Asthma Education Postgraduate CourseAsthma Education Postgraduate Course

THE DEFINITIONS OF THE DEFINITIONS OF

ASTHMA SEVERITY ASTHMA SEVERITY

AND CONTROL AND CONTROL

Professor Tatiana SlavyanskayaProfessor Tatiana SlavyanskayaRussian University, MRussian University, Moscow, Russiaoscow, Russia

WHAT IS ASTHMA? WHAT IS ASTHMA?

According to GINAAccording to GINA ((Global Initiative for Global Initiative for

AsthmaAsthma)) 2009:2009:

•• Asthma is a chronic inflammatory disorder Asthma is a chronic inflammatory disorder

of the airways, which is associated with airway of the airways, which is associated with airway

hyperresponsiveness that leads to current hyperresponsiveness that leads to current

episodes of wheezing, breathlessness, chest episodes of wheezing, breathlessness, chest

tightness, and coughing, particularly at night tightness, and coughing, particularly at night

or in the early morning. or in the early morning.

This episodes are usually associated with This episodes are usually associated with

widespread, but variable airflow obstruction widespread, but variable airflow obstruction

within the lung that is often reversible either within the lung that is often reversible either

spontaneously or with treatment. spontaneously or with treatment.

UUNFORTUNATELYNFORTUNATELY……

Asthma Asthma is one of the most widespread chronicis one of the most widespread chronic

diseases in the world, which prevalence is diseases in the world, which prevalence is

increasing, especially among children.increasing, especially among children.

FORTUNATELYFORTUNATELY ……

•• Asthma can be treated and controlled.Asthma can be treated and controlled.

•• Almost all patients can:Almost all patients can:

-- DonDon’’t have any symptoms, t have any symptoms, either either night night

oror

day.day.

-- To prevent severe attacks.To prevent severe attacks.

-- TTo use minimal or dono use minimal or don’’t use relievert use reliever

(drugs relieving symptoms).(drugs relieving symptoms).

-- To live active, productive lives.To live active, productive lives.

-- To have normal or near normal lungTo have normal or near normal lung

function.function.

WHAT ARE THE RISK FACTORS OF ASTHMA?WHAT ARE THE RISK FACTORS OF ASTHMA?

Factors that influence the risk of asthma can be divided Factors that influence the risk of asthma can be divided

into those that cause the development of asthma and those into those that cause the development of asthma and those

that trigger asthma symptoms, some do both.that trigger asthma symptoms, some do both.

The former include host factors (which are primarily The former include host factors (which are primarily

genetic) and the later are usually environmental factors.genetic) and the later are usually environmental factors.

All known and suspected risk factors of asthma are divided All known and suspected risk factors of asthma are divided

into two groups (Table 1):into two groups (Table 1):

•• INTERNAL (HOST) FACTORSINTERNAL (HOST) FACTORS

•• EXTERNAL (ENVIROMENTAL) FACTORSEXTERNAL (ENVIROMENTAL) FACTORS

-- Factors that contribute to the development of asthma Factors that contribute to the development of asthma

-- Factors that trigger preFactors that trigger pre--existingexisting diseasedisease

Factors influencing the Development and Expression of AsthmaFactors influencing the Development and Expression of Asthma

HOST FACTORSHOST FACTORS

Genetic, e.g.,Genetic, e.g.,

-- genes pregenes pre--disposing to atopydisposing to atopy

-- genes pregenes pre--disposing to airway hyperresponsivenessdisposing to airway hyperresponsiveness

ObesityObesity

SexSex

ENVIROMENTAL FACTORSENVIROMENTAL FACTORS

AllergensAllergens

IndoorIndoor::

••Domestic mitesDomestic mites

••Furred animals (dog, cat, mice, bird)Furred animals (dog, cat, mice, bird)

••CCockroach allergen ockroach allergen

••Fungi, molds, yeasts Fungi, molds, yeasts

OutdoorOutdoor::

••pollenspollens

••Fungi, molds, yeasts Fungi, molds, yeasts

Occupational sensitizersOccupational sensitizers

Tobacco smokeTobacco smoke::

••Passive smokingPassive smoking

••Active smokingActive smoking

Outdoor/Indoor Air PollutionOutdoor/Indoor Air Pollution

DietDiet

Table 1.Table 1.

