Management of asthma at Primary &

general hospitals
MANAGEMENT OF ASTHMA IN ADULTS
AND ADOLESCENTS ≥ 12 YEARS OF AGE
Learning objectives
– By the end of this unit, the learner should be able to:
 Describes the goals of asthma management
 Assess severity of asthma
 State criteria for diagnosis of severe asthma
 Describe means of minimizing or avoiding precipitating
factors
 List the main groups of asthma medications
 Describe asthma management based on control
 Describe the supportive care for acute severe asthma
management
 Identify patient who need referral to specialist.
Goal of Asthma Management
– 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).
 Goal of Asthma Management
– Achieving these goals requires a partnership between
patient and their health care providers

 Ask the patient about their own goals regarding their asthma.
Shared decision-making is associated with improved outcome
 Good communication strategies are essential
 Consider the health care system, medication availability, cultural
and personal preferences and health literacy

 Take every opportunity to assess patients, particularly

when they are symptomatic or after a recent
exacerbation
 Asthma control
– Asthma control –Has two main domains

 Assessment of symptom control over the last 4 weeks

 Assessment of risk factors for poor outcomes

 Assessment of Asthma control
(In the Past 4 weeks)
1. Symptom control Level of asthma symptom control
assessment
 In the past 4 weeks, he/she had: Well Partly Uncontrolled
controlled

 Daytime asthma symptoms for N

more than twice/week? o
 Yes No n
 Any activity limitation due to e
asthma? none 1-2 of 3-4 of
 Yes No these o these
f
 Reliever needed* more than once a
week? t
 Yes No h
 Any night waking or night e
coughing due to asthma? s
 Yes No  e
How should control be measured in asthma?
Functional
Utilization of Status Daytime
Healthcare Symptoms
Resources

Nighttime
Inflammation Awakenings
Direct or Indirect
Asthma
Control Use of a
Lung “Quick Relief”
Function Inhaler and/or
Nebulizer

Missed Work Patient Self-Report

and/or School of Control
Adapted with permission from Chipps BE, Spahn JD. J Asthma. 2006;43:567-572.
Assessment of risk factors for poor outcomes
(In the past 12 months)

2. Assessment of risk factors for poor outcomes

Risk factors for exacerbations
 Uncontrolled asthma symptoms
Additional risk factors, even if the patient has few symptoms
 High SABA use (≥3 canisters/year)
 Having ≥1 exacerbation in last 12 months
 Incorrect inhaler technique and/or poor adherence
 Smoking
 Obesity, chronic rhinosinusitis, pregnancy, blood eosinophilia, low socioeconomic
status, depression, anxiety
Risk factors for fixed airflow limitation include
 Lack of Inhaled Corticosteroid (ICS) treatment, smoking, occupational exposure,
mucus hypersecretion, preterm birth, low birth weight.
Risk factors for medication side effects include
 Frequent Oral corticosteroid (OCS) use, high dose and /or potent ICS, some drugs
that decrease steroid metabolism, poor inhaler technique
 Principles of asthma management

1. Asthma management of patients not on treatment

or for first time presenters
– For patients presenting with acute symptoms, follow the
algorithm for management of asthma exacerbation
– For patients with indolent but variable symptoms once
the diagnosis is confirmed, assess for any risk for poor
outcome
– Patients with any risk factor for poor outcome are
eligible to start higher dose of controller therapy and
based on response/control of asthma, treatment can be
stepped up or down.
 Principles of asthma management cont…
2. Management of asthma among patients on
pharmacologic treatment
– Assess for asthma control in each visit and determine
asthma severity based on the level of step needed to
control the symptoms
• Mild asthma – Control achieved with step 1 or 2 medications
• Moderate asthma – Step 3 management is required to control
asthma
• Severe asthma- Steps higher than 3 are needed for control
– Reassess for risk factor for poor outcome
Asthma management for Adults and Adolescents 12 years
and above at PHC in Ethiopia

Step 1. Low dose inhaled Beclometasone 100µg taken

whenever Inhaled Salbutamol (SABA) is needed.

