cme asthma

55
G IN A lobal itiative for sthma

Transcript of cme asthma

Page 1: cme asthma

G INA

G INA

lobal

itiative for

sthma

lobal

itiative for

sthma

Page 2: cme asthma

GINA Program Objectives

GINA Program Objectives

Increase appreciation of asthma as a global public health problem

Present key recommendations for diagnosis and management of asthma

Provide strategies to adapt recommendations to varying health needs, services, and resources

Identify areas for future investigation of particular significance to the global community

Increase appreciation of asthma as a global public health problem

Present key recommendations for diagnosis and management of asthma

Provide strategies to adapt recommendations to varying health needs, services, and resources

Identify areas for future investigation of particular significance to the global community

Page 3: cme asthma

Global Strategy for Asthma Management and Prevention Global Strategy for Asthma Management and Prevention

Definition and Overview Diagnosis and

Classification Asthma Medications Asthma Management and

Prevention Program

Definition and Overview Diagnosis and

Classification Asthma Medications Asthma Management and

Prevention Program

Updated 2007Updated 2007

Page 4: cme asthma

Apa itu Asthma ?

Adalah penyakit paru paru melibatkan radangan ( inflamasi) yang kronik pada saluran.

Apa yang berlaku pada saluran tersebut

• Radang pada saluran pernafasan

• Saluran pernafasan terlalu sensitif

• Penyempitan saluran pernafasan (Bronchoconstriction)

Page 5: cme asthma

Source: Peter J. Barnes, MDSource: Peter J. Barnes, MD

Asthma Inflammation: Cells and Mediators

Page 6: cme asthma

PERUBAHAN PERUBAHAN YANG BERLAKU PADA SALURAN

PERNAFASAN

RADANG SALURAN

Penyempitan saluran

pernafasan

Faktor Sekitaran dan Biologi ( Penyebab )

Tanda / gejalaFaktor pencetus serangan

Saluran pernafasan terlalu sensitif

Page 7: cme asthma

hidungtekak

farink

Trakea

bronkiol

Bronkus

alveolus

diafragm

Page 8: cme asthma

The picture below shows what your lungs look like when everything is working normally. The muscles that are wrapped around the airways are very thin and loose, and the airway is wide open. This makes it easy to move air in and out of the air sacs.

During an asthma attack, the muscles around the airways tighten, or "spasm" (like when you make a fist) and the lining inside the airways swell or thicken, and get clogged with lots of thick mucous. This makes the airways much skinnier than usual so it is harder to move air in and out of the air sacs. This makes it hard to breathe! The picture below shows what

your lungs would look like during an asthma attack.

SALURAN PERNAFASAN

NORMAL

SALURAN PERNAFASAN

ASTHMA

OTOT

KERATAN RENTAS

KERATAN RENTAS

SEMPIT SEMPIT & BENGKAK

SEMPIT,BENGKAK & LENDIR

Page 9: cme asthma

This animation shows normal breathing. As you breathe in, red air that contains lots of oxygen is pulled into the lungs. The oxygen slowly moves out of the lungs and into the blood, and then blue air that contains carbon dioxide is pushed out of the lungs. When

things are working normally, the amount of air we breathe in is about the same as the amount of air we breathe out.

Page 10: cme asthma

This animation shows breathing during an asthma attack. Notice that the airways are narrowed so less air can move in and out of the lungs. When things are working normally, the amount of air we breathe in is about the same as the amount of air we breathe out however during an asthma attack air gets trapped inside

the lungs making it harder and harder to breathe.

During an asthma attack, it is actually harder to breathe out than it is to breathe in. This means that during an asthma attack, it takes much longer to breathe out (expire) than it does to breathe in (inspire

Page 11: cme asthma

Burden of Asthma

Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals

Prevalence increasing in many countries, especially in children

A major cause of school/work absence

Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals

Prevalence increasing in many countries, especially in children

A major cause of school/work absence

Page 12: cme asthma

Risk Factors for Asthma

Host factors: predispose individuals to, or protect them from, developing asthma

Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist

Host factors: predispose individuals to, or protect them from, developing asthma

Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist

Page 13: cme asthma

Factors that Exacerbate AsthmaFactors that Exacerbate Asthma

Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs

Page 14: cme asthma

Factors that Influence Asthma Development and Expression

Host Factors Genetic - Atopy - Airway

hyperresponsiveness Gender Obesity

Host Factors Genetic - Atopy - Airway

hyperresponsiveness Gender Obesity

Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet

Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet

Page 15: cme asthma

Is it Asthma?Is it Asthma?

