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Dr S Raju

Asthma is a common disorder

◦ It can happen to anybody
◦ It is not contagious
◦ It produces recurrent attacks of cough
with or without wheeze
◦ It can be effectively treated
◦ Between attacks people with asthma
lead normal lives as anyone else
◦ In most cases there is some history of
allergy in the family
 Mostpatients with asthma are
treated by primary care
physicians (>60%).

 Some asthmatics have

management problems that
should be referred to a specialist
in asthma.
 15 – 20 million asthmatics in India
 In Delhi prevalence estimated at 12% in

 Significant cause of school/ work

 Increasing morbidity and mortality
 More than one of the symptoms e:g : wheeze,
cough, difficulty breathing, chest tightness
especially if
◦ Frequent and recurrent
◦ Worse at night and early morning
◦ Occur in response to, or worse after
 Exercise or other trigger – eg exposure to pets, cold or
damp air, emotions or laughter
◦ Occur apart from colds
 Personal history of atopic disorder
 Family history of atopic disorder and/or asthma
 Widespread wheeze heard on auscultation
 History of improvement in symptoms or lung
function in response to adequate therapy
 Symptoms with cold only, no interval symptoms
 Isolated cough in absence of wheeze or
difficulty breathing
 History of moist cough
 Repeatedly normal chest examination whilst
 Normal PEF or spirometry whilst symptomatic
 No response to trial of asthma treatment
 Clinical features pointing to alternative
 Prevention of triggers
 Patient education
 Pharmacological drugs
 PEFR measurement
 Minimal (ideally no) chronic symptoms
 Minimal (infrequent) exacerbations
 No emergency visits
 Minimal (ideally no) need for "as needed” use of β 2-
 No limitations on activities, including exercise
 PEF circadian variation of less than 20 percent
 (Near) normal PEF/FEV1
 Minimal (or no adverse effects from medicine)
"The aim of asthma
management should be
control of the disease"
Gain control as quickly as possible; then
decrease treatment to the least medication
necessary to maintain control. Gaining
control may be accomplished by either
starting treatment at the step most
appropriate to the initial severity of the
condition or starting at a higher level of
therapy (e.g., a course of systemic
corticosteroids or higher dose of inhaled
corticosteroids) and then stepping down
 Review treatment every 1-6 months; a
gradual stepwise reduction in
treatment may be possible.
 If control is not maintained, consider
step up.
At each step, patients should control their
environment to avoid or control factors
that make their asthma worse (e.g.,
allergens, irritants); this requires specific
diagnosis and education.
 Step down
◦ Review treatment every 1-6 months.
◦ If control is sustained for at least 3 months, a
gradual stepwise reduction in treatment may be
 Step up
◦ If control is not achieved, consider step up.
◦ But first, review patient medication technique,
adherence and environmental control (avoidance of
allergens or other precipitant factors)
 The stepwise approach presents guidelines
to assist clinical decision-making.

 Asthma is highly variable; clinicians should

tailor specific medication plans to the needs
and circumstances of individual patients
 Asthma management in 2007 is focused on control of
the individual patient’s asthma symptoms, a
paradigm shift from earlier recommendations of a
step-wise increase in therapy based on asthma
 Patient self-management plans play an important role
in prevention of exacerbations;
 Successful asthma interventions lead to increased
medication costs but decreased costs for
hospitalization, and decreased death rates;
 Allergen exposure is an important contributory factor
in exacerbations of IgE-mediated asthma.
Tobacco smoke
Indoor pollutants and irritants
 Animal dander
◦ Remove animal from house / keep animal out of patient’s bedroom

 House dust mite

◦ Encase mattresses in an allergen-impermeable cover
◦ Wash sheets and blankets in hot water weekly
◦ Remove carpets from bedroom / avoid sleeping on upholstered furniture

 Cockroaches
◦ Poison baits / Do not leave food and garbage exposed

 Indoor mould
◦ Fix all leaks and eliminate water sources associated with mould growth
◦ Clean moldy surfaces