Factors that cause worsening of asthma or perpetuate Factors that cause worsening of asthma or perpetuate

symptoms (triggers):symptoms (triggers):

••Indoor and outdoor allergensIndoor and outdoor allergens

••Outdoor/Indoor Air PollutionOutdoor/Indoor Air Pollution

••Respiratory infectionsRespiratory infections

••Exercise and hyperventilationExercise and hyperventilation

••Changes in weather conditionsChanges in weather conditions

••Sulfur dioxideSulfur dioxide

••Food, food additives, drugsFood, food additives, drugs

••Excessive emotional stressExcessive emotional stress

••Smoking (active and passive)Smoking (active and passive)

••Irritants (home sprays, smells of paint)Irritants (home sprays, smells of paint)

Significant role in causing asthma, Significant role in causing asthma, especially especially

among childrenamong children, is played by such external , is played by such external

factors as: respiratory and parasitic infections, factors as: respiratory and parasitic infections,

socioeconomic statussocioeconomic status, , amount amount of family of family

members, drugs and perinatal factors.members, drugs and perinatal factors.

HOW TO AVOID THE RISK FACTORS AND THEIR IMPACT ON THE HOW TO AVOID THE RISK FACTORS AND THEIR IMPACT ON THE

PATIENT WITH ASTHMA?PATIENT WITH ASTHMA?

Table 2.Table 2.

TRIGGERSTRIGGERS HOW TO AVOID?HOW TO AVOID?

Domestic mitesDomestic mites

(they are so small that (they are so small that

they canthey can’’t be seen with t be seen with

the naked eye)the naked eye)

To wash To wash linens and blankets once a week in hot linens and blankets once a week in hot

water, drying them in a hot dryer or the sun. water, drying them in a hot dryer or the sun.

To package To package of pillows and mattresses in special airof pillows and mattresses in special air--

tight (antitight (anti--allergy protection) cases. allergy protection) cases.

To remove To remove carpets, especially from the dormitory. carpets, especially from the dormitory.

To use To use vinyl, leather, or a simple wooden furniture vinyl, leather, or a simple wooden furniture

instead of upholstered. instead of upholstered.

If itIf it’’s possible, to s possible, to use a vacuum cleaner to clean the use a vacuum cleaner to clean the

filter.filter.

Tobacco smoke Tobacco smoke (if the (if the

patient smokes himself, or patient smokes himself, or

he is in a room where he is in a room where

others smoke)others smoke)

To avoid To avoid exposure to tobacco smoke. Patients and exposure to tobacco smoke. Patients and

their parents should not smoke.their parents should not smoke.

HOW TO AVOID THE RISK FACTORS AND THEIR IMPACT ON HOW TO AVOID THE RISK FACTORS AND THEIR IMPACT ON

THE THE

PATIENT WITH ASTHMA?PATIENT WITH ASTHMA?

Table 2.Table 2.Allergens animals Allergens animals

covered with haircovered with hair

To remove To remove animals from the house, at least animals from the house, at least -- from from

dormitorydormitory

CCockroach allergen ockroach allergen Thoroughly and frequently Thoroughly and frequently to clean to clean the apartment. the apartment.

To use To use a pesticide spray. a pesticide spray.

During the processing the patient should not be at homeDuring the processing the patient should not be at home..

Pollen and moulds Pollen and moulds

((outdoor allergensoutdoor allergens))

To close doors and windows and to stay indoorsTo close doors and windows and to stay indoors, , when when

the amount of pollen and fungal spores in the air is the amount of pollen and fungal spores in the air is

maximummaximum

Moulds Moulds

((indoor allergensindoor allergens))

To maintain low humidity in the house, to clear To maintain low humidity in the house, to clear

frequently those areas where the humidity is raisedfrequently those areas where the humidity is raised

Physical activityPhysical activity Not to avoid physical activity. Not to avoid physical activity. Asthma symptoms can be Asthma symptoms can be

prevented, taking up exercise inhaled prevented, taking up exercise inhaled ββ22--agonist fast or agonist fast or

longlong--acting or sodium cromoglycate. acting or sodium cromoglycate.

DrugsDrugs Not to take Not to take aspirin or betaaspirin or beta--blockers, if these drugs cause blockers, if these drugs cause

asthma symptoms in a patient.asthma symptoms in a patient.

KEY POINTS:KEY POINTS:

•• The development of asthma is related to the complex influenceThe development of asthma is related to the complex influence

of internal and external factors.of internal and external factors.

•• Internal (innate) factors contribute to genetic predisposition Internal (innate) factors contribute to genetic predisposition toto

the emergence of human asthma, atopy, bronchial the emergence of human asthma, atopy, bronchial

hyperreactivity and today is unmanaged.hyperreactivity and today is unmanaged.

•• External factors are numerous and controlled, directly triggerExternal factors are numerous and controlled, directly trigger

the manifestation of asthma or cause its aggravation. The the manifestation of asthma or cause its aggravation. The

majormajor

ones include exposure to allergens, viral and bacterialones include exposure to allergens, viral and bacterial

infections, diet, smoking, socioeconomic status and infections, diet, smoking, socioeconomic status and amount amount

of family members.of family members.

•• The most common factor responsible for the outbreak The most common factor responsible for the outbreak

and exacerbation of asthma in children is exposure to and exacerbation of asthma in children is exposure to

allergens and respiratory infections.allergens and respiratory infections.

KEY POINTS:KEY POINTS:

•• Measurements of allergic status can help to identify riskMeasurements of allergic status can help to identify risk

factors that cause asthma symptoms in individual patients.factors that cause asthma symptoms in individual patients.

•• Measures to prevent the development of asthma, asthmaMeasures to prevent the development of asthma, asthma

symptoms, and asthma exacerbations by avoiding or reducingsymptoms, and asthma exacerbations by avoiding or reducing

exposure to risk factors should be implement wherever possibexposure to risk factors should be implement wherever possible.le.

WHAT IS THE CLASSIFICATION OF ASTHMA?WHAT IS THE CLASSIFICATION OF ASTHMA?

In the form:In the form:

••AAtopictopic

••IInfectiousnfectious--allergicallergic

••MixedMixed

According to an inflammatory phenotype (GINAAccording to an inflammatory phenotype (GINA--Global Initiative for Global Initiative for

Asthma Asthma --2009): 2009):

••Eosinophilic phenotypeEosinophilic phenotype

••NonNon-- eosinophilic phenotypeeosinophilic phenotype

It is recognized that different asthma phenotypes may have diffeIt is recognized that different asthma phenotypes may have different rent

levels of responsiveness to conventional treatment. As phenotypelevels of responsiveness to conventional treatment. As phenotype--

specific treatment becomes available, asthma which was previousspecific treatment becomes available, asthma which was previously ly

considered to be severe could become mild. considered to be severe could become mild.

By the nature of the disease: By the nature of the disease:

••IIntermittent (episodic) ntermittent (episodic)

••Persistent (permanent)Persistent (permanent)

Severity (measured before treatment):Severity (measured before treatment):

••IntermittentIntermittent

••Mild persistent Mild persistent

••Moderate persistentModerate persistent

••Severe persistentSevere persistent

According to GINAAccording to GINA--2009:2009:

Asthma severity is classified on the basis of the intensity of tAsthma severity is classified on the basis of the intensity of treatment reatment

required to achieve good asthma control.required to achieve good asthma control.

Mild asthmaMild asthma is asthma that can be wellis asthma that can be well--controlled with low intensity controlled with low intensity

treatment such as low dose inhaled glucocorticosteroids, leukotrtreatment such as low dose inhaled glucocorticosteroids, leukotriene iene

modifiers or cromones.modifiers or cromones.

Severe asthmaSevere asthma is asthma that requires high intensity treatment, GINA is asthma that requires high intensity treatment, GINA

Step 4, to maintain good control, or where good control is not aStep 4, to maintain good control, or where good control is not achieved chieved

despite high intensity treatment. despite high intensity treatment.

Period of the disease:Period of the disease:

••EExacerbationxacerbation

••RemissionRemission

Possible Complications of Asthma:Possible Complications of Asthma:

••Pulmonary heartPulmonary heart

••Chronic pulmonary emphysemaChronic pulmonary emphysema

••PneumosclerosisPneumosclerosis

••Segmental or polysegmental atelectasisSegmental or polysegmental atelectasis

••EmphysemaEmphysema

••Spontaneous pneumothoraxSpontaneous pneumothorax

••Asthmatic statusAsthmatic status

••Neurological complicationsNeurological complications

HOW TO ASSESS THE SEVERITY OF CURRENT HOW TO ASSESS THE SEVERITY OF CURRENT

ASTHMA?ASTHMA?

To assess the severity of asthma is sometimes To assess the severity of asthma is sometimes

difficult, however, for clinicians itdifficult, however, for clinicians it’’s a key point, since s a key point, since

the severity determines the solution of the the severity determines the solution of the

substantive issues of medical tactics and plan of the substantive issues of medical tactics and plan of the

patientpatient’’s treatment in the short and longs treatment in the short and long--term term

programsprograms..

Key indicators of severity of asthma:Key indicators of severity of asthma:

•• Characteristics of daytime and nighttime symptoms Characteristics of daytime and nighttime symptoms

•• EExercise tolerance xercise tolerance

•• Frequency of Frequency of ββ22--agonist short duration agonist short duration

•• PEF (peak expiratory flow) or FEV1 (forcedPEF (peak expiratory flow) or FEV1 (forced

expiratory volume in 1 second) values expiratory volume in 1 second) values

•• Daily fluctuations (variability) PEFDaily fluctuations (variability) PEF

Severe asthma is characterized by:Severe asthma is characterized by:

••frequent, several times a week or daily, several times frequent, several times a week or daily, several times

a day, attacks, including frequent nighttimea day, attacks, including frequent nighttime

symptoms;symptoms;

••usually severe attacks, stopped by the combined useusually severe attacks, stopped by the combined use

of bronchodilatators and corticosteroids;of bronchodilatators and corticosteroids;

••significantly reduced exercise tolerance;significantly reduced exercise tolerance;

••disturbed sleep.disturbed sleep.

Patients will often perceive asthma as severe if they Patients will often perceive asthma as severe if they

have intense or frequent symptoms, but ithave intense or frequent symptoms, but it’’s important s important

to convey that this may merely represent inadequate to convey that this may merely represent inadequate

treatment.treatment.

In clinical practice, sometimes there are In clinical practice, sometimes there are extremely extremely

severe variants of asthmasevere variants of asthma, in which all the criteria , in which all the criteria

for severity is maximally expressed. Such patients for severity is maximally expressed. Such patients

often require intensive care. Severe course of asthma often require intensive care. Severe course of asthma

among children, and adults differs in a number of among children, and adults differs in a number of

singularities, what allowed to offer to mark it out as a singularities, what allowed to offer to mark it out as a

special phenotype (PRACTALL). The severity of special phenotype (PRACTALL). The severity of

asthma is caused by the persistence and resistance asthma is caused by the persistence and resistance

to treatment. The severity is also dependent on age. to treatment. The severity is also dependent on age.

In early childhood persistent disease is regarded as In early childhood persistent disease is regarded as

severe, often requiring hospitalization.severe, often requiring hospitalization.

However, it should be remembered that However, it should be remembered that the severity the severity

of the attack doesnof the attack doesn’’t always determine the severity t always determine the severity

of asthma.of asthma.

Exacerbation may occur as an acute attack or the Exacerbation may occur as an acute attack or the

prolonged state of bronchial obstruction. Asthma prolonged state of bronchial obstruction. Asthma

exacerbations may be caused by a variety of risk exacerbations may be caused by a variety of risk

factors, sometimes referred to as factors, sometimes referred to as ««triggertrigger»», including , including

allergens, viral infections, pollutants, and drugs.allergens, viral infections, pollutants, and drugs.

Clinical parameters that characterize the Clinical parameters that characterize the

severity of acute asthma: severity of acute asthma:

••RRespiratespiratoryory raterate

••Participation of the auxiliary muscles in the act of breathingParticipation of the auxiliary muscles in the act of breathing

••Intensity of wheezingIntensity of wheezing

••SSwelling of the chest welling of the chest

••The nature and conduct of breathing in the lungs The nature and conduct of breathing in the lungs

(auscultation)(auscultation)

••HHeart rateeart rate

••FForced position orced position

••TThe degree of restriction of physical activity he degree of restriction of physical activity

•• The amount of therapy (drugs and methods of The amount of therapy (drugs and methods of

administration), used for cuppingadministration), used for cupping

Assessment of asthma in children is held with Assessment of asthma in children is held with

the visiting physician based on: the visiting physician based on:

•• Survey of patients Survey of patients

•• The nature of clinical manifestations The nature of clinical manifestations

•• Study the functional state of respiratoryStudy the functional state of respiratory

•• Patient diary Patient diary

The PEF measurement using a peak flow meter in The PEF measurement using a peak flow meter in

school age children school age children helps in objectively assessing helps in objectively assessing

the degree of bronchial obstruction and compiling the degree of bronchial obstruction and compiling

the treatment guidelinesthe treatment guidelines..

In In each case, the doctor should give the patient an each case, the doctor should give the patient an

individualized plan of his actionsindividualized plan of his actions during during

exacerbations and in the future.exacerbations and in the future.

The study of respiratory function among children The study of respiratory function among children

under 5 years is limited and difficult, therefore, under 5 years is limited and difficult, therefore,

determining the severity of asthma is mainly based determining the severity of asthma is mainly based

on clinical criteria, results of questionnaire data, on clinical criteria, results of questionnaire data,

patientpatient’’s treatment diary.s treatment diary.

KEY POINTS:KEY POINTS:

•• Measurements of lung function (spirometry or peakMeasurements of lung function (spirometry or peak

expiratory flow) provide an assessment of the severity ofexpiratory flow) provide an assessment of the severity of

airflow limitation, its reversibility, and its variability, airflow limitation, its reversibility, and its variability, and and

provide confirmation of the diagnosis of asthma.provide confirmation of the diagnosis of asthma.

•• Asthma severity may change over time, and depends notAsthma severity may change over time, and depends not

only on the severity of the underlying diseases but also itsonly on the severity of the underlying diseases but also its

responsiveness to treatment.responsiveness to treatment.

•• From a practical point of view, the most appropriate From a practical point of view, the most appropriate

classification of asthma according to severity, since suchclassification of asthma according to severity, since such

approach provides the optimal selection of therapeutic approach provides the optimal selection of therapeutic

activities and plan of the patientactivities and plan of the patient’’s treatment.s treatment.

KEY POINTS:KEY POINTS:

•• The identification of the severity of asthma beforeThe identification of the severity of asthma before

treatment is based on the evaluation of clinical and treatment is based on the evaluation of clinical and

functional indices; the severity of illness on thefunctional indices; the severity of illness on the

background of the treatment is determined by thebackground of the treatment is determined by the

volume required therapy.volume required therapy.

•• The severity of asthma and the severity of the attackThe severity of asthma and the severity of the attack

must be distinguished.must be distinguished.

HOW TO MAKE MONITORING AND CONTROL ASTHMA?HOW TO MAKE MONITORING AND CONTROL ASTHMA?

Each patient is assigned to one of Each patient is assigned to one of five five ««treatment stepstreatment steps»»

depending on their current level of control and treatment depending on their current level of control and treatment

is adjusted in a continuous cycle driven by changes in is adjusted in a continuous cycle driven by changes in

their asthma control status. their asthma control status.

This cycle involvesThis cycle involves::

�� Assessing Asthma ControlAssessing Asthma Control

�� Treating to Achieve ControlTreating to Achieve Control

�� Monitoring to Maintain ControlMonitoring to Maintain Control

Another Another ««treatment stepstreatment steps»» relates to the treatment and relates to the treatment and

level of control for asthma exacerbations.level of control for asthma exacerbations.

ASSESSING ASTHMA CONTROLASSESSING ASTHMA CONTROL

Each patient should be assessed to establish their Each patient should be assessed to establish their

current treatment regiment, adherence to the current current treatment regiment, adherence to the current

regimen, and level of asthma control. A simplified regimen, and level of asthma control. A simplified

scheme for recognizing controlled, partly controlled, scheme for recognizing controlled, partly controlled,

and uncontrolled asthma in a given week is provided and uncontrolled asthma in a given week is provided

in Table 3 (GINAin Table 3 (GINA--2009).2009).

CharacteristicCharacteristic Controlled Controlled

(all of the following)(all of the following)

Party Controlled Party Controlled

(any measures (any measures

present in any week)present in any week)

UncontrolledUncontrolled

Daytime a Daytime a

symptomssymptoms

Twice or less/weekTwice or less/week More than More than

twice/weektwice/week

Three or more Three or more

features or partly features or partly

controlled asthma controlled asthma

present in any present in any

week*,**week*,**

Limitations of Limitations of

activitiesactivities

NoneNone AnyAny

Noctural Noctural

symptoms/awakenisymptoms/awakeni

ngng

NoneNone AnyAny

Need for reliever/ Need for reliever/

rescue treatmentrescue treatment

Twice or less/weekTwice or less/week More than More than

twice/weektwice/week

Lung function (PEF Lung function (PEF

or FEV1)***or FEV1)***

NormalNormal ‹‹ 80% predicted or 80% predicted or

personal best (if personal best (if

known)known)

LEVELS OF ASTHMA CONTROLLEVELS OF ASTHMA CONTROLTable 3.Table 3.