Recurrent episodes of wheezing Troublesome cough at night Cough or wheeze after exercise Cough, wheeze or chest tightness after

exposure to airborne allergens or pollutants

Colds “go to the chest” or take more than 10 days to clear

Page 16: cme asthma

Asthma Diagnosis

History and patterns of symptoms

Measurements of lung function

- Spirometry - Peak expiratory flow

Measurement of airway responsiveness

Measurements of allergic status to identify risk factors

Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly

History and patterns of symptoms

Measurements of lung function

- Spirometry - Peak expiratory flow

Measurement of airway responsiveness

Measurements of allergic status to identify risk factors

Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly

Page 17: cme asthma

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

Page 18: cme asthma

Levels of Asthma Control

CharacteristicControlled

(All of the following)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

Page 19: cme asthma

1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations

5. Special Considerations

1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations

5. Special Considerations

Asthma Management and PreventionProgram: Five ComponentsAsthma Management and PreventionProgram: Five Components

Revised 2006

Page 20: cme asthma

Asthma Management and Prevention Program: Five Interrelated Components

1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations

5. Special Considerations

1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations

5. Special Considerations

Page 21: cme asthma

Asthma Management and Prevention Program

Goals of Long-term Management

Achieve and maintain control of symptoms

Maintain normal activity levels, including exercise

Maintain pulmonary function as close to normal levels as possible

Prevent asthma exacerbations Avoid adverse effects from asthma

medications Prevent asthma mortality

Achieve and maintain control of symptoms

Maintain normal activity levels, including exercise

Maintain pulmonary function as close to normal levels as possible

Prevent asthma exacerbations Avoid adverse effects from asthma

medications Prevent asthma mortality

Page 22: cme asthma

Asthma Management and Prevention Program

Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms

Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.

Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms

Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.

.

Page 23: cme asthma

Asthma Management and Prevention Program

Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control

Page 24: cme asthma

Example Of Contents Of An Action Plan To Maintain Asthma Control

Your Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________

WHEN TO INCREASE TREATMENTAssess your level of Asthma ControlIn the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No YesIf you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment.

HOW TO INCREASE TREATMENTSTEP-UP your treatment as follows and assess improvement every day:____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number]

WHEN TO CALL THE DOCTOR/CLINIC.Call your doctor/clinic: _______________ [provide phone numbers]If you don’t respond in _________ days [specify number]______________________________ [optional lines for additional instruction]

EMERGENCY/SEVERE LOSS OF CONTROLIf you have severe shortness of breath, and can only speak in short sentences,If you are having a severe attack of asthma and are frightened,If you need your reliever medication more than every 4 hours and are not improving.1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid]3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________4. Continue to use your _________[reliever medication] until you are able to get medical help.

Page 25: cme asthma

Asthma Management and Prevention Program

Factors Involved in Non-AdherenceAsthma Management and Prevention Program

Factors Involved in Non-Adherence

Medication Usage Difficulties associated

with inhalers

Complicated regimens

Fears about, or actual side effects

Medication Usage Difficulties associated

with inhalers

Complicated regimens

Fears about, or actual side effects

Non-Medication Factors

Misunderstanding/lack of information

Fears about side-effects

Inappropriate expectations

Underestimation of severity

Attitudes toward ill health

Cultural factors

Poor communication

Non-Medication Factors

Misunderstanding/lack of information

Fears about side-effects

Inappropriate expectations

Underestimation of severity

Attitudes toward ill health

Cultural factors

Poor communication

Page 26: cme asthma

Asthma Management and Prevention Program

Component 2: Identify and Reduce Exposure to Risk Factors

Asthma Management and Prevention Program

Component 2: Identify and Reduce Exposure to Risk Factors

Measures to prevent the development of asthma, and asthma exacerbations by avoiding or reducing exposure to risk factors should be implemented wherever possible.

