Peter CrawleyPulmonary/CCM

Guidelines

q National Asthma Education and Prevention Program Expert Panel Report 2007

q https://www.nhlbi.nih.gov/guidelines/asthma/asthgdln. htm

q GINA Initiative 2019q https://ginasthma.org/gina-

reports/

¨ Definition/Epidemiology/Pathogenesis¨ Diagnosis

¡ Spirometry interpretation¨ Treatment

¡ Components of Asthma Management¡ Managing Acute Exacerbations

¨ Special cases¡ Vocal cord dysfunction¡ Post deployment dyspnea¡ Exercise induced asthma¡ Obesity and asthma¡ “COPD” vs asthma

¨ Asthma is a chronic inflammatory disorder of the small airways (bronchioles) in which many cells and chemical mediators play a role.

¨ Clinically characterized as recurrent episodes of wheezing, breathlessness, chest tightness, and coughing.

¨ Associated with airflow obstruction as measured by spirometry that is often reversible.

¨ Bronchoconstriction¨ Persistent

Inflammation and Airway Remodeling

¨ Airway Hypersensitivity

¨ Increased inflammatory cells

¨ Airway wall edema¨ Goblet cell (mucous)

hyperplasia¨ Smooth muscle

hyperplasiaBMJ 2014;349

¨ prevalence hindered by varying definitions

¨ ranges from 5% percent to 22%

¨ prevalence has been increasing

¨ mortality in US decreasing

¨ Clinical history¨ Spirometry¨ Exclude alternative diagnoses

¨ NAEPP ¡ “To establish a diagnosis of asthma, the clinician

should determine that symptoms of recurrent episodes of airflow obstruction or airway hyperresponsiveness are present; airflow obstruction is at least partially reversible; and alternative diagnoses are excluded.”

1. Symptoms; wheeze, cough, chest tightness2. Precipitating factors3. History of exacerbations 4. Family History5. Smoking

§ Three basic components

§ Spirometry§ Lung Volumes (Plethysmography)§ Diffusing Capacity

“normal breathing”

“deep breath in”

“blow it out”

¨ FVC : Volume of air forcefully exhaled after full inspiration

¨ FEV1: Volume of air forcefully exhaled in the first second of the FVC

¨ FV loop adequate?¨ Ratio of FEV1/FVC to

identify obstruction¨ FEV1 defines severity¨ Bronchodilator

response?

¨ Step 1 – Look at FEV1/FVC ratio¨ Obstruction is defined by a “low” FEV1/FVC

ratio¡ Gold Criteria = 70% predicted as absolute cut off¡ ATS guidelines use the lower limit of normal (LLN) ≤ 5 percentile

¡ Ethnically appropriate National Health and Nutrition Examination Survey (NHANES) III reference equations are recommended for those aged 8–80 yrs.

¨ Step 2 – Look at FVC¡ low FVC - may indicate additional restrictive process¡ need lung volumes (TLC) to determine restriction

¨ Step 3 – Define severity based on FEV1¨ Step 4 – Look for bronchodilator response

¡ ≥12% change in either FEV1 or FVC

FEV1/FVC ratio ≤ LLN

FVC ≤ LLN FVC ≤ LLNyes no

Step 1 – look at FEV1/FVC ratio

Step 2 – look at FVC

Obstruction

no no

yes

yesMixed Obstruction/Restric

tive PatternNormal

Restrictive Pattern

obstruction normal

FEV1Mild >70%Moderate 60-69%Moderately Severe 50-59%Severe 35-49%Very Severe <35%

¨ Not part of diagnostic criteria for asthma¨ High negative predictive value ( 95%)¨ Flow volume loops are critical – absolute

numbers do not tell the complete story¨ Can induce vocal cord dysfunction¨ Used as diagnostic adjuvant for unexplained

dyspnea with exertion in military

¨ NO regulates vascular and bronchial tone (promoting dilation of both vessels and airways) within respiratory system.

¨ The fraction of exhaled NO (FENO), can be detected in exhaled gas and varies in health and disease.

¨ It has been hoped that using FENO in conjunction with symptoms would increase diagnostic accuracy and direct therapy

¨ FENO levels can predict which patients will respond to inhaled glucocorticoid

¨ The largest clinical trials have not found sufficient evidence to support routine use of FENO to guide asthma therapy or in diagnosing asthma

¨ CXR¡ Bronchiectasis¡ Lung mass

¨ Flow volume loops¡ Fixed airway obstruction¡ Vocal cord dysfunction

¨ Physical Exam¡ Heart disease?

¨ Basic labs for dyspnea¡ Anemia?