LEVELS OF ASTHMA CONTROLLEVELS OF ASTHMA CONTROLTable 3.Table 3.

B. B. Assessment of Future RiskAssessment of Future Risk (risk of exacerbations, high instability, rapid (risk of exacerbations, high instability, rapid

decline in lung function, sidedecline in lung function, side--effect)effect)

Patients with any of the following features are at increased risPatients with any of the following features are at increased risk of adverse k of adverse

events in the future: poor clinical control, frequent exacerbatievents in the future: poor clinical control, frequent exacerbations in past ons in past

year*, ever admitted to critical care for asthma, low FEV1, expoyear*, ever admitted to critical care for asthma, low FEV1, exposure to sure to

cigarette smoke, high dose medication requirement.cigarette smoke, high dose medication requirement.

* * -- Any exacerbation should prompt review of maintenance treatment Any exacerbation should prompt review of maintenance treatment to ensure that it isto ensure that it is

adequate. adequate.

** ** -- By definition, exacerbation in any week makes that an uncontrBy definition, exacerbation in any week makes that an uncontrolled asthma week.olled asthma week.

******-- Lung function is not reliable for children 5 years and youngeLung function is not reliable for children 5 years and younger.r.

Conduct analysis Conduct analysis of treatment every 3of treatment every 3--6 months 6 months after the control under asthma is placed.after the control under asthma is placed.

Consult a specialistConsult a specialist if the patient has clinical if the patient has clinical signs complicate asthma (for example, sinusitis), signs complicate asthma (for example, sinusitis), or if the patient doesnor if the patient doesn’’t respond to the ongoing t respond to the ongoing optimal therapy or if a treating needed by optimal therapy or if a treating needed by schemes 3, 4 and 5 stages.schemes 3, 4 and 5 stages.

To achieve control of asthma it is necessary:To achieve control of asthma it is necessary:

•• to sto select appropriate medications elect appropriate medications

•• to carry out longto carry out long--term treatment term treatment

•• to treat exacerbation of asthmato treat exacerbation of asthma

•• to establish risk factors that worsen asthma, and to establish risk factors that worsen asthma, and

avoid them avoid them

•• to educate patients to manage their conditionto educate patients to manage their condition

•• to monitor and modify the treatment of asthma in to monitor and modify the treatment of asthma in

order to achieve effective longorder to achieve effective long--term controlterm control

LONGLONG--TERM CONTROL OF ASTHMATERM CONTROL OF ASTHMA

To classify the severity of asthma and the plan of To classify the severity of asthma and the plan of

treatment there used the stepped approach.treatment there used the stepped approach.

This approach involves the increasing of number and This approach involves the increasing of number and

frequency of drug use (frequency of drug use (««step upstep up»») with increasing severity ) with increasing severity

of asthma and decrease (of asthma and decrease (««step downstep down»») when asthma ) when asthma

control is achieved.control is achieved.

�� ««Step upStep up»»

If asthma control is not achieved or if itIf asthma control is not achieved or if it’’s not constant. s not constant.

Usually, improvement should be achieved within 1 month. Usually, improvement should be achieved within 1 month.

However, before you climb on a However, before you climb on a ««step upstep up»», check patient , check patient

inhalation technique, compliance with doctorinhalation technique, compliance with doctor’’s s

recommendations, check whether the possible impact recommendations, check whether the possible impact

of risk factors is excluded.of risk factors is excluded.

�� ««Step DownStep Down»»

If control is maintained for the last 3 months, in this case If control is maintained for the last 3 months, in this case

the gradual reduction of medication is possible. The aim the gradual reduction of medication is possible. The aim ––

is to reduce the drug use to a minimum level, providing is to reduce the drug use to a minimum level, providing

asthma control.asthma control.

Achieving control is possible in two ways:Achieving control is possible in two ways:

•• 1th way (preferred):1th way (preferred):

Quickly get asthma under control through the appointment of Quickly get asthma under control through the appointment of

maximum therapymaximum therapy (for example, to conventional treatment, (for example, to conventional treatment,

corresponding to the severity of asthma in a patient, additionalcorresponding to the severity of asthma in a patient, additionally ly

assign a short course of prednisolone or a higher dose of inhaleassign a short course of prednisolone or a higher dose of inhaled d

corticosteroids) corticosteroids) with subsequent transition to with subsequent transition to ««step downstep down»»..

