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Asthma

Asthma
Definition
Diagnosis and Classification
Asthma Medications
Asthma Management and
Prevention Program

Asthma
Chronic inflammatory disorder of
airway
Airway hyper-responsiveness
Widespread, but variable, airflow
obstruction within lung that is
reversible

Asthma Inflammation: Cells and


Mediators

Source: Peter J. Barnes, MD

Mechanisms: Asthma
Inflammation

Source: Peter J. Barnes,

Airway smooth
muscle

Hypertrophy
Hyperplasia
Edema
Contraction
Mucus
hypersecretion

Airway
hyperresponsivenes
s

Pathogenesis of asthma
Intermittent airway constriction
Airway inflammation
Bronchial hyperresponsiveness

Factors that Influence Asthma


Development and Expression
Host Factors

Environmental Factors

Genetic
- Atopy
- Airway
hyperresponsiveness
Gender
Obesity

Indoor allergens
Outdoor allergens
Occupational sensitizers
Tobacco smoke
Air Pollution
Respiratory Infections
Diet

Classification of asthma
1. Allergic asthma (extrinsic asthma)
childhood onset and seasonal variation
history of allergy to a variety of inhaled
factors

2. Non-allergic asthma (intrinsic asthma)


usually begins after the age of 30 years
It tends to be more continuous and more
severe.
Status asthmaticus is common in this group

Is it Asthma?
Recurrent episodes of wheezing
cough at night
Cough or wheeze after exercise
Cough, wheeze or chest tightness after
exposure to airborne allergens or
pollutants

Asthma Diagnosis
History and patterns of symptoms
Measurements of lung function
- Spirometry
- Peak expiratory flow
Measurement of airway responsiveness
Measurements of allergic status to
identify risk factors

History and Physical exam


Physical examination
- Absence of wheezing , poor air entry
poor predictor severe asthma
- Severe airflow obstruction
: use of the accessory muscles
: pulsus paradoxus
: cyanosis
- Suggest allergy eg. eczema, rhinitis, polyps
- Clubbing is not a feature of asthma

Pulmonary function tests


Peak expiratory flow rate
To diagnosis &
monitor asthma severity
- PEFR > 15 %
after received bronchodilator
- Variability
=
PEFmax PEFmin
< PEFmax + PEFmin >
> 20 % Dx

X 100%

Pulmonary function tests


Spirometry
To diagnosis & monitor
asthma severity
- FEV1 > 12 % and > 200
ml
after received
bronchodilator < 4 puff >

Differential diagnosis

COPD
Acute pulmonary edema
Foreign body aspiration
Gastroesophageal reflux
Bronchiectasis
Vocal cord dysfunction
Endobronchial mass

Typical Spirometric (FEV1)


Tracings
Volume
FEV1
Normal Subject
Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)

2
3
4
Time (sec)

Note: Each FEV1 curve represents the highest of three repeat measurements

Clinical Control of Asthma


No (or minimal)* daytime symptoms

No limitations of activity
No nocturnal symptoms
No (or minimal) need for rescue
medication
Normal lung function
No exacerbations
_________

Levels of Asthma Control


Characteristic
Daytime symptoms

Controlled

Partly controlled

(All of the following)

(Any present in any week)

None (2 or less /
week)

More than
twice / week

Limitations of
activities

None

Any

Nocturnal
symptoms /
awakening

None

Any

Need for rescue /


None (2 or less /
reliever treatment week)
Lung function
(PEF or FEV1)
Exacerbation

Normal
None

More than
twice / week

Uncontrolled

3 or more
features of
partly
controlled
asthma
present in
any week

< 80% predicted or


personal best (if
known) on any day
One or more / year

1 in any week

Goals of Long-term
Management
Achieve and maintain control of
symptoms
Maintain normal activity levels
(+exercise)
Maintain pulmonary function~ normal
levels
Prevent asthma exacerbations
Avoid adverse effects from
medications
Prevent asthma mortality

Controller Medications

Inhaled glucocorticosteroids (ICS)


Leukotriene modifiers
Long-acting inhaled 2-agonists (LABA)
Systemic glucocorticosteroids
Theophylline
Cromones
Long-acting oral 2-agonists
Anti-IgE

Daily Dosages for Inhaled Glucocorticosteroids


Drug

Low Daily Dose (g)


> 5 y Age < 5 y

Medium Daily Dose (g)


> 5 y Age < 5 y

Beclomethasone

200-500

100-200

>500-1000

>200-400

Budesonide

200-600
200

100-

600-1000

>200-400

Budesonide-Neb
Inhalation Suspension
Ciclesonide

250500
80 160

High Daily Dose (g)