Asthma exacerbations may be caused by a variety of risk factors – allergens, viral infections, pollutants and drugs.

Reducing exposure to some categories of risk factors improves the control of asthma and reduces medications needs.

Page 27: cme asthma

Reduce exposure to indoor allergens Avoid tobacco smoke Avoid vehicle emission Identify irritants in the workplace Explore role of infections on asthma

development, especially in children and young infants

Asthma Management and Prevention Program

Component 2: Identify and Reduce Exposure to Risk Factors

Asthma Management and Prevention Program

Component 2: Identify and Reduce Exposure to Risk Factors

Page 28: cme asthma

Asthma Management and Prevention Program

Component 3: Assess, Treat and Monitor Asthma

Asthma Management and Prevention Program

Component 3: Assess, Treat and Monitor Asthma

The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional

The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional

Page 29: cme asthma

Asthma Management and Prevention Program

Component 3: Assess, Treat and Monitor Asthma

Asthma Management and Prevention Program

Component 3: Assess, Treat and Monitor Asthma

Depending on level of asthma control, the patient is assigned to one of five treatment steps

Treatment is adjusted in a continuous cycle driven by changes in asthma control status. The cycle involves:

- Assessing Asthma Control

- Treating to Achieve Control

- Monitoring to Maintain Control

Page 30: cme asthma

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

Page 31: cme asthma

Component 4: Asthma Management and Prevention Program

Controller MedicationsComponent 4: Asthma Management and Prevention Program

Controller Medications

Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists Systemic glucocorticosteroids Theophylline Long-acting oral β2-agonists Anti-IgE Systemic glucocorticosteroids

Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists Systemic glucocorticosteroids Theophylline Long-acting oral β2-agonists Anti-IgE Systemic glucocorticosteroids

Page 32: cme asthma

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by AgeEstimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)

> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)

> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide 200-600 100-200

600-1000 >200-400 >1000 >400

Budesonide-Neb Inhalation Suspension

250-500

>500-1000

>1000

Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320

Flunisolide 500-1000 500-750

>1000-2000 >750-1250 >2000 >1250

Fluticasone 100-250 100-200

>250-500 >200-500 >500 >500

Mometasone furoate 200-400 100-200

> 400-800 >200-400 >800-1200 >400

Triamcinolone acetonide 400-1000 400-800

>1000-2000 >800-1200 >2000 >1200

Page 33: cme asthma

Component 4: Asthma Management and Prevention Program

Reliever MedicationsComponent 4: Asthma Management and Prevention Program

Reliever Medications

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids

Anticholinergics

Theophylline

Short-acting oral β2-agonists

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids

Anticholinergics

Theophylline

Short-acting oral β2-agonists

Page 34: cme asthma

controlled

partly controlled

uncontrolled

exacerbation

LEVEL OF CONTROLLEVEL OF CONTROL

maintain and find lowest controlling step

consider stepping up to gain control

step up until controlled

treat as exacerbation

TREATMENT OF ACTIONTREATMENT OF ACTION

TREATMENT STEPSREDUCE INCREASE

STEP

1STEP

2STEP

3STEP

4STEP

5

RE

DU

CE

INC

RE

AS

E

Page 35: cme asthma
Page 36: cme asthma
Page 37: cme asthma
Page 38: cme asthma
Page 39: cme asthma
Page 40: cme asthma
Page 41: cme asthma

Treating to Maintain Asthma Control

When control as been achieved, ongoing monitoring is essential to:

- maintain control

- establish lowest step/dose treatment

Asthma control should be monitored by the health care professional and by the patient

Page 42: cme asthma

Treating to Maintain Asthma Control

Stepping down treatment when asthma is controlled

When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (Evidence B)

When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (Evidence A)

Page 43: cme asthma

Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness

Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)

