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

Bronchial asthma

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

Source: Peter J. Barnes, MD

Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD

Mechanisms: Asthma Inflammation

Source: Peter J. Barnes, MD

Asthma Inflammation: Cells and Mediators

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 Prevalence and Mortality

Source: Masoli M et al. Allergy 2004

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

Factors 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

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

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

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

Measuring Variability of Peak Expiratory Flow

Measuring Airway Responsiveness

