0F0EruOHD86C53Y381pMVzRbMD0CFiFgUZaakoOZK4ZZSslpB32WFwxTtz

Uploaded by

Copyright:

Available Formats

®

Module Obstructive & Restrictive Lung Diseases

Credit Hours 2 CME Credit Hours

Prof. Nasir Shah

Professor and Head, Department of Family Medicine

Dean Family Medicine Faculty, College of Physicians

Convener National Family Medicine Committee of

OBSTRUCTIVE & RESTRICTIVE DISEASES ®

OBSTRUCTIVE LUNG DISEASES RESTRICTIVE LUNG DISEASES

DEFINITION (WHO – 2021) ®

• Cough and/or Intermittent

DEFINITION (OHGP – 2020) ®

IMPACT ON DAILY LIFE ®

DIAGNOSIS l STRUCTURED CLINICAL ASSESSMENT ®

DIAGNOSIS OF ASTHMA l THE DON’TS ®

1 & 3 are used to identify triggers once diagnosis of Asthma is

SPIROMETRY: FEV1/FEV RATIO ®

• Obstructive defect (Asthma/COPD)

• Restrictive defect ( Lung fibrosis)

Not related to time

VOLUME TIME CURVE ®

Variability over 20% is

1. Day time symptoms more than twice per week

5. Well control: 0 symptom

• Regular Preventer Therapy (Controller medicines)

• LABA Long Acting Beta2 Agonist

• MART Maintenance And Reliever Therapy

DRUGS FOR EXCERBATIONS ®

Step 1 Step 2 Step 3 Step 4

Salbutamol Yes Yes Yes Yes

ICS Yes Yes Yes Yes

LABA Yes Yes Yes

Increase ICS Yes Yes

LTRA Yes Yes

Step 1 Step 2 Step 3 Step 4

Salbutamol Yes Yes Yes Yes

Very low dose ICS Yes Yes Yes Yes

LTRA Yes (<5y) Yes (<5y) Yes Yes

LABA Yes Yes Yes

Low dose ICS Yes Yes

ICS DOSES FOR AGES 17 & ABOVE ®

• Maintain on the lowest dose of inhaled steroid controlling

• When reducing steroids, cut dose by 25–50% each time

Treat at home or in clinic and assess treatment response!

PRE-HOSPITAL CARE IN ACUTE EXACERBATIONS ®

4. BRONCHODILATOR PLUS STEROID (NUT SHELL)

SIGNIFICANT AIRWAY OBSTRUCTION AND ICS? ®

• Treat with oral prednisolone 30 mg od for 2 weeks

MANAGEMENT OF EXACERBATION IN CHILDREN < 2 Y ®

Severe wheezing  ADMIT

SUMMARY OF TREATMENT OF ACUTE ®

Moderate Severe Life threatening

Oral steroid Yes Yes Yes

Oxygen Yes Yes

Ipratropium neb Yes

Major socioeconomic problems

ASTHMA l RISK FACTORS WITH POOR OUTCOME ®

6. Risk factors for flare-ups

Avoid the trigger!

Causes Not well understood!

Term is replaced by Severe Asthma!

EXERCISE INDUCED ASTHMA ®

• Also known as EIB (Exercise Induced Bronchoconstriction)