 Pollen
◦ Stay indoors esp. in the afternoons
◦ Windows closed during the season in which they have problems with outdoor allergens
 Stop smoking or smoke outside home (patients and
others at home)
 Smoking reduces the response to inhaled steroid
 Daycare providers / workplace smoke

 Reduce wood-burning stoves and fire-places

 Unvented stoves and heaters
 Reduce perfumes / cleaning agents / sprays

Quick Relief Preventive (controller)
• Short-acting β2-agonist • Inhaled Corticosteroids
• Salbutamol • Beclomethasone
• Terbutaline • Budesonide
• Anticholinergics • Fluticasone
• Ipratropium Bromide • Ciclesonide
• Tiotropium bromide • Leukotriene modifiers
• Short-acting theophylline Montelukast
• Aminophylline • Long-acting bronchodilators
• Doxophylline • Salmeterol (inhaled)
• Adrenaline injections • Formoterol (inhaled)
• SA salbutamol (oral)
• SR theophyllines (oral)
GINA Workshop Report,
 If a patient uses
◦ b2 agonists > twice per week in day time,
◦ or awakens > twice per month with nocturnal
◦ or refills a b2-inhaler > twice in a year,
 then the patient's asthma is mild
persistent or greater and daily anti-
inflammatory therapy is required.
GINA Workshop Report,
Inhaled steroid
 Inhaled corticosteroids
 Budesonide/ beclomethasone/

fluticasone/ ciclesonide – use any

 Start (400-1000 mcg/day approx. in 2

divided doses)
 Maintain for 2 to 3 months
 Taper slowly
 Safe for long-term use (years)
 Most potent anti-inflammatory
medications for asthma
 Prevent decline in lung function
 Safer than other equally effective

 Most cost-effective
 Throat infections (gargle/ use spacer)
 Hoarseness (singers/teachers/ least

with ciclesonide)
 Cataracts?
 Osteoporosis?
 Same dose for at least 3 months
 Then, gradual stepwise reduction in

treatment (25% - 50% every 1 - 3

 Use peak flow meter – very imp
New EU scale
 No symptoms
 Asymptomatic during exercise and

 Sleep undisturbed
 Minimal / no use of ‘relief’

 ~ 400 mcg/day (budesonide)
 Over 9 years of continuous use
 No growth retardation
 Uncontrolled asthma causes growth


Pedersen and Agertoft NEJM 2000;

 Non-compliance / non-adherence
 Habitual b2-agonist overuse
 GE reflux
 Sinusitis
 Hyperventilation
 Others:
◦ Bronchiectasis /PE
◦ OSA /Cardiac disease
first reconfirm diagnosis

Check Inhaler
Technique /
Check Regular Theophylline
Formoterol /

Increase dose Add

of inhaled Leukotriene
steroid modifier
 First-line add-on therapy at Step 3
 But over a 4-fold dosage range (200-

800 mcg BDP/BUD)

 So the dilemma is at what dose to

add the LABA ?

 80-90 % of the maximum therapeutic
benefit of ICS is achieved at daily dose
of 200mcg FP or 400mcg BUD
 200 mcg FP or equivalent should

be the preferred dose at which to

consider adding LABA if control is
Masoli M et al, Thorax 2005;60:730-734
 Prednisolone
 Acute severe episodes
 Dispense preferably
 Steroid-dependent asthma (regular

 Montelukast 10mg/day (5mg/4mg for
 Oral anti-inflammatory
 Not as effective as inhaled steroid
 First-line option for 2 to 5 yr. olds in

mild persistent asthma

 All your ‘regular’ bronchodilator users
 As an add-on agent at every step of
persistent asthma
 As an option particularly in children < 5

years with mild persistent asthma

 When patients strongly resist taking

inhalation medication in spite of adequate

training and counseling
 Exercise-induced asthma
 Aspirin-sensitive asthma
 Allergic rhinitis and asthma
 Sustained release for regular use
 Inexpensive , but toxic
 Not more than 400 mg per day