> 5 y Age < 5 y
>1000
>1000

>500-

>400
>400

>1000

1000
80-160

>160-320

>160-320

>320-1280

>750-1250

>2000

>1250

>200-500

>500

>500

Flunisolide

500-1000
750

500-

>1000-2000

Fluticasone

100-250
200

100-

>250-500

Mometasone furoate

200-400
200

100-

> 400-800

>200-400

>800-1200

Triamcinolone acetonide

400-1000
800

400-

>1000-2000

>800-1200

>2000

>320

>400
>1200

Reliever Medications
Rapid-acting inhaled 2-agonists
Systemic glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral 2-agonists

REDUCE

LEVEL OF CONTROL

TREATMENT OF ACTION
maintain and find lowest
controlling step

partly controlled

consider stepping up to
gain control
INCREASE

controlled

uncontrolled
exacerbation

REDUCE

step up until controlled


treat as exacerbation

INCREASE

TREATMENT STEPS

STEP

STEP

STEP

STEP

STEP

Asthma Control: Treatment Steps


Children Older than Five Years, Adolescents, Adults

Treating to Achieve Asthma


Control
Step 1 As-needed reliever medication
Patients with occasional daytime symptoms of
short duration
A rapid-acting inhaled 2-agonist is the
recommended reliever treatment (Evidence A)

Step 2 Reliever medication plus


a single controller
A low-dose ICS is recommended as the initial
controller treatment (Evidence A)
Alternative controller : leukotriene modifiers
(Evidence A)

Step 3 Reliever medication plus


one or two controllers
combine a low-dose ICS with an inhaled
LABA (Evidence A)
Inhaled LABA must not be used as
monotherapy

Additional Step 3 Options


Increase to medium-dose inhaled
glucocorticosteroid (Evidence A)
Low-dose inhaled glucocorticosteroid
combined with leukotriene modifiers
(Evidence A)
Low-dose sustained-release theophylline
(Evidence B)

Step 4 Reliever medication plus


two or more controllers
Medium or high-dose ICS combined with LABA
(Evidence A)
Medium- or high-dose ICS combined with
leukotriene modifiers (Evidence A)
Low-dose sustained-release theophylline added
to medium- or high-dose ICS combined with a
LABA (Evidence B)

Step 5 Reliever medication plus


additional controller options
Addition of oral glucocorticosteroids may be
effective (Evidence D) but is associated with
severe side effects (Evidence A)
Addition of anti-IgE treatment improves
control of allergic asthma when control has
not been achieved on other medications
(Evidence A)

Treating to Maintain Asthma


Control
When control as been achieved,
ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment

Treating to Maintain Asthma


Control
Stepping down treatment
when asthma is controlled

When controlled on medium to high-dose


ICS: 50% dose reduction at 3 month
intervals
When controlled on low-dose ICS: switch
to once-daily dosing

Treating to Maintain Asthma


Control
Stepping up treatment in response to loss of control

Rapid-onset, SA or LABA provide


temporary relief.
Need for repeated dosing over more
than 1-2 days signals need for
possible increase in controller therapy

Avoiding precipitating factors

Drugs : ASA , NSAIDS , Beta-blocker


Unspecified allergen : , , ,
Emotional stress
Gastroesophageal reflux disease
Post-nasal drip syndrome
Infection URI
Pre-menstrual worsening
Air-pollution smoking , sulfurdioxide , oxone

Patient Education
key components of successful asthma
management
how to monitor their symptoms and
pulmonary function
what triggers asthma attacks and how to
avoid
what medicine to take and how to use
inhalers
what to do in the emergency events

Manage Asthma Exacerbations


episodes of progressive increase in
shortness of breath, cough, wheezing, or
chest tightness
characterized by expiratory airflow
(FEV1 or PEF)
Severe exacerbations are potentially lifethreatening

Manage Asthma Exacerbations

High risk of asthma-related death ?