Step 2a. Standing dose of daily Beclometasone inhaler

100µg (1 puff) BID plus Salbutamol puff when needed.
Step 2b. Standing dose of daily Beclometasone inhaler
200µg (2 puffs ) BID plus Salbutamol puff when needed.
If total daily dose of Beclometasone is more than
400µg, patient should be referred to higher level of
care
 During initial presentation
• Start in step 1
– Symptoms less than twice per month

• Start with Step 2

– Symptoms twice a month or more, but less than daily
Asthma management for Adults and Adolescents above 12
years
at General hospital & above in Ethiopia
Steps 1 and 2 – Refer management for PHC

Step 3. Standing dose of Low dose Budesonide - Formoterol combination (160/4.5µg)

one puff BID
OR
Standing Medium dose of Beclomethasone 400µg (4 Puffs of 100µg) BID alone
OR
Low dose Beclomethasone 200µg (2 puffs) BID + Monteleukast 10mg po daily
OR
Low dose Beclomethasone 200µg (2 puffs) BID +Theophylline 10mg/kg
Asthma management at General hospital &
above in Ethiopia
Step 4. Medium dose Budesonide- Formoterol
combination (160/4.5µg) two puffs BID
OR
High dose Beclomethasone 600µg puffs BID (200µg of
beclomethasone 3 puffs BID) + Monteleukast or
Theophylline

Step 5. High dose Budesonide-Formoterol combination

(160/4.5µg) three puffs BID
OR
add Prednisolone 10 mg po daily on Step 4
 During initial presentation
• Start with Step 3 if :
– Symptoms most days, or waking with asthma once
a week or more

• Start with step 4 if :

– Symptoms most days, or waking with asthma once
a week or more, and low lung function
 Reliever Therapy
• The preferred reliever therapy for those on standing
dose of Budesonide- Formoterol is the use of the
same combination of low dose ICS-formoterol
(SMART) as-needed based.

• Maximum Total Daily dose of Formoterol should not

exceed 72μg.

• Alternative reliever is Salbutamol puff as needed .

 Asthma control
– Follow the continuous control-based asthma
management cycle:

– Assess symptom control + risk factors

– Adjust treatment (pharmacological and non-

pharmacological)

– Review the response: symptoms, exacerbations,

side effect
Reviewing Response and Adjusting treatment

 Stepping up asthma treatment;

 Sustained step-up, for at least 2-3 months if asthma

poorly controlled;
 Short-term step-up, for 1-2 weeks, e.g. with viral
infection or allergen;
 Day-to-day adjustment;
 For patients prescribed low-dose ICS/formoterol maintenance
and reliever regimen
 Stepping down asthma treatment;

 Consider step-down after good control

maintained for 3 months.
 Find each patient’s minimum effective dose that
controls both symptoms and exacerbations without
the development of adverse effects.

 Stopping ICS often leads to potentially dangerous

worsening of asthma.
Asthma medication and common side effects
– SABAs- Short acting beta agonists bronchodilators
 Should be the main therapy only during acute exacerbations but
 NOT recommended as a stand-alone therapy except in pediatric age
group

– LABAs- Long acting beta agonists

 Provide bronchodilation for up to 12 hours after a single dose.
 Salmeterol and formoterol are the LABAs available for asthma in
combination with ICS.
 Formoterol has similar duration of action with salmeterol but
bronchodilation with formoterol is significant within minutes of
inhalation, maximal within 2 hours

