Asthma PED Thai CPG 2555

5/22/2018 Asthma PED Thai CPG 2555

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.. 2555


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100

(bronchial hyper-responsiveness)

(variable airow obstruction) (wheeze)


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1. Airway inammation 2. Structural changes in the airways (airway remodeling) 3. Bronchial hyper-responsiveness

4. Variable and partially reversible airway obstruction

/

1. ( ++)

1.1

1.2


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1.3 atopic dermatitis, allergicrhinitis

1.4

Cough-variant asthma peak expiratory ow bronchial hyper-

responsiveness

1.

2. 3. 4. 5. (> 10 ) 6.

2.

2.1 (wheeze)


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2.2 2.3

2.4 allergicrhinitis, allergic conjunctivitis atopic dermatitis

3.

3.1 ( +) 1) Spirometry 5 FEV1 FVC

- FEV1 12 % 200 . (pre and postbronchodilator) - FEV1/FVC ratio < 0.75

2) Peak expiratory ow (PEF) meter- PEF 20 % (pre and post bronchodilator)

- PEF variability > 20%

PEF variability = PEF max PEF min x 100%

1/2(PEF max + PEF min)


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3.2 1) allergy skin test, serum spe-cic IgE 2) bronchial hyperresponsiveness methacholine, histamine, mannitol, exercise challenge

test3) airway inammation non-invasive

sputum eosinophil, exhaled nitric oxide, exhaledcarbon monoxide


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3

Viral-induced Wheezing

-5 ----

Suggestive of Asthma

------Options: ( )

Pre-post bronchodilator PEFR FEV112%

- Skin test positive to aeroallergens

1

Therapeutic trial2-3 - ICS (Budesonide) 200 mcg - LTRA

gastroesophagealreflux, anatomical

anomaly,

immunodeficiency,

cows milk protein

allergy, etc.

-ICSLTRA- - ICS LTRA

1


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recurrent wheezing

1. Chronic rhinosinusitis 2. Gastroesophageal reux 3. Recurrent lower respiratory tract infections

4. Cows milk protein allergy 5. Congenital heart diseases 6. Bronchopulmonary dysplasia 7. Tuberculosis 8. Congenital malformation causing narrowing of the

intrathoracic airways 9. Foreign body aspiration 10. Immune deciency 11. Primary ciliary dyskinesia syndrome

12. Cystic brosis


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1. 2. 3. 4.

5. 6.

5 1.

2. 3. 4.

5.


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1.

( > 5 )

2.

(1)


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/

- 55-60 30

-

- () - -

- - -

- - ()

1 /


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/

- ( - ) -

- (pesticides)

(exterminator)

-

- - HEPA -

-

-


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/

-

-

-

-

- -

-

-

-

- short-acting beta 2 agonist long-acting beta 2 agonist 15-30


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/

-

(warm-up) 6-10

- food preservative

aspirin NSAIDs -

- beta-blockers

3.

(Assessing asthma control)

2 3

controlled, partly controlled uncontrolled


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2 (Levels of Asthma Control)

( 7)

2.1

( 4 )

Controlled Partly Controlled Uncontrolled() ( 1 )

( 2

partly controlled 3

(< 2 ) > 2 (reliever/rescue

treatment)

< 80% predicted (PEF or personal best ()FEV1) 1 1


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2.2 (

)

- - 1 *

- - FEV1- -

*

3.1 1) (Treating toachieve asthma control) 2) (Monitoring to maintain control)

3)


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1) (Treating toachieve asthma control) 2 3 1 5

(Reliever medications) (Rapid-acting 2-agonist,RABA) (con-

troller medications) RABA

uncontrolled partly controlled (step up) controlled controlled 3 (step down) () controlled

controlled 1


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persistentasthma 2 (2) 3

1 (Step 1: As-needed reliever medication)

inhaled RABA ( ++) con-

trolled 2 RABA 2 step up (2) inhaled RABA ( +) RABA short-actingtheophylline exercise-induced bronchospasm inhaled RABA bronchospasm leukotriene modier

(LTRA) cromone (sodium cromoglycate)