•• 2nd way:2nd way:

Begin treatment with a stage, which corresponds to the severity Begin treatment with a stage, which corresponds to the severity

of asthma in this patientof asthma in this patient with the transition if necessary to with the transition if necessary to

««step upstep up»»..

AntiAnti--inflammatory drugs, particularly inhaled corticosteroids are inflammatory drugs, particularly inhaled corticosteroids are

currently the most effective drugs for longcurrently the most effective drugs for long--term preventive term preventive

treatment of asthma.treatment of asthma.

MONITORING AND MODIFICATION OF ASTHMA MONITORING AND MODIFICATION OF ASTHMA

TREATMENT TO ACHIEVE EFFECTIVE LONGTREATMENT TO ACHIEVE EFFECTIVE LONG--TERM TERM

CONTROLCONTROL

�� Control of asthma requires a consistent and longControl of asthma requires a consistent and long--term treatment term treatment

and monitoring .and monitoring .

�� Monitoring includes an assessment of symptoms and, if possiblMonitoring includes an assessment of symptoms and, if possible,e,

measurement of functionalmeasurement of functional indices of lung.indices of lung.

�� Monitoring indicators Monitoring indicators pick expiratory flow measure pick expiratory flow measure at each visit at each visit

to a doctor (spirometry is preferable, but it is not alwaysto a doctor (spirometry is preferable, but it is not always

available). Monitoring along with an assessment of symptomavailable). Monitoring along with an assessment of symptoms s

helps to assess the patienthelps to assess the patient’’s response to treatment and adjust s response to treatment and adjust

the treatment. The value of PEFthe treatment. The value of PEF›› 80% of the best individual 80% of the best individual

performance means that the asthma is under control. performance means that the asthma is under control.

MONITORING AND MODIFICATION OF ASTHMA MONITORING AND MODIFICATION OF ASTHMA

TREATMENT TO ACHIEVE EFFECTIVE LONGTREATMENT TO ACHIEVE EFFECTIVE LONG--TERM TERM

CONTROLCONTROL

�� Long pick flow monitoring at home can help patients identifyLong pick flow monitoring at home can help patients identify

the early signs of deterioration in asthma (PEF the early signs of deterioration in asthma (PEF ‹‹ 80% of the80% of the

best individual performance) before the onset of symptoms.best individual performance) before the onset of symptoms.

The patient can take immediate action in accordance withThe patient can take immediate action in accordance with

individual treatment plans in order, to avoid serious attackindividual treatment plans in order, to avoid serious attacks.s.

Pick flow monitoring at home is not always possible, howeverPick flow monitoring at home is not always possible, however, ,

for patients who canfor patients who can’’t recognize the symptoms, or for thoset recognize the symptoms, or for those

who have already had cases of hospitalization, it is extremewho have already had cases of hospitalization, it is extremelyly

important.important.

�� Regular visits to the doctor (intervals from 1 to 6 months) arRegular visits to the doctor (intervals from 1 to 6 months) aree

necessary even after the control of asthma. necessary even after the control of asthma.

STEPPED APPROACH TO LONGSTEPPED APPROACH TO LONG--TERM CONTROL OF TERM CONTROL OF

ASTHMA IN ADULT AND CHILDREN OLDER THAN 5 YEARSASTHMA IN ADULT AND CHILDREN OLDER THAN 5 YEARS

The goal of treatment is to achieve asthma control:The goal of treatment is to achieve asthma control:

•• Minimal chronic symptoms (ideally Minimal chronic symptoms (ideally -- the lack thereof), the lack thereof),

including night including night

•• Minimal (infrequent) episodes Minimal (infrequent) episodes

•• Lack of conditions requiring emergency Lack of conditions requiring emergency

•• Minimal need for Minimal need for ββ22--agonists emergency agonists emergency

•• No limitation of activity, including exercise No limitation of activity, including exercise

•• Fluctuations PIF Fluctuations PIF ‹‹ 20%20%

•• ((NNear) normal PEF ear) normal PEF

•• Minimal side effects from medicines (or absence of such effectMinimal side effects from medicines (or absence of such effects).s).

IMPORTANTIMPORTANT::

•• To establish asthma control as quickly as possible (use the 1To establish asthma control as quickly as possible (use the 1--stst

way of control), then to reduce the medication to the minimway of control), then to reduce the medication to the minimum um

level, providing control over the symptoms.level, providing control over the symptoms.

