ASTHMA

KAPS PREP

PRIVATE AND CONFIDENTIAL

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 ASTHMA

• Caused by inflammation and bronchoconstriction

• Irreversible
• SYMPTOMS:
 Chest tightness
 Wheezing
 Coughing
 Breathlessness
 Airflow limitation

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 ASTHMA

• DIAGNOSIS:
 Spirometry
 Pulmonary function test
Pulmonary function:
Is measured at baseline and after a medication called Albuterol which is SABA
TEST FOR REVERSIBILITY:
Defined by FEV1 increased greater than 12%.

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• TRIGGERS:
• Asthma can be triggered by the environment (allergens, dust, viral URTIs etc)
and inflammatory mediators like histamine, and leukotrienes, and cytokines.
• RISK FACTORS
 Smoking ( avoid smoking)
 Avoid triggers
 Exercise
 Stress
 Medications such as NSAIDS(including Aspirin) and Beta-Blockers worsen
asthma in some patients.

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 PULMONARY FUNCTION TESTING
(SPIROMETRY)
FEV1 FVC FEV1/FVC RATIO

Forced Expiratory air Forced vital capacity.  FEV1/FVC Ratio

volume in 1 sec FVC is the total volume doesn’t change
Volume of air that can be of air that can be expelled significantly with
expelled out in one out in a deep breath ( after mild asthma, in
second. deep inhalation)with no general, the ratio is
 Low FEV1 means regard to time. reduced in both
slowing of expiratory  FVC usually doesn’t obstructive diseases.
flow change significantly.  In patients with
 FEV1 is a good COPD, FEV1/FVC
indicator of morbidity ratio is <0.70
& mortality in COPD

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 SPIROMETER

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 PEAK EXPIRATORY FLOW(PEF)

• PEF is a measure of the maximum flow of air that a person can exhale in one breath. It is used
to monitor the air flow through the airways of people with asthma. It is important for
asthmatics to measure their PEF regularly to keep track of the severity of their asthma
symptoms and to make adjustments to their treatment plan if necessary.
• To measure PEF using a peak flow meter:
1.Stand up straight and hold the peak flow meter horizontally.
2.Seal your lips around the mouthpiece and breathe in deeply.
3.Blast the air out as quickly as possible, as if blowing out a birthday candle.
4.Read the result and repeat the measurement two more times.
5.Choose the highest of the three readings.
6.Compare the result with your personal best (the highest PEF reading you have ever recorded).
• It is important to note that PEF readings can be influenced by factors such as body position,
effort, and technique, so it is important to follow these instructions carefully to obtain accurate
readings.

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PEAK EXPIRATORY FLOW METER

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 PERSONAL BEST

• Personal Best PEF is the highest flow reading achieved during a 2-3 week
period.
 All future readings will be compared to the personal best.
ESTABLISHING PERSONAL BEST:
Measure PEF twice daily for 2-3 weeks, between noon and 2 PM each day, and
after using a beta-agonist (this should be done when asthma is well-managed).

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 ASTHMA EXACERBATION ZONES

• The severity of an asthma episode is evaluated by comparing the Peak flow

meter reading to the individual’s Personal best.

GREEN ZONE YELLOW ZONE RED ZONE

PEF 80-90% of personal 50-80% of personal < 50% of personal
best best best

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 RED ZONE MANAGEMENT
(MUST BE REFERRED TO ER)

 The patient in the red zone has <50% PEF.

 Low-dose ICS+ Formoterol as a rescue inhaler instead of Albuterol SABA.
 Alternative: Low dose ICS+ SABA
 Start oral steroids if available(Steroids take hours to work)
 Refer to the ER.

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 GINA GUIDELINES

• GINA guidelines recommend the use of low-dose ICS+Formoterol(i.e

symbicort) as a rescue inhaler for step 1 instead of albuterol(SABA) for both
intermittent and mild asthma, based on low exacerbation rate compared to PRN
SABA.
• Alternative med: Low dose ICS + SABA

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 YELLOW ZONE MANAGEMENT

 Patient in the yellow zone has 50-80% of personal best.

 PRN Low dose ICS –Formoterol
 Alternative: Low dose ICS+ SABA
 The symptoms are assessed after an hour of therapy if the patient has improved
to the green zone(80-90% ), then continue the LABA/ICS combo for 7-10
days.
If the patient is still in the yellow zone then we need to add oral steroids.

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 ASTHMA ACTION PLAN
ASTHMA FLARE-UP MANAGEMENT

 A written Asthma plan should be provided to patients.

 The action plan is based on symptoms and/or PEF reading(severity of asthma)
 Action plan help patients recognize and respond to the worsening of asthma
attacks.
 The aim of a written Action plan is to reduce/prevent asthma exacerbations and
improve patient however if an asthma flare-up occurs, its time to review the
plan, watch for the triggers of asthma attacks, medication use technique, and
patient’s compliance.

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 ASTHMA ACTION PLAN
ASTHMA FLARE-UP MANAGEMENT

• The written Asthma action plan should include:

 Patient’s name
 Patient’s meds
 Dose of ICS and when to increase it
 When to start oral steroids
 How to access medical care if needed.

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 CATEGORIZATION OF ASTHMA SEVERITY
(12 OR >12YEARS AGE)

Intermittent Mild Mild Persistent Moderate Severe

Persistent Persistent
Symptoms days < 2 days a week  2-7d 7d(daily) >7d throughout the
per week  2 days a week, day, everyday
but not daily
Night awakening < 2 a month 3-4 a month >4 a month,but not nightly
per month nightly

Rescue inhaler use < 2 days a week 2-7d 7d(daily) >7 throughout the
per week >2 days but not day,everyday
daily
Interference None minor some extreme
w/activity

FEV1 If Asymptomatic 80-100% 60-80% <60%

normal FEV1.
If symptomatic:80-
100%
 GINA
GLOBAL INITIATIVE F OR ASTHM A
GOALS OF T HERAP Y

 Minimize exacerbation risk/symptom control.

 Minimize the use of rescue inhaler.
 Maintain near normal PEF(Variability <20%) and maintain normal activity
levels
 Daily ICS is recommended for asthmatics with asthma symptoms more than
twice/a month, or night waking more than a month or risk factors for
exacerbations.
 All asthmatics should have a rescue inhaler.

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 GINA S TEPWISE THERAPY AP PROACH
(BAS ED ON S YMP TOM S REL IEF )
> 1 2 YE ARS OF AGE

• Patients using ICS+ Formoterol combo as reliever and controller

Step 4 Step 5
Step 2 Step 3 Symptoms everyday or waking with
asthma
Step 1 Symptoms most Add on
days or waking Daily medium LAMA, refer
Symptoms <4-5 days a week with asthma dose ICS- for phenotypic
formoterol(for assessment ,+
PRN Low Daily low dose maintenacce) anti-IgE, anti
dose ICS+ ICS- +OCS( as IL5/5R, anti-
Formoterol PRN Low dose ICS+ Formoterol for needed IL4R,
Consider high
combo Formoterol combo maintenance occasionally) dose ICS-
formoterol

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 GINA ST EPWIS E THERAP Y APP ROACH
( BAS ED ON SYMPTOM S RE LIE F)
> 12 YEARS OF AGE

• Patients using SABA Inhaler+separate ICS inhaler as reliever

Step 4 Step 5
Symptoms everyday or waking with
Step 3 Symptoms everyday or waking with asthma
asthma
Step 1 Step 2 Symptoms most Add on
Daily medium LAMA, refer refer
days or waking Add on LAMA,
Symptoms Symptoms twice a DailyICS-
dose med- for phenotypic
for phenotypic
with asthma
<twice a month month or more but formoterol(for
high dose assessment,+,+anti-
assessment
<4-5 x a week maintenacce)
ICS+ LABA
IgE, anti IL5/5R,
anti-IgE, anti anti-
SABA( Take Daily low-dose +OCS( as IL4R,
IL5/5R, anti-
ICS for Consider
IL4R, high dose
Daily low dose ICS ICS+ LABA needed ICS+ LABA
whenever maintenance
occasionally)
Consider high
for
SABA is for maintenance dose ICS-
taken) maintenance formoterol

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 FENO GUIDED THERAPY

 FENO➡️Nitric oxide
 Nitric oxide is produced by inflamed airway cells in patients with allergic pr
eosinophilic asthma.
 An exhaled nitric oxide test or FeNo test is done to assess lung inflammation and
inhaled steroid’s effectiveness in suppressing this inflammation.
 In children and adolescents with allergic eosinophilic asthma, FENO-Guided therapy
showed a significantly lower exacerbation rate than therapy based on current
guidelines however no difference was seen in adults.
 FENO-guided therapy is not recommended for the general asthma population at
present.

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LONG-TERM THERAPY VS RESCUE
MEDS

RESCUE
LONG-TERM  ICS + Formoterol
CONTROLLERS  Alternative med: SABA+ ICS
 ED TREATMENT:
 ICS SABA
 Mast cell stabilizers PO/IV Corticosteroids
 Anti-leukotrienes(LTRA) oxygen
 Methylxanthines If severe, then add :
 LABA Nebulized ipratropium(Atrovent)
IV magnesium sulfate
 Anti-IgE(omalizumab)
Heliox(Helium & oxygen)(better
 Anti IL5 (e.g. penetration)
benralizumab) Possible intubation for mechanical
ventilation

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