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2 (Step 2: Reliever medication )

inhaled corticoster-oid (ICS) 200-400 (low-mediumdose inhaled corticosteroid) ( ++) (3) leukotriene modier ( +)

ICS ICS sustained-release theophylline ( +)

cromone (sodi-um cromoglycate)

3 (Step 3: Reliever medication

) low-dose ICS (Long-acting 2-agonist, LABA) ( ++)

low-dose ICS 3-4 ICS uncontrolled

partly controlled


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formoterol LABA formoterol reliever controller ( +) < 5 3 ICS ( ++) MDI spacer

low-dose ICS LTRA ( +) low-dose ICS sustained-release theophylline ( +) 2

(< 5 )

4 (Step 4: Reliever medication )

4 ( +)

(dicult-to-treat asthma)


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medi-um-dose ICS LABA ( ++)

3 LTRA sustained-release theo-phylline high-doseICS LABA 3-6 corticosteroid ICS LTRA ICS

sustained-release theophylline ICS LABA

5 (Step 5: Reliever medication

step 4) 4

(uncontrolled) oral corti-costeroid step 4 corticosteroid anti-IgE al-lergic asthma 4 ( +)


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1 2 3 4 5

2-agonist

ICS* ICS* +

LABA

ICS* + LABA

Steroid

()LTRA ICS* + LTRA IgE

ICS* + LTRA + theophylline

ICS* +theophylline

* ICS = steroid

LABA = long-acting 2-agonist, 2-agonist

LTRA = leukotriene modier Theophylline = sustained-release theophylline

2 > 5

( 7)


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3

( 7)

*

ICS = inhaled corticosteroid

LTRA = leukotriene modifier

Theophylline = sustained-release theophylline

* = controlled** = partly controlled uncontrolled controlled 1

ICS

2 (3)ICS + LABA

ICS + LTRAICS + Theophylline (3 )

ICS50% 3

-LABA LTRA

Theophylline

-

ICS 50%3

ICS +LTRA +

Theophylline (4)

ICS 200-400 mcg/

LTRA (2)

3

ICS 50%3

1-3 3

***

*

*

**

***

**

(5)


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1.

2. 3. 4. allergic rhinitis, sinusitis, obesity,obstructive sleep apnea, gastroesophageal reux,

/ 5. 1-3 ()

6.

- ()

- () -

- - -

: (spirom-etry) 6-12


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3 inhaled corticosteroids

(equivalent dose)

Drug Low Daily Dose

(mcg)

Medium Daily

Dose (mcg)

High Daily Dose

(mcg)

Beclomethasone dipropionate

- MDI (50, 100, 200, 250 mcg)

- DPI (Easyhaler; 200 mcg)

100 200 > 200 400 > 400

Budesonide*

- MDI (100, 200 mcg)

- DPI (Easyhaler, Turbuhaler; 100, 200 mcg)

- Nebulized solution (500, 1000 mcg)

100 200 > 200 400 > 400

Ciclesonide* #

- MDI (80, 160 mcg)

80 160 > 160 320 > 320

Fluticasone propionate

- MDI (50, 125, 250 mcg)

- DPI (Accuhaler; 100, 250 mcg)

- Nebulized solution (500, 2000 mcg)

100 200 > 200 500 > 500

Mometasone furoate* #

- DPI (220 mcg)

100 > 200 > 400

* #


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2) (Monitoring to maintain control)

1-3 3 controlled

4-6

step down

controlled

1. controlled ICS 3 50%

low-dose ICS 2. controlled ICS LABA ICS LTRA LABA LTRA ICS ICS 3 low-dose ICS


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3. controlled 1

step up

(Loss of control)

- - - -

- (Gastroesophageal reux) obstructive sleepapnea

1. RABA RABA 1-2

2. ICS formoterol

controlled


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3. low-medium dose ICS step up ICS LABA ICS ICS LTRA 4. (acute exacer-

bation) step up

3) 2

1. (Reliever) RABA LABA

2. (Controller)


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( 4) 2.1 Corticosteroids meditors cytokines 2-adrenergic receptors

corticosteroids 2

1) (Systemic form) corticosteroids

2) (Inhalation form)

(Persistent asthma) 2

ICS < 200 / ()

2.2 Leukotriene modier (LTRA) leukotriene leukot-riene receptor

mild persistent asthma low-dose ICS LTRA

(add-on) ICS


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LTRA viral inducedasthma exacerbation 2-5 intermit-tent asthma

2.3 Inhaled 2-agonist (Long-acting 2-agonist) 12

ICS (uncontrolled) medium-dose ICS 4

2.4 Sustained-release theophylline ICS drug interaction 10 ././

2

2.5 Anti-IgE (omalizumab) 6 IgE


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(IgE-mediated) ICS anti-IgE 6-60

(add-on therapy) anaphylacticreaction 2


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4

( 7)


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5

5

( 7)

< 4 MDI plus spacer Nebulizer with face mask with face mask4 - 6 MDI plus spacer Nebulizer with mouthpiece with mouthpiece

> 6 DPI MDI plus spacer Nebulizer with mouthpiece with mouthpiece

:

DPI accuhaler, easyhaler turbuhaler

Spacer corticosteroid spacer valve valve

spacer mouth piece


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Allergen immunotherapy

Allergen immunotherapy

1. 2. 3. 4.

4.

asthma exacerbation

66 asthma exacerbation

Mild Moderate Severe

Respiratory arrest

* 30 /


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Mild Moderate Severe

Respiratory arrest

paradoxical thoraco-

suprasternal abdominal

retraction movement

wheeze

wheeze

and expiratory (/) < 100 100-120 > 120

PEF > 80 % 60-80% > 60 %(% predicted

personal best) PaO2(on air) > 60 mmHg >60 mmHg(dyanosis)/ < 45 mmHg < 45 mmHg > 45 mmHg

PaCO2 SaO2% (on air) > 95% 91-95% < 90%

*

< 2 < 60 / 2 - 12 < 50 / 1 - 5 < 40 /

6 - 8 < 30 / **

2 - 12 < 160 / 1 - 2 < 120 /2 - 8 < 110 /

6 asthma exacerbation ()


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4.1 asthma exacerbation

1) asthma exacerbation (4)


,

Inhaled RABA* 2-4 puffs/dose3 20

4PEF> 80% predicted personalbest-inhaled RABA2-4 puffs 3-4 . 24 - 48 .

PEF < 60%predicted personal best-inhaled RABA6-10 puffs 1-2 .

3 PEF 60-80% predictedpersonal best- inhaled RABA6-10 puffs 1-2.

1-2

* MDI with spacer DPI1


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(1) (2) inhaled RABA

(3) (4)

2) asthma exacerbation (5)

(1) SaO2> 95% nasal canula, mask head box

SaO2

(2) SIADH


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(3) 2-agonist nebulized RABA salbutamol respiratory solution

0.15 ././ ( salbutamol respules 2.5-5./, terbutaline respules 5 -10 ./) NSS 2.5-4 . oxygen ow 6-8 / MDI with spacer 2-4 puffs/ 20-30

10puffs/ 4-6 nebulized RABA an-ticholinergic (ipratropium bromide) 250 / (

20 .) 500 / (20 .) poor air entry systemic 2-agonist terbutaline continuous nebulized sys-

temic IV drip2-agonist monitor EKG, heart rate

hypokalemia


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()


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(4) glucocorticosteroids 3-4

prednisolone 1-2 ././ 60 ./ 5-7 hydrocorti-sone 5 ././ 6 250 ./ methylprednisolone 1 ././

6 60./ hydrocortisone methylprednisolone systemic corticosteroid predni-solone 5-7 taper off steroid

nebulized ICS acute ex-acerbation (+/-) ICS ICS

(+/-) (5) - Epinephrine 1:1000 (adrenaline) 0.01 ./. 0.3 .

- RABA NB MDI - anaphylaxis angioedema


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- Aminophylline 5./. loading dose IV drip 1 ././. loading dose

5-15 ./. (6) -

- (mucolytic) -

- asthma exacerbation

3)

(1) (2) 1-3 (PEF < 70%predicted personal best oxygen saturation < 95%) (3) (high risk)

- near fatal asthma ventilator


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- - prednisolone - 2-agonists ( 1 ) -

4) -

- oxygen saturation / PEF - arterial blood gas - 2-agonist - - exacerbation prednisolone

7


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5)

5.1 5.2

5.3 5.4 (Action Plan)

5.5 1-6 PEF (Action

Plan)

1.

