Download - Latest Guidelines for Asthma Management
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Latest Guidelines for Asthma Management
Global Initiative for AsthmaBy: Dr. Mahmoud Taheri
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Strategies for Asthma Management and Prevention
Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and
Prevention Program Implementation of Asthma
Guidelines in Health Systems
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Definition 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
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Asthma Inflammation: Cells and Mediators
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Factors that Exacerbate Asthma
Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs
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Factors that Influence Asthma Development and Expression
Host Factors Genetic - Atopy - Airway
hyperresponsiveness Gender Obesity
Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet
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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
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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
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Typical Spirometric (FEV1) Tracings
1Time (sec)
2 3 4 5
FEV1
Volume
Normal Subject
Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)
Note: Each FEV1 curve represents the highest of three repeat measurements
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Measuring Variability of Peak Expiratory Flow
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Measuring Airway Responsiveness
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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
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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 Exacerbations5. Special Considerations
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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.
.
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Asthma Management and Prevention Program
Part 1: Educate Patients to Develop a Partnership
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
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Asthma Management and Prevention Program
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
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Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership
Key factors to facilitate communication: Friendly demeanor Interactive dialogue Encouragement and praise Provide appropriate information Feedback and review
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Asthma Management and Prevention Program
Factors Involved in Non-Adherence
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 Inappropriate expectations Underestimation of severity Attitudes toward ill health Cultural factors Poor communication
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Asthma Management and Prevention ProgramComponent 2: Identify and Reduce Exposure to Risk Factors
Measures to help reducing exposure to risk factors should be implemented wherever possible.
Asthma exacerbations are caused by a variety of risk factors – allergens, viral infections, pollutants and drugs.
Reducing exposure to some risk factors improves the control of asthma and reduces medications needs.
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Reduce exposure to indoor allergens Avoid tobacco smoke Avoid vehicle emission Identify irritants in the workplace Explore role of infections on asthma
development
Asthma Management and Prevention ProgramComponent 2: Identify and Reduce Exposure to Risk Factors
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Asthma Management and Prevention Program
Influenza Vaccination
Routine influenza vaccination of children and adults with asthma does not appear to protect them from asthma exacerbations or improve asthma control
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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
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Global Strategy for Asthma Management and Prevention
Clinical Control of Asthma
The focus on asthma control isimportant because: the attainment of control
correlates with a better quality of life, and
reduction in health care use
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Determine the initial level of control to implement treatment
(assess patient impairment) Maintain control once
treatment has been implemented
(assess patient risk)
Global Strategy for Asthma Management and Prevention
Clinical Control of Asthma
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Levels of Asthma Control(Assess patient impairment)
Characteristic Controlled(All of the following)
Partly controlled(Any present in any week)
Uncontrolled
Daytime symptoms Twice or less per week
More than twice per 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
Twice or less per week
More than twice per week
Lung function (PEF or FEV1)
Normal< 80% predicted or
personal best (if known) on any day
Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)
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Assess Patient Risk Features that are associated with increased risk of adverse events in the future include:
Poor clinical control Frequent exacerbations in past year Ever admission to critical care for asthma Low FEV1, exposure to cigarette
smoke, high dose medications
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*IMPORTANT*
Any exacerbation should prompt review of
maintenance treatment
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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
Step 2 is the initial treatment for most patients. If the patient is severely uncontrolled, we start from step 3.
Our approach includes: - Assessing Asthma Control - Treating to Achieve Control - Monitoring to Maintain Control
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Controller Medications Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists in
combination with inhaled glucocorticosteroids
Systemic glucocorticosteroids Theophylline Cromones Anti-IgE
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Salbutamol (Albuterol)
Availability: Aerosol 90 mcg/inh. Brand Names: Ventolin Onset: 5-15 min Peak: 1 Hour Duration: 3-6 hrs.
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Salmeterol
Availability: Aerosol 25 mcg/inh. Brand Names: Serevent Onset: 10-25 min Peak: 3-4 hrs. Duration: 12 hrs.
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Beclomethasone
Availability: Aerosol 40 mcg/inh. Aerosol 80 mcg/inh. Brand Names: Becotide, Beclazone,
Qvar Onset: Within 24 hrs. Peak: 1-4 Weeks Duration: Unknown
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Fluticasone
Availability: Aerosol 44 mcg/inh. Aerosol 110 mcg/inh. Aerosol 220 mcg/inh. Brand Names: Flovent Onset: Within 24 hrs. Peak: 1-4 Weeks Duration: Days after DC.
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Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
Beclomethasone 200-500 >500-1000 >1000
Budesonide 200-600 600-1000 >1000
Ciclesonide 80 – 160 >160-320 >320-1280
Flunisolide 500-1000 >1000-2000 >2000
Fluticasone 100-250 >250-500 >500
Mometasone furoate 200-400 > 400-800 >800-1200
Triamcinolone acetonide 400-1000 >1000-2000 >2000
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Reliever Medications
Rapid-acting inhaled β2-agonists
Systemic glucocorticosteroids
Anticholinergics Theophylline Short-acting oral β2-agonists
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Component 4: Asthma Management and Prevention Program 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
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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
STEP1
STEP2
STEP3
STEP4
STEP5
RED
UC
EIN
CR
EASE
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Shaded green - preferred controller options
TO STEP 3 TREATMENT, SELECT ONE OR MORE:
TO STEP 4 TREATMENT, ADD EITHER
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Shaded green - preferred controller options
TO STEP 4 TREATMENT, ADD EITHER
TO STEP 3 TREATMENT, SELECT ONE OR MORE:
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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
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Shaded green - preferred controller options
TO STEP 4 TREATMENT, ADD EITHER
TO STEP 3 TREATMENT, SELECT ONE OR MORE:
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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
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Shaded green - preferred controller options
TO STEP 4 TREATMENT, ADD EITHER
TO STEP 3 TREATMENT, SELECT ONE OR MORE:
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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
Treating to Achieve Asthma Control
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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
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TO STEP 3 TREATMENT, SELECT ONE OR MORE:
TO STEP 4 TREATMENT, ADD EITHER
Shaded green - preferred controller options
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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
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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
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TO STEP 3 TREATMENT, SELECT ONE OR MORE:
TO STEP 4 TREATMENT, ADD EITHER
Shaded green - preferred controller options
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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)
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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
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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)
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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)
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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
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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 effective 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)
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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
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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
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Asthma Management and Prevention Program
Special ConsiderationsSpecial 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
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