Guidelines for management of asthmaGuidelines for management of asthma

Global INitiative for Asthma (updated Dec 2008)

Guidelines for management of asthmaGuidelines for management of asthma

The British Thoracic Society/Scottish Intercollegiate Guidelines Network

British Guideline on the Management of Asthma (updated May 2008)

Current Understanding of Asthma

A chronic inflammatory disorder of the airway

Infiltration of mast cells, eosinophils and lymphocytes

Airway hyperresponsiveness Recurrent episodes of wheezing,

coughing and shortness of breath Widespread, variable and often

reversible airflow limitation

The Underlying Mechanism

INFLAMMATIONINFLAMMATION

Risk Factors (for development of asthma)

AirwayHyperresponsiveness Airflow Limitation

Symptoms- (shortness of breath, cough,

wheeze)

Risk Factors(for exacerbations)

Asthma: Pathological changes

Risk Factors that Lead to Asthma Development

Predisposing Factors Atopy

Causal Factors Indoor Allergens

– Domestic mites– Animal Allergens– Cockroach Allergens– Fungi

Outdoor Allergens– Pollens– Fungi

Occupational Sensitizers

Contributing Factors Respiratory infections Small size at birth Diet Air pollution

– Outdoor pollutants– Indoor pollutants

Smoking– Passive Smoking– Active Smoking

About asthma…About asthma…

One of the most chronic diseases, with an estimated 300 million individuals affected worldwide

Prevalence is increasing especially among children

Asthma is a chronic inflammatory disorder of the airways

Chronically inflamed airways are hyperresponsive, they become obstructed and airflow is limited by Bronchoconstriction Mucus plug Increased inflammation

when airways are exposed to various risk factors

A stepwise approach to pharmacologic treatment to achieve and maintain control of asthma should take into account the safety of treatment, potential for adverse effects and the cost of treatment

Controller medication must be taken daily and reliever medication may occasionally be used to treat acute symptoms

DiagnosisDiagnosis

Spirometry preferred method of measuring airflow

limitation and its reversibility to establish a diagnosis of asthma.

An increase in FEV1 of >12% and 200 ml after administration of a bronchodilator indicates reversible airflow limitation consistent with asthma.

GINA 2008

DIAGNOSIS OF ASTHMA

History and patterns of symptoms

Physical examination

Measurements of lung function

PATIENT HISTORY

Has the patient had an attack or recurrent episodes of wheezing?

Does the patient have a troublesome cough, worse particularly at night, or on awakening?

Does the patient cough after physical activity (eg. Playing)?

Does the patient have breathing problems during a particular season (or change of season)?

Do the patient’s colds ‘go to the chest’ or take more than 10 days to resolve?

Does the patient use any medication (e.g. bronchodilator) when symptoms occur? Is there a response?

If the patient answers “YES” to any of the above questions, suspect asthma.

Physical Examination

Wheeze -Usually heard without a stethoscope

Dyspnoea -Rhonchi heard with a stethoscopeUse of accessory muscles

Remember -Absence of symptoms at the time of examination does not exclude the diagnosis of asthma

Diagnostic testing

Diagnosis of asthma can be confirmed by demonstrating the presence of reversible airway obstruction using Peak flow meter.

Classification of Asthma Severity

STEP 4

Severe Persistent

STEP 3

Moderate Persistent

STEP 2

Mild Persistent

STEP 1

Intermittent

The presence of one of the features of severity is sufficient to place a patient in that category.

Global Initiative for Asthma (GINA) WHO/NHLBI, 2002

SymptomsNighttimeSymptoms

PEF

CLASSIFY SEVERITYClinical Features Before Treatment

ContinuousLimited physical activity

DailyUse 2-agonist dailyAttacks affect activity

>1 time a week but <1 time a day

< 1 time a weekAsymptomatic and normal PEF between attacks

Frequent

>1 time week

>2 times a month

<2 times a month

<60% predictedVariability >30%

>60%-<80% predictedVariability >30%

>80% predictedVariability 20-30%

>80% predictedVariability <20%

Classification of asthma controlClassification of asthma control

GINA 2008

4 components of asthma care4 components of asthma care

1. develop doctor/patient relationship 2. identify and reduce exposure to risk

factors 3. Assess, treat and monitor asthma 4. Manage asthma exacerbations

GINA 2008

Component 1: develop doctor-Component 1: develop doctor-patient relationshippatient relationship