•• Patients to avoid risk factors (triggers) or to control contaPatients to avoid risk factors (triggers) or to control contact ct

with them at every stage. with them at every stage.

•• At each stage of treatment education program for patients At each stage of treatment education program for patients

should be includedshould be included

STEPPED APPROACH TO LONGSTEPPED APPROACH TO LONG--TERM CONTROL OF TERM CONTROL OF

ASTHMA IN INFANTS AND YOUNG CHILDREN ASTHMA IN INFANTS AND YOUNG CHILDREN

(5 YEARS AND YOUNGER) (5 YEARS AND YOUNGER) has its own characteristics has its own characteristics

The goal of treatment is to achieve asthma control The goal of treatment is to achieve asthma control

((difference difference -- the lack of the value of PIFthe lack of the value of PIF):):

-- Minimal chronic symptoms (ideally Minimal chronic symptoms (ideally -- the lack thereof),the lack thereof),

including night including night

-- Minimal (infrequent) episodes Minimal (infrequent) episodes

-- Lack of conditions requiring emergency Lack of conditions requiring emergency

-- Minimal need for Minimal need for ββ22--agonists emergency agonists emergency

-- No limitation of activity, including exercise No limitation of activity, including exercise

-- ((NNear) normal lung function ear) normal lung function

-- Minimal side effects from medicines (or absence of such effecMinimal side effects from medicines (or absence of such effects).ts).

IMPORTANT TO REMEMBERIMPORTANT TO REMEMBER::

•• There is few research on treatment of asthma in There is few research on treatment of asthma in

infants.infants.

•• Assign treatment to the patients from the steps, which Assign treatment to the patients from the steps, which

is appropriate to their condition. Short course of is appropriate to their condition. Short course of

prednisolone may help in achieving rapid control of prednisolone may help in achieving rapid control of

asthma.asthma.

•• Patients to avoid risk factors (triggers) or to controlPatients to avoid risk factors (triggers) or to control

contact with them at every stage.contact with them at every stage.

•• At each stage of treatment the education program forAt each stage of treatment the education program for

patientspatients and/or their parents should be included.and/or their parents should be included.

••Clinical control of asthma is defined as:Clinical control of asthma is defined as:

-- No (twice or less/week) daytime symptomsNo (twice or less/week) daytime symptoms

-- No limitations of daily activities, including exerciseNo limitations of daily activities, including exercise

-- No nocturnal symptoms or awakening because ofNo nocturnal symptoms or awakening because of

asthmaasthma

-- No (twice or less/week) need for reliever treatmentNo (twice or less/week) need for reliever treatment

-- Normal or nearNormal or near--normal lung functionnormal lung function

-- No exacerbations No exacerbations

KEY POINDS:KEY POINDS:

•• To aid in clinical management, a classification of asthmaTo aid in clinical management, a classification of asthma

by level of control is recommended.by level of control is recommended.

•• Treatment should be adjusted Treatment should be adjusted in in aa continuouscontinuous cyclecycle

driven by the patientsdriven by the patients’’ asthma control status. If asthma asthma control status. If asthma

is not controlled on the current treatment regimen,is not controlled on the current treatment regimen,

treatment should be treatment should be ««stepped upstepped up»» until control isuntil control is

achieved.achieved. When control is maintained for at least threeWhen control is maintained for at least three

months, treatment can be months, treatment can be ««stopped downstopped down»»..

KEY POINDS:KEY POINDS:

•• In treatmentIn treatment--naive patients with persistent asthma,naive patients with persistent asthma,

treatment should be started at Step 2, or, if verytreatment should be started at Step 2, or, if very

symptomatic (uncontrolled), at Step 3. For Step 2symptomatic (uncontrolled), at Step 3. For Step 2

through 5, a variety of controller medications are through 5, a variety of controller medications are

available.available.

•• Ongoing monitoring is essential to maintain control andOngoing monitoring is essential to maintain control and

establish the lowest step and dose of treatment toestablish the lowest step and dose of treatment to

minimize cost and maximize safety.minimize cost and maximize safety.

•• Reducing a patientReducing a patient’’s exposure to some categories of risks exposure to some categories of risk

factors improves the control of asthma and reducesfactors improves the control of asthma and reduces

medication needs.medication needs.

Thank you for attention!Thank you for attention!