(serum levels 1 – 5 mcg/ml)

 Anti-inflammatory effects
 Long acting Beta²-agonist (LABA)
 Montelukast
 SR Theophylline
 Non-pharmacological methods
-insufficient evidence (Acupuncture,
Homeopathy, Immunotherapy)
 Breast feeding, smoking cessation,

weight control for obesity

 Role of non-static spacers
 Action plans
 Monotherapy with cromones is no
longer given as an alternative to
monotherapy with a low dose of ICS
in adults.
 Long-acting beta-2-agonists like

bambuterol are no longer

recommended as add-on agents in
severe asthma.
 Patients still suffer poor asthma control despite being
prescribed regular ICS or ICS/LABA treatment
 Patients recognize impending worsening and manage
these spontaneously by increasing their medication, but
in a sub-optimal way
 The time from early warning signs and the peak of a
worsening provides a window of opportunity for better
self-management to reduce and prevent symptoms and
 There is a clear need of awareness at the level of both the
physician and patient to effectively control asthma
Number of inhalations/day





0 10 20 30 40

Patients (%)

Base: all respondents (n=3,415)

Proportion of patients reporting disease ‘relatively good’ in the
Well- past
well- Uncontrolled
controlled by controlled by ACQ by ACQ

y good
y good 55%
y good

Patridge MR et al,BMC Pulmonary Medicine 2006,6

Respiratory Medicine Vol 96 (2002) 835-840
Respir Med 2002; 96: 835-40
 Fear about steroids
 Do not like public labeling as asthmatic
 Fear of addiction
 Feel pumps reserved for serious or

severe attacks or will fail to act

 Misconception that costly
 Prefer oral medications
 Physicians lack of knowledge and time
A new approach to asthma management
 ICS plus LABA for prophylaxis and relief
 Simple one device treatment strategy
 Improves daily control
 Prevents severe exacerbations more

effectively than higher dose ICS plus

SABA or maintenance ICS/LABA plus
SABA reliever
 Recommended in recent GINA

“to achieve and maintain

“Treating to target” Partly controlled

Not well
 The goal of management is CONTROL
of asthma
 Current Clinical Control and controlling

Future Risk
 Addressing OBSTACLES to asthma

 Develop a doctor / patient partnership

Doctor-directed patient self-

 Single inhaler for relief and
 Regular maintenance dose (usually

twice daily) with additional inhalation(s)

as needed
 Patients do not require a separate SABA
 Use of reliever is always accompanied

by an extra dose of anti-inflammatory

 Single maintenance and relief therapy
 For better informed and less compliant

 Not for poor perceivers of worsening
 Home PEFR use preferred
 Patient directed rather than physician

controlled (now proven to be effective in

over 6 studies)
 A highly effective way of stepping up anti-
inflammatory therapy in line with disease activity
 If a combination inhaler containing formoterol
and budesonide is selected, it may be used for
both rescue and maintenance. This approach has
been shown to result in reductions in
exacerbations and improvements in asthma
control in adults and adolescents at relatively low
doses of treatment (Evidence A)
 Emphasizes Asthma management on
◦ Clinical control rather than classification of
patient by severity
 Exacerbation
◦ One of the important criteria in assessing
asthma control
 This important shift reflects in
pharmacological care asthma including
new treatment approach
 Treats the underlying inflammation with
every inhalation 
 Reduces exacerbations

 Improves daily asthma control

 Reduces overall steroid load

Is simple to use with only one inhaler for

maintenance and relief

O’Byrne PM, et al. Am J Respir Crit Care Med 2005;171:129–136; Rabe KF, et al. Lancet
1 2

Vogelmeier C, et al. Eur Respir J 2005;26:819–828; 4Rabe KF, et al. Chest
Scicchitano R, et al. Curr Med Res Opin 2004;20:1403–1418; 6Kuna P, et al. Int J Clin
Pract 2007;In Press.
 One or more present:
◦ Use of accessory muscles of respiration
◦ Pulses' paradoxicas >25 mm Hg
◦ Pulse > 110 pm
◦ Inability to speak sentences
◦ Respiratory rate >25 - 30 breaths/min
◦ PEFR or FEV1 < 50% predicted
◦ SaO2 < 91- 92%