Patients should learn to: Avoid risk factors Take drugs regularly Understand the difference between “controller”

and “reliever” medications Monitor the status using symptoms and if relevant,

PFR recognize signs that asthma is worsening and take

action Seek medical help as appropriate

Component 2: identify and reduce Component 2: identify and reduce exposure to risk factorsexposure to risk factors

Exercise may lead to asthmatic symptoms but patients should not avoid exercise but use beta agonist as prophylaxis instead

Advice patient with moderate to severe asthma to have influenza vaccine every year

Component 2: identify and reduce Component 2: identify and reduce exposure to risk factorsexposure to risk factors

Avoidance that improve the control of asthma: Tobacco smoke Drugs, food and addictives Occupational sensitizers

Reasonable avoidance measures can be recommended but have not been shown to have clinical benefit: House dust mites, animals with fur, cockroaches,

outdoor pollens and mild, indoor mold

Component 3: assess, treat and Component 3: assess, treat and monitor asthmamonitor asthma

Assess:

Component 3: assess, treat and Component 3: assess, treat and monitor asthmamonitor asthma

Treatment: GINA 2008

Stepwise treatmentStepwise treatment

Step 1: No need for controller Reliever: rapid acting beta 2 agonist

Step 2: Controller:

– low dose inhaled corticosteroid– Leukotriene modifier

Reliever:– Rapid acting beta 2 agonist

Step 3: Controller:

low dose inhaled corticosteroid + long acting beta 2 agonist

Medium or high dose ICS Low dose ICS + leukotriene modifier Low dose ICS plus SR theophylline

Reliever: Rapid acting beta 2 agonist

Step 4: Controller:

Medium/high dose inhaled corticosteroid + long acting beta 2 agonist

Add one or more: leukotriene modifier SR theophylline

Reliever: Rapid acting beta 2 agonist

Step 5: Controller:

– Controller as in step 4, add one or more:– Oral glucocorticosteriod (lowest dose)– Anti-IgE treatment

Reliever:– Rapid acting beta 2 agonist

Component 3: assess, treat and Component 3: assess, treat and monitor asthmamonitor asthma

Monitoring: Typically patients should be seen 1-3

months after the initial visit, and every 3 months thereafter

After an exacerbation, FU within 2-4 weeks

Adjusting medicationAdjusting medication

If asthma is not well controlled: step up treatment and improvement should be seen within 1 month

Review the patient’s medication technique, compliance and avoidance of risk factors

Partly controlled: consider stepping up treatment considering the safety, cost, effectiveness of treatment and the patient’s satisfaction

If control is maintained for 3 months, step down with gradual stepwise approach

BTS guideline: Stepwise management in adultsBTS guideline: Stepwise management in adults

RelieversRelievers

Short acting beta 2 agonists Anticholinergics Short acting theophylline

RelieverReliever

Short acting beta 2 agonists Salbutamol (Ventolin) Terbutaline (Bricanyl) – tablet/injection SE:

– Tachycardia, tremor, headache, irritability– At very high dose hyperglycaemia,

hypokalemia– Systemic administration increase risk of SE

RelieverReliever

Anticholinergics: Ipratropium bromide (Atrovent) SE: minimal dry mouth or bad taste in the

mouth May provide addictive effect to beta agonist

but slower onset

RelieverReliever

Short acting theophylline Aminophylline (7mg/kg loading over 20min

then 0.4mg/kg/hr infusion) SE:

– Nausea, vomiting, headache– Higher serum concentration: seizure,

tachycardia, arrhythmia– Require level monitoring

ControllersControllers

Inhaled corticosteroid (ICS) Oral steroid Sodium cromoglycate Long acting beta 2 agonist Combination ICS/LABA SR theophylline Antileukotriene Immunomodulators

Inhaled corticosteroidInhaled corticosteroid

Beclotide (beclomethasone dipropionate 50mcg/dose)

Becloforte (beclomethasone dipropionate 250mcg/dose)

Beclazone (beclomethasone easi-breathe 100mcg/dose or 250mcg/dose)

Pulmicort (budesonide 100mcg/dose or 200mcg/dose)

Flixotide (fluticasone propionate) In accuhaler or inhaler

Inhaled corticosteroidInhaled corticosteroid

SE: High daily doses may be associated with

skin thinning, bruises, and adrenal suppression

Hoarseness, oral candidasis Growth delay or supression in children

(average 1cm)