Severe exacerbations are potentially life-threatening and treatment requires close supervision

Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness

Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)

Severe exacerbations are potentially life-threatening and treatment requires close supervision

Asthma Management and Prevention Program

Component 4: Manage Asthma Exacerbations

Asthma Management and Prevention Program

Component 4: Manage Asthma Exacerbations

Page 44: cme asthma

Primary therapies for exacerbations:

• Repetitive administration of rapid-acting inhaled β2-agonist

• Early introduction of systemic glucocorticosteroids

• Oxygen supplementation

Closely monitor response to treatment with serialmeasures of lung function

Primary therapies for exacerbations:

• Repetitive administration of rapid-acting inhaled β2-agonist

• Early introduction of systemic glucocorticosteroids

• Oxygen supplementation

Closely monitor response to treatment with serialmeasures of lung function

Asthma Management and Prevention Program

Component 4: Manage Asthma Exacerbations

Asthma Management and Prevention Program

Component 4: Manage Asthma Exacerbations

Page 45: cme asthma

Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms

Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control

Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms

Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control

Asthma Management and Prevention Program: SummaryAsthma Management and Prevention Program: Summary

Page 46: cme asthma

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

The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered

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

The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered

Asthma Management and Prevention Program: SummaryAsthma Management and Prevention Program: Summary

Page 47: cme asthma

A. PERSEDIAAN PERALATAN• Kad pesakit asthma• Buku pendaftaran pesakit luar• Peralatan ukur timbang/ tinggi• Blood Pressure set• Peak flow meter (adult/ paediatric)• Pulse oxymeter• Nebuliser and face mask• Inhaler placebo - ( untuk tujuan pendidikan kesihatan)• Ubatan reliever- Salbutamol MDI/ Bricanyl MDI • Ubatan controller – Budesonide/ Beclomethasone MDI, Budesonide Turbohaler• Ubatan bronchodilator – untuk acute case ( Salbutamol, Bricanyl, Combivent, Atrovent)• Oxygen supply• Oral steroids prednisolone, Intravenous Steroids ( hydrocortisone)• Flow chart untuk management of acute asthma• Flow chart untuk asthma assessment• Carta pengkelasan asthma control• Bahan pendidikan kesihatan asthma• Written asthma plan•

Page 48: cme asthma

Alternate Slides for Alternate Slides for Asthma TreatmentAsthma Treatment

Page 49: cme asthma

Characteristic Controlled(All of the following)

Partly Controlled(Any measure present in any week)

Uncontrolled

Daytime symptoms None (twice or less/week)

More than twice/week

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

Limitations of activities

None Any

Nocturnal symptoms/awakening

None Any

Need for reliever/ rescue treatment

None (twice or less/week)

More than twice/week

Lung function (PEF or FEV1)

Normal < 80% predicted or personal best (if known)

Exacerbations None One or more/year* One in any week†

Levels of Asthma Control

* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate.† By definition, an exacerbation in any week makes that an uncontrolled asthma week.

Page 50: cme asthma
Page 51: cme asthma
Page 52: cme asthma
Page 53: cme asthma
Page 54: cme asthma

Asthma Control: Treatment StepsChildren Older than Five Years, Adolescents, Adults

Page 55: cme asthma

Example Of Contents Of An Action Plan To Maintain Asthma Control

Your Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________

WHEN TO INCREASE TREATMENTAssess your level of Asthma ControlIn the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No YesIf you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment.

HOW TO INCREASE TREATMENTSTEP-UP your treatment as follows and assess improvement every day:____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number]

WHEN TO CALL THE DOCTOR/CLINIC.Call your doctor/clinic: _______________ [provide phone numbers]If you don’t respond in _________ days [specify number]______________________________ [optional lines for additional instruction]

EMERGENCY/SEVERE LOSS OF CONTROLIf you have severe shortness of breath, and can only speak in short sentences,If you are having a severe attack of asthma and are frightened,If you need your reliever medication more than every 4 hours and are not improving.1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid]3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________4. Continue to use your _________[reliever medication] until you are able to get medical help.