History of near-fatal asthma / intubation
Hospitaliztion in past year
Currently using or recently stopped using oral
steroids
Not currently using inhaled corticosteroid (ICS)
Overdependent on rapid-acting inhaled 2-agonists
Psychiatric disease, including use of sedatives
Noncompliance with medication plan

Mild
Walking
Breathless
Can lie down
Talk in
Alertness

Sentences
May be agitated

Respiratory rate

Increased

Accessory
muscles

Usually not

Wheeze

Often only
expiration

Pulse rate

< 100

Pulsus
paradoxus

Absent < 10

PEF after BD
( % predicted or
% personal best )

PaO2 (on air)


and/or PaCO2
SaO2 (on air)

Over 80%
Normal
< 45 mmHg
> 95%

Moderate

Severe

Respiratory
arrest

Mild

Moderate

Severe
At rest

Breathless
Hunched forward
Talk in
Alertness

Words
Usually agitated

Respiratory rate

Often > 30 /min

Accessory
muscles

Usually

Wheeze

Usually loud

Pulse rate

> 120

Pulsus
paradoxus

Often present

PEF after BD

< 60 % or

( % predicted or
% personal best )

PaO2 (on air)


and/or PaCO2
SaO2 (on air)

< 100 L/min


< 60 mmHg
> 45 mmHg
< 90%

Respiratory
arrest

Mild

Moderate

Severe

Respiratory
arrest

Breathless
Talk in
Alertness

Drowsy or
confused

Respiratory rate
Accessory
muscles

Abdominal
paradox

Wheeze

Absence

Pulse rate

Bradycardia

Pulsus
paradoxus

Absent

PEF after BD
( % predicted or
% personal best )

PaO2 (on air)


and/or PaCO2
SaO2 (on air)

Acute care setting


Brief history and physical examination
- Severity, duration, current treatment + dose
- Risk of asthma-related death
Functional assessment : PEF or FEV1
CXR

- Suspected complicating cardiopulmonary process


- Required hospitalization or not response to Rx
Arterial blood gas
- PEF 30-50% predicted
- Not response to Rx or deterioration

- Respiratory failure PaO2<60, PaCO2>45 mmH

Asthma exacerbations

Medication
Treatment

Remark

Rapid-acting

Salbutalmol 2.5-5 mg nebulized (NB)

inhaled
2-agonists

or Terbutaline NB or MDI with spacer 28 puffs (max : 16 puffs)


Regular intervals
eg. every 15-20 min in 1st hour
No evidence support for iv 2-agonists

Rapid-acting inhaled 2-agonist

Rapid-acting inhaled 2-agonist


MDI with spacer nebulizer
MDI with spacer 2-4 puff q 15-20 min in 1st
hour
Nebulizer
- Volume 4 ml
- Oxygen flow rate 6-8 L/min
- eg. salbutamol solution (2.5 mg/ml) 2 ml

+ NSS 2 ml

Medication
Treatment
Ipratropium

Remark
Produce better bronchodilation than
either drug alone

bromide
in combination of 0.5 mg or 0.5-1 ml or 0.5-1 nebule q 4-8
hr
NB
MDI + spacer 2-8 puffs q 4-8 hr
-agonists
2

Theophylline

Minimal role :
- Severe side effects
- Bronchodilator effect < 2-agonists
Benefit as add-on treatment is not clear

Medication
Treatment

Remark

Systemic

Speed resolution of exacerbation

glucocorticosteroids

Should be use in all, except mildest exacerbation


Oral steroid
- As effective as iv route
- At least 4 hrs to produce clinical improvement
Dose equivalent to
- 200-400 mg of hydrocortisone (devided dose)
- Prednisolone 30-40 mg/day
7-day course as effective as 14-day course
No benefit to tapering dose of oral steroid

Medication
Treatment
Remark
Inhaled gluco- Effective as part of exacerbation
corticosteroids As effective as oral steroid to prevent relapses
High-dose ICS (2.4 mg budesonide daily)
relapse rate similar to 40 mg oral prednisone daily
Pts discharge with prednisone + inhaled
budesonide was lower relapse rate than those on
prednisone alone

Medication
Treatment
Epinephrine
Magnesium
(MgSO4 2 g iv over 20 min)

Remark
Not routinely indicated
Not recommended for routine use
Reduce hospitalization in adults
with FEV1 25-30% predicted, fail to
initial Rx
NB salbutamol in isotonic MgSO4
greater benefit than in NSS

Helium oxygen
therapy

No routine role

Sedatives

Should be strictly avoided

Asthma exacerbations

Asthma exacerbations

Asthma exacerbations

After discharge
Minimum 7-day course of oral steroid
As-needed bronchodilator until return to
normal
Continue ICS
Review inhaler technique and use of PEF
meter
Precipitating factor should be identified and
avoided

Management in acute asthmatic attack


Concept

Assess severity
Initial management

Evaluation and consideration of further management


Continuating management
Finds out precipitating factors
<prevent recurrent>

Patient education Discharge

Asthma