 Cont…
– Inhaled Corticosteroids (ICS)
 Preferred, first-line controller agents for all patients
especially for those at risk for poor outcome
 Most patients with asthma don’t need high dose, at a group
level, most of the benefit is obtained at low dose.
 Have few side effects at standard treatment doses.
 Local side effects include oral candidiasis, dysphonia, reflex
cough and bronchospasm.
 High dose ICS and long-term use of oral steroids predisposes
to systemic side effects which includes adrenal suppression,
osteoporosis, skin thinning, easy bruising, diabetes,
hypertension, infections, glaucoma and cataracts
 Theophylline
 Provides mild bronchodilation in asthmatic patients. Has also
weak anti-inflammatory and immunomodulatory properties
 Theophylline use needs to be monitored closely owing to
 The medication’s narrow therapeutic-toxic range,
 Individual differences in metabolism, and
 The effects of many factors on drug absorption and metabolism.
 At therapeutic doses, potential adverse effects include
 Insomnia, aggravation of dyspepsia ,GERD, and urination
difficulties in men with prostatic hyperplasia.
 Dose-related toxicities include :
 nausea, vomiting, tachyarrhythmias, headache,
seizures,hyperglycemia, and hypokalemia.
 Leukotriene antagonist(LTRA)
– Leukotriene receptor antagonists (LTRA) are less
effective than ICS particularly for exacerbations.;

– Used as add on for

 Patients who experience intolerable side-effects from ICS; or

 For patients with concomitant allergic rhinitis.

– Before prescribing montelukast (adult dose 10 mg once

daily), health professionals should counsel patients about
the risk of neuropsychitric events.
 Inhaled corticosteroids (ICS) and Combinations for Adults and adolescents (≥12 years)

Inhaled corticosteroid Total daily dose (mcg)

Low Medium High
Beclomethasone dipropionate 200–500 500–1000 >1000
(HFA)
Fluticasone/salmeterol (DPI) 100/50 250/50 500/50

Budesonide (DPI) 200-400 400-800 >800

Mometasonefuroate 200-400  400

(HFA-pMDI)

NB: DPI-Dry Powder inhaler, MDI -Metered dose inhaler CFC-Chloroflourocarbon HFA-
Hydroflouroalkane
*When Budesonide/formoterol is prescribed as maintenance and reliever therapy, the
maximum recommended dose of formoterol in a single day is 72 mcg.
Non-Pharmacological Strategies and Interventions for
asthma management
– Reduce indoor air pollution by cooking outside or using
smokeless cooking stoves
– Avoid allergens that the patient is sensitive to
– Avoidance of tobacco smoke exposure
– Occupational asthma
– Encourage Physical activity
– Avoid medications that may worsen asthma
– Remediation of dampness or mold in homes
Patients with poor asthma control should be assesses for
the following
– Reasons for poor adherence and misunderstanding the
difference between relievers and controllers
– Poor inhaler technique
– Exposure to trigger factors at home and work
– Presence of gastro-esophageal acid reflux disease (GERD)
– Rhinitis and sinusitis
– Use of medications that may aggravate asthma such as
aspirin, non-steroidal anti-inflammatory drugs and ß
blockers
– Other medical conditions mimicking asthma symptoms
(e.g. cardiac disease).
 Case study 2 (30 min)

• A 30 years old man came with history of cough for 1 month. The
cough is Productive of whitish sputum and phlegm in the
morning, it is worse at night, day and better during the day. He
feels shortness of breath during the day when he goes upstairs.
His mother is asthmatic. He is a banker and used to have
sneezing and running nose whenever he counts money. He has
no night Sweating, weight loss, or fever no chest pain, no pedal
Edema, or Orthopnea. Physical findings show no distress but has
wheezing in the chest bilaterally.
• What is the most likely diagnosis? Differentials?
• How do you classify the severity of patient?
• How do you manage this patient?
 Summary

– Asthma is a chronic inflammatory disorder of the airway,

persistent asthma is most effectively controlled with daily
long-term control medication directed toward
suppression of airway inflammation.

– A stepwise approach to pharmacologic therapy is

recommended to gain and maintain control of asthma in
both the impairment and risk domains.

– Asthma treatment should contain appropriate controller

medicines with as needed reliever.
• We would like to thank
– Dr. Amsalu Bekele, Dr Hanan Yusuf, Dr Tewodros
Haile and Dr Rahel Argaw for preparing this
powerpoint