McFadden Am J Respir Crit Care

Med 2003
 Tachypnea
 Tachycardia
 Wheeze
 Hyperinflation
 Accessory muscle use
 Pulses paradoxicus
 Diaphoresis (profuse sweating)
 Cyanosis
 Obtundation (altered mental state)

Brenner, Tyndall and Crain In: Emergency Asthma. Marcel

Dekker 1999
 Previous episode of near-fatal asthma
 Multiple prior ER visits or hospitalizations
 Poor compliance with medical treatments
 Adolescents or inner city asthmatics
 Recent use of oral corticosteroid (OCS)
 Inadequate therapy:

◦ Excessive use of β-agonists

◦ No inhaled corticosteroid (ICS)
◦ Concomitant β-blockers

Ramirez and Lockey In: Asthma, American College of

Physicians, 2002
 Lower or upper respiratory infections
 Cessation or reduction of medication
 Concomitant medication, e.g. β-blocker
 Allergen or pollutant exposure
 Respiratory frequency: (count)
◦ Speech: sentences, single words
 Auxiliary respiratory muscle use
 Posture: sitting, can patient lie down?
 Airway patency: rhonchi, silent chest (PEF)
 Respiration: cyanosis (SaO2, blood gases)
 General appearance, effort of breathing:

activity level (pulse rate)

 Oral corticosteroids are the most powerful
medications available to reduce airway
 Use until attack has completely abated:

◦ PEFR and FEV1 at baseline levels

◦ Symptoms gone
 Taper to QOD and determine if patient can
remain well if corticosteroids are withdrawn
 Treat the condition symptomatically
 Determine what caused the exacerbation:

◦ inhalant allergen
◦ food allergen
◦ drug reaction (ASA, vaccination, etc)
◦ infection
◦ worsening of a chronic condition:
◦ poor therapy compliance
 Treatment needs adjustment
 Use antibiotics if any suspicion of
bacterial infection
 If antibiotics are prescribed,

recommendation is for broad spectrum

macrolide antibiotics that cover atypical
bacteria (chlamydia, mycoplasma), eg,
azithromycin, clarithromycin,
erythromycin, roxithromycin,
dirithromycin, amoxicillin + clavulan;
moxifloxacin, cefuroxin
 Consider improved prophylaxis:

◦ Treat, Monitor and Follow-up

 allergen avoidance
allergen vaccination
pharmacological treatment update
stop smoking
 enhance compliance to recommendations
teaching and monitoring
 Seasonal asthma
◦ Use same stepwise approach as for the long-term
management of asthma.
◦ Begin anti-inflammatory agents two weeks prior
to the anticipated onset of the season and
continue through the season.
 Seen more in young children.
 Use same stepwise approach as for the
long-term management of asthma.
 Chronic use of anticholinergics for this
disorder is not recommended
 Poorly controlled asthma during
pregnancy results in increased
perinatal mortality; increased
prematurity and low birth weight
 Controlling the mother's asthma with
the use of bronchodilators and anti-
inflammatory medication is best for the
baby and mother
 Surgical patients receiving systemic
corticosteroids during the last 6 months
 Give 100 mg hydrocortisone q 8 h i.v.

during the surgical period and reduce

dose rapidly 24 h following surgery
 Missing cardiac asthma and treating it
as bronchial asthma
 Missing near fatal asthma cases
 Misdiagnosing the severity of asthma
 Not giving inhaled steroid to patients
with persistent asthma
 Not differentiating between asthma and
 Buying a Peak Flow Meter (severity of asthma,
diagnosis of asthma, drug titration, aggravating
factors, diagnosing exercise induced asthma,
personal best parameter: chargeable test)
 FEV1 test: small machine gives the FEV1 and can
be billed as mini spirometry
 Asthma group counseling sessions can be charged