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Transcript of Prof. Mohamad Fawzy Ismail Consultant Pulmonist Dallah Hospitals Professor of Chest Diseases Faculty...
Prof. Mohamad Fawzy IsmailConsultant Pulmonist
Dallah Hospitals Professor of Chest Diseases
Faculty of MedicineZagazig University
Bronchial Asthma Management
Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and Prevention
Program Implementation of Asthma Guidelines
in Health Systems
Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and Prevention
Program Implementation of Asthma Guidelines
in Health Systems
Bronchial asthma
Definition of AsthmaDefinition of Asthma
A chronic inflammatory disorder of the airways
Many cells and cellular elements play a role
Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing
Widespread, variable, and often reversible airflow limitation
A chronic inflammatory disorder of the airways
Many cells and cellular elements play a role
Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing
Widespread, variable, and often reversible airflow limitation
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
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
Factors that Exacerbate AsthmaFactors that Exacerbate Asthma
Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs
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
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
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
Typical Spirometric (FEV1) TracingsTypical Spirometric (FEV1) Tracings
1Time (sec)Time (sec)
2 3 4 5
FEV1FEV1
VolumeVolume
Normal Subject
Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)
Note: Each FEV1 curve represents the highest of three repeat measurements
Levels of Asthma Control
Characteristic Controlled(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
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
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
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.
.
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
Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams
Clear communication between health care professionals and asthma patients is key to enhancing compliance
Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams
Clear communication between health care professionals and asthma patients is key to enhancing compliance
Component 1: Develop Patient/Doctor Partnership Component 1: Develop Patient/Doctor Partnership
Component 1: Develop Patient/Doctor Partnership Component 1: Develop Patient/Doctor Partnership
Educate continually
Include the family
Provide information about asthma
Provide training on self-management skills
Emphasize a partnership among health care providers, the patient, and the patient’s family
Educate continually
Include the family
Provide information about asthma
Provide training on self-management skills
Emphasize a partnership among health care providers, the patient, and the patient’s family
Component 1: Develop Patient/Doctor PartnershipComponent 1: Develop Patient/Doctor Partnership
Key factors to facilitate communication:
Friendly demeanor
Interactive dialogue
Encouragement and praise
Provide appropriate information
Feedback and review
Key factors to facilitate communication:
Friendly demeanor
Interactive dialogue
Encouragement and praise
Provide appropriate information
Feedback and review
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.
Factors Involved in Non-AdherenceFactors Involved in Non-Adherence
Medication Usage Difficulties associated
with inhalers Complicated regimens Fears about, or actual
side effects Cost Distance to pharmacies
Medication Usage Difficulties associated
with inhalers Complicated regimens Fears about, or actual
side effects Cost Distance to pharmacies
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
Component 2: Identify and Reduce Exposure to Risk FactorsComponent 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.
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
Component 2: Identify and Reduce Exposure to Risk FactorsComponent 2: Identify and Reduce Exposure to Risk Factors
Influenza VaccinationInfluenza Vaccination
Influenza vaccination should be provided to patients with asthma when vaccination of the general population is advised
However, routine influenza vaccination of children and adults with asthma does not appear to protect them from asthma exacerbations or improve asthma control
Component 3: Assess, Treat and Monitor AsthmaComponent 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
Component 3: Assess, Treat and Monitor AsthmaComponent 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
A stepwise approach to pharmacological therapy is recommended
The aim is to accomplish the goals of therapy with the least possible medication
Although in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommended
A stepwise approach to pharmacological therapy is recommended
The aim is to accomplish the goals of therapy with the least possible medication
Although in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommended
Component 3: Assess, Treat and Monitor AsthmaComponent 3: Assess, Treat and Monitor Asthma
The choice of treatment should be guided by: Level of asthma control Current treatment Pharmacological properties and availability
of the various forms of asthma treatment Economic considerations
Cultural preferences and differing health caresystems need to be considered
The choice of treatment should be guided by: Level of asthma control Current treatment Pharmacological properties and availability
of the various forms of asthma treatment Economic considerations
Cultural preferences and differing health caresystems need to be considered
Component 3: Assess, Treat and Monitor AsthmaComponent 3: Assess, Treat and Monitor Asthma
Controller MedicationsController Medications
Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists Systemic glucocorticosteroids Theophylline Cromones Long-acting oral β2-agonists Anti-IgE Systemic glucocorticosteroids
Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists Systemic glucocorticosteroids Theophylline Cromones Long-acting oral β2-agonists Anti-IgE Systemic glucocorticosteroids
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