2.


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3.

(Action Plan)

: 1. ................................................................

2. .............................................

:

3

2

2

peak ow ............... L/min

3

1. ()...................... 2

.........(14)..........

2. 2 puffs 4-6

:

-


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-

- 4

1. ......................................2 4 puffs

2. prednisolone........................mg

3. ..........................................

............................................................................ 4.

* (Action Plan)


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1. 2. (dicult-to-treatasthma) 3. asthma with respiratory failure

4. inhaled corticosteroid prednisolone 5. / immunotherapy,

anti-IgE

5.


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perinatal mortality perinatal prognosis

theo-

phylline, ICS budesonide beta2-agonists, montelukast LTRA fetal anomalies ICS asthma exacerbation

acute exacerbation hypoxia nebulized SABA systemic glucocorticosteroids


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() ()

FEV1 80 gluco-

corticosteroids systemic glucocorticoster-oids 6 (hydrocortisone 1-2 ././, 100 . 8

) 24 systemic glucocorticosteroids

(allergic rhinitis)


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2 glucocorticosteroids, cromones, leu-kotriene modier anticholinergic intranasal steroid

leukotriene modi-ers, allergen-specic immunotherapy anti-IgE therapy 2


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rhinosinusitis 10

topical nasal decongestants topical nasal sys-temic steroids

(Nasal polyps)

aspirin hypersensitivity 40 36-96 aspirin intolerance nasal polyp 29-70 nasal polyp

nasal polyps cystic brosis

immotile cilia syndrome Nasal polyps topical steroids nasal polyps topical steroids

(Occupational asthma)


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Respirato-ry syncytial virus wheezing

Rhinovirus

wheezing Parainuenza, Inuenza, Adenovirus Coronavirus Mycoplasma wheezing , IgE antibody , mediators late asthmatic re-sponse

asthma exacerbation


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inhaled SABA glucocorticosteroid inhaled corticosteroid 4

anti-inammatory drug

(Gastroesophageal reux disorder)

3 hiatalhernia theophylline, 2-agonist

pH (lungfunction test) theophylline 2-agonist proton pump

inhibitor, H2-antagonist


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(subgroup)

esophagitis

Aspirin-induced asthma (AIA) 28 asthma exacerbation aspirin NSAIDs severe asthma 30-40 vasomotorrhinitis nasal polyps asthma hypersensitivity aspirin

1 2 aspirin asthmatic attack


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aspirin COX-1 inhibitor dose bronchospasm respi-ratory arrest

markedeosinophilic inammation, epithelial disruption cy-tokines IL-5 adhesion molecules 70 genetic polymorphism LTC4 synthase gene aspirin bronchoconstriction

NSAIDs

aspirin challenge test

FEV1 70 predicted personal best bronchial nasal challenge lysine as-pirin oral challenge AIA aspirin


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COX-1 inhibitor progression inammation hydrocortisone hemisuccinate COX-2 inhibitor 1 asthma AIA ICS leukot-riene modier additional treatment

NSAIDs desensitization desensitization lower respiratory

tract desensitization aspirin 600-1,200 . adult onset nasal polyposis

NSAIDs paracetamol

Anaphylaxis Anaphylaxis acute wheezing

(biological substances)


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exercise-induced anaphylaxis exercise-inducedbronchoconstriction anaphylaxis 2-agonist epinephrine anaphylaxis

3 1. (primary prevention)

1.1 (prenatal prevention)

wheezing illness


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1.2 (postnatal prevention) 1)

46 (AAP 2008) (partially or extensively hy-

drolysated formula) (solid foods) 4-6

2) prenatal 3) RSV bronchiolitis

2. (secondary prevention) allergic sen-

sitization second generation H1-antihistamine

allergen immunotherapy


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3. (tertiary prevention)

(1)

Asthma PED Thai CPG 2555

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