¨ Assess severity and control¨ Treatment based on “steps” corresponding to

level of severity and control¨ Asthma Education¨ Treat comorbid conditions¨ Pharmacotherapy

¨ Severity: pretreatment clinical parameters¡ Impairment – symptoms, functional limitations and

FEV1¡ Risk – number of exacerbations

¨ Control: post treatment ¡ Impairment - symptoms, functional limitations and

validated questionnaire (Asthma Control Test)¡ Risk – number of exacerbations or loss of lung

function ( FEV1)

© Global Initiative for Asthma

GINA Global Strategy for Asthma Management and Prevention

This slide set is restricted for academic and educational purposes only. No additions or changes may be made to slides. Use of the slide set or of individual slides for

commercial or promotional purposes requires approval from GINA.

* Off-label; data only with budesonide-formoterol (bud-form)† Off-label; separate or combination ICS and SABA inhalers

PREFERRED CONTROLLERto prevent exacerbations and control symptoms

Other controller options

Other reliever option

PREFERRED RELIEVER

STEP 2

Daily low dose inhaled corticosteroid (ICS), or as-needed low dose ICS-formoterol *

STEP 3

Low dose ICS-LABA

STEP 4

Medium dose ICS-LABA

Leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken †

As-needed low dose ICS-formoterol *

As-needed short-acting β2 -agonist (SABA)

Medium dose ICS, or low dose ICS+LTRA #

High dose ICS, add-on tiotropium, or add-on LTRA #

Add low dose OCS, but considerside-effects

As-needed low dose ICS-formoterol for patients prescribed maintenance and reliever therapy ‡

Box 3-5AAdults & adolescents 12+ years

Personalized asthma management:Assess, Adjust, Review response

Asthma medication options: Adjust treatment up and down for individual patient needs

STEP 5

High dose ICS-LABARefer for phenotypic assessment± add-on therapy, e.g.tiotropium, anti-IgE,anti-IL5/5R,anti-IL4R

Symptoms Exacerbations Side-effects Lung functionPatient satisfaction

Confirmation of diagnosis if necessary Symptom control & modifiablerisk factors (including lung function)ComorbiditiesInhaler technique & adherence Patient goals

Treatment of modifiable risk factors & comorbiditiesNon-pharmacological strategies Education & skills training Asthma medications

1© Global Initiative for Asthma, www.ginasthma.org

STEP 1

As-needed low doseICS-formoterol *Low dose ICS taken whenever SABA is taken †

‡ Low-dose ICS-form is the reliever for patients prescribed bud-form or BDP-form maintenance and reliever therapy

# Consider adding HDM SLIT for sensitized patients withallergic rhinitis and FEV >70%predicted

¨ rescue inhaler vs daily control medications

¨ using inhalers correctly

¨ use of peak flow meter

¨ action plan

¨ gastroesophageal reflux¨ obesity¨ OSA ¨ rhinitis/sinusitis¨ anxiety/depression

¨ very rare in isolation – other triggers generally present

¨ exercise-related symptoms of dyspnea, cough, or wheeze)

¨ classically with cold dry air¨ demonstration of reversible airflow limitation

in response to exercise ¨ improves with pre-treatment with albuterol

¨ Leukotriene Modifiers¡ LTRA

ú Accolate (Zafirlukast)ú Singulair (Montelukast)

¡ 5-lipooxygenase inhibitorsú Zyflo (Zileuton)

¨ Anti-IgE antibody¨ Dose and interval

based on weight and IgE levels

¨ Anaphylactic reactions

¨ ? Increased maligancy¨ ? Churg-strauss

¨ benralizumab –fasenra

¨ mepolizumab –nucala

¨ reslizumab - cinqair

¨ life-threatening asthma exacerbation ( hospitalization for asthma)

¨ not meeting the goals of asthma therapy after 3–6 months of treatment.

¨ signs and symptoms are atypical¨ patient requires additional education. ¨ patient requires step 4 care or higher ¨ patient has required two or more bursts of oral

corticosteroids in 1 year

¨ Constrictive Bronchiolitis in Soldiers Returning from Iraq and Afghanistan

¨ 80 soldiers from Fort Campbell, Kentucky ¨ inhalational exposures ¨ dyspnea that prevented meeting U.S. Army's standards for physical fitness¨ 49 soldiers who underwent lung biopsy¨ 38 diagnostic of constrictive bronchiolitis¨ Normal CXR, HRCT scan, spirometry

N Engl J Med July, 2011; 365:222-230

¨ Study of Active Duty Military for Pulmonary Disease related to Environmental Dust Exposure

¨ Active duty service members who report new symptoms of dyspnea following deployment

¨ CXR, HRCT, PFTs, MCT, Bronchoscopy with BAL

¨ Quick reference guidelines available¡ NAEPP – 2007¡ GINA - 2019

¨ Diagnosis requires objective data with spirometry and consideration of other possible etiologies¡ CXR, FV loops, CBC (for dyspnea)¡ Refer if something seems odd

¨ Components of asthma management¡ Severity/control¡ Education¡ Controlling comorbid conditions

¨ Severity and Control involve two clinical parameters¡ Impairment – day to day symptoms¡ Risk – hospitalizations/objective decline in FEV1

¨ New injectables target difficult to treat asthma¨ VCD very common and should be considered in nearly all

patients with exertional symptoms only