Inhaled corticosteriodInhaled corticosteriod

LABALABA

Salmeterol (serevent) Should not use as monotherapy for

controller therapy, always use as adjunct to ICS

Not used in acute attack

Combines inhalersCombines inhalers

ICS + LABA Symbicort (budesonide + formoterol turbuhaler

160/4.5mcg, 80/4.5mcg, 320/9mcg) Seretide (salmeterol + fluticasone 50/100mcg,

50/250mcg, 50/500mcg) Seretide lite (salmeterol + fluticasone 25/50mcg) Seretide medium (salmeterol + fluticasone

25/125mcg) Seretide forte (salmeterol + fluticasone

25/250mcg)

ControllersControllers

SR theophylline Aminophylline

– Starting dose 10mg/kg/d with usual 800mg max in 1-2 doses

– SE: • nausea, vomiting, • high serum concentration: seizure, tachycardia,

arrhythmia

ControllersControllers

Antileukotrienes Montelucast (Singulair) Adult: 10mg daily Children: 5mg daily No specific SE to date

ControllersControllers

Immunomodulators Anti IgE Omalizumab Subcutaneous injection every 2-4 weeks

How to monitor asthma control?How to monitor asthma control?

Questions to ask the patient: Has your asthma awaken you at night? Have you needed more reliever medication as

usual? Have you needed any urgent medical care? Has your peak flow been below your personal

best? Are you participating in your usual physical

activities?

How to monitor asthma control?How to monitor asthma control?

is the patient using the inhaler, spacer or peak flow meters correctly?

Is the patient taking the medications and avoiding risk factors according to the asthma management risk factors according to the asthma management plan?

Does the patient have any other concerns?

Component 4: manage Component 4: manage exacerbationsexacerbations

Signs and symptoms of severe attack:– Breathless at rest, – talks in words rather than sentences (infant

stops feeding), – agitated, drowsy, or confuse– Tachycardia (pulse>120) or Bradycardia– Tachypnea– PEF < 60% predicted– Patient is exhausted

The response to the initial bronchodilator treatment is not prompt and sustained for at least 3 hours

There is no improvement within 2-6 hours after oral steroid

There is further deterioration

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_________* Minimal = twice or less per week

Levels of Asthma Control

Characteristic Controlled Partly controlled(Any present in any week)

Uncontrolled

Daytime symptomsNone (2 or less / week)

More than twice / week

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

Limitations of activities

None Any

Nocturnal symptoms / awakening

None Any

Need for rescue / “reliever” treatment

None (2 or less / week)

More than twice / week

Lung function (PEF or FEV1)

Normal< 80% predicted or

personal best (if known) on any day

Exacerbation None One or more / year 1 in any week

Treatment of acute attackTreatment of acute attack

Inhaled rapid-acting beta agonist begin with 2-4 puff q20min for the first hour, then mild attack:

2-4 puff q3-4hmod attack: 6-10 puff q1-2h

Oral steroid 0.5-1mg prednisolone/kg/day Oxygen (keep SaO2>95%) combination of beta agonist/anticholinergic therapy is

associated with lower hospitalization rates and greater improvement in PEF and FEV1

Methylxanthines are not recommended together with high doses of inhaled beta agonists. If patient is already on theophylline daily, check level before adding short acting theophylline

Therapies not recommended for treating Therapies not recommended for treating asthma attacksasthma attacks

Sedatives Mucolytic drugs (may worsen cough) Chest physio (may increase patient discomfort) Hydration with large volume of fluid for adults and

older children (may be necessary for younger children and infants)

Antibiotics (do not treat attacks, only use when pneumonia present)

Epinephrine/adrenaline (may be indicated for acute treatment of anaphylaxis and angioedema but not indicated for asthma attacks)

ASTHMAMANAGEMENT

DIAGNOSIS OF ASTHMA

History and patterns of symptoms

Physical examination

Measurements of lung function

Goals to Be Achieved in Asthma Control

Achieve and maintain control of symptoms Prevent asthma episodes or attacks Minimal use of reliever medication No emergency visits to doctors or hospitals Maintain normal activity levels, including exercise Maintain pulmonary function as close to normal

as possible Minimal (or no) adverse effects from medicine

Tool Kit for Achieving Management Goals

Relievers Preventers Peak Flow meter Patient education

What Are Relievers?

- Rescue medications- Quick relief of symptoms- Used during acute attacks- Action lasts 4-6 hrs

RELIEVERS

Short acting 2 agonistsSalbutamolLevosalbutamol

Anti-cholinergicsIpratropium bromide

XanthinesTheophylline

Adrenaline injections

What are Preventers?

- Prevent future attacks- Long term control of asthma- Prevent airway remodelling

PREVENTERS

Corticosteroids Anti-leukotrienesPrednisolone, Betamethasone Montelukast, ZafirlukastBeclomethasone, Budesonide Fluticasone Xanthines

Theophylline SR

Long acting 2 agonists Mast cell stabilisersBambuterol, Salmeterol Sodium cromoglycate

Formoterol

COMBINATIONS

Salmeterol/FluticasoneFormoterol/Budesonide

Salbutamol/Beclomethasone

Reliever

Reliever (also known as rescue medication)

Bronchodilator (beta2 agonist)

Quickly relieves symptoms (within 2-3 minutes)

Not for regular use

Rescue Medication

SALBUTAMOL INHALER

100 mcg:

1 or 2 puffs as necessary

LEVOSALBUTAMOL INHALER

50 mcg :

1 or 2 puffs as necessary

Anti-inflammatory

Takes time to act (1-3 hours)

Long-term effect (12-24 hours)Only for regular use

(whether well or not well)

Preventer

ICS + LABA

Which LABA ? Formoterol: Immediate relief (as fast as

salbutamol)

12 hours effect

Can be combined with budesonide

Ideal combination

Formoterol ( fast relief and sustained relief ) +

Budesonide ( twice or even once daily use )

Dose: 1- 4 puffs ( OD/BD )

Another combination

Salmeterol + Fluticasone

Formoterol + Budesonide combinationthe ‘flexible’ preventerA

sth

ma s

ign

s

Time

2x2 2x2 1x11x21x2

Quicklygains control

Maintainscontrol

Asthmaworsening

Maintainscontrol

Reduce tolowest adequatedose that maintainscontrol

All Asthma Drugs Should Ideally Be Taken Through The Inhaled Route.

Why inhalation therapy?

Oral

Slow onset of action

Large dosage used

Greater side effects

Not useful in acute

symptoms

Inhaled routeRapid onset of action

Less amount of drug used

Better tolerated

Treatment of choicein acute symptoms

Aerosol delivery systems currently available

Metered dose inhalers

Dry powder inhalers (Rotahaler)

Spacers / Holding chambers

SpacerDry PowderInhaler Metered Dose

inhaler

Inhalation devices you can use

Advantages of Spacer

No co-ordination required

No cold - freon effect

Reduced oropharyngeal deposition

Increased drug deposition in the lungs

Key Messages

Asthma can be effectively controlled, although it cannot be cured.

Effective asthma management programs include education, objective measures of lung function, environmental control, and pharmacologic therapy.

A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication.

Update on Management of Chronic Update on Management of Chronic Disease -- AsthmaDisease -- Asthma

Thenny M.C.P. Wongkar, SpPDPulmonology Division Department of Internal Medicine

Faculty of Medicine Sam Ratulangi University – Prof. R.D. Kandou General Hospital , M A N A D O

Case 1Case 1

M/16, F.4 student History of asthma on Becotide 2 puff BD

and prn Ventolin How would you assess the control of

asthma?

He had more frequent cough and chest tightness recently during the cold weather and require to use Ventolin ~3 days per week

PE: occasional wheeze over bilateral chest, AE fair

How would you manage him?

Case 2Case 2

3/M Asthma on Becotide 400 mcg/d ( 2 puff

QID) Persistently poor control with 2 attacks in 3

months Further management?

Case 3Case 3

M/5 Currently on Becotide (beclomethasone

dipronpionate) at 200mcg/d Wheezing every morning when he wakes

up Use Ventolin every morning Further management?

Case 4Case 4

F/12 On Seretide 100 1 puff BD and prn Ventolin She has not been using Ventolin from last

FU 3 months ago Further management?

Take home message…Take home message…

Good asthma control: Risk factor control Compliance Inhaler technique Step up/down treatment as appropriate Suitable treatment for acute exacerbation

ReferenceReference

GINA 2008 BTS guideline May 2008