Reliever MedicationsReliever 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
Allergen-specific Immunotherapy Allergen-specific Immunotherapy
Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis
The role of specific immunotherapy in asthma is limited
Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma
Perform only by trained physician
Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis
The role of specific immunotherapy in asthma is limited
Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma
Perform only by trained physician
controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROL
maintain and find lowest controlling step
consider stepping up to gain control
step up until controlled
treat as exacerbation
TREATMENT OF ACTION
TREATMENT STEPSREDUCE INCREASE
STEP
1STEP
2STEP
3STEP
4STEP
5
RE
DU
CE
INC
RE
AS
E
Step 1 – As-needed reliever medication
Patients with occasional daytime symptoms of short duration
A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A)
When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)
Treating to Achieve Asthma Control
Step 2 – Reliever medication plus a single controller
A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A)
Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids
Treating to Achieve Asthma Control
Step 3 – Reliever medication plus one or two controllers
For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2-agonist either in a combination inhaler device or as separate components (Evidence A)
Inhaled long-acting β2-agonist must not be used as monotherapy
For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)
Treating to Achieve Asthma Control
Additional Step 3 Options for Adolescents and Adults
Increase to medium-dose inhaled glucocorticosteroid (Evidence A)
Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)
Low-dose sustained-release theophylline (Evidence B)
Treating to Achieve Asthma Control
Step 4 – Reliever medication plus two or more controllers
Selection of treatment at Step 4 depends on prior selections at Steps 2 and 3
Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthma
Treating to Achieve Asthma Control
Step 4 – Reliever medication plus two or more controllers
Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence A)
Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)
Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence B)
Treating to Achieve Asthma Control
Treating to Achieve Asthma Control
Step 5 – Reliever medication plus additional controller options
Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A)
Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)
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
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)
Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
When controlled on combination inhaled glucocorticosteroids and long-acting inhaled β2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β2-agonist (Evidence B)
If control is maintained, reduce to low-dose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D)
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
Rapid-onset, short-acting or long-acting inhaled β2-agonist bronchodilators provide temporary relief.
Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
Use of a combination rapid and long-acting inhaled β2-agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations (Evidence A)
Doubling the dose of inhaled glucocortico-steroids is not effective, and is not recommended (Evidence A)
Childhood and adult asthma share the same underlying mechanisms. However, because of processes of growth and development, effects of asthma treatments in children differ from those in adults.
Childhood and adult asthma share the same underlying mechanisms. However, because of processes of growth and development, effects of asthma treatments in children differ from those in adults.
Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger
Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger
Many asthma medications (e.g. glucocorticosteroids, β2- agonists, theophylline) are metabolized faster in children than in adults, and younger children tend to metabolize medications faster than older children
Many asthma medications (e.g. glucocorticosteroids, β2- agonists, theophylline) are metabolized faster in children than in adults, and younger children tend to metabolize medications faster than older children
Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger
Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger
Long-term treatment with inhaled glucocorticosteroids has not been shown to be associated with any increase in osteoporosis or bone fracture
Studies including a total of over 3,500 children treated for periods of 1 – 13 years have found no sustained adverse effect of inhaled glucocorticosteroids on growth
Long-term treatment with inhaled glucocorticosteroids has not been shown to be associated with any increase in osteoporosis or bone fracture
Studies including a total of over 3,500 children treated for periods of 1 – 13 years have found no sustained adverse effect of inhaled glucocorticosteroids on growth
Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger
Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger
Rapid-acting inhaled β2-agonists are the most effective reliever therapy for children
These medications are the most effective bronchodilators available and are the treatment of choice for acute asthma symptoms
Rapid-acting inhaled β2-agonists are the most effective reliever therapy for children
These medications are the most effective bronchodilators available and are the treatment of choice for acute asthma symptoms
Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger
Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger
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
Component 4: Manage Asthma ExacerbationsComponent 4: Manage Asthma Exacerbations
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
Component 4: Manage Asthma ExacerbationsComponent 4: Manage Asthma Exacerbations
Special ConsiderationsSpecial Considerations
Special considerations are required tomanage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma
Special considerations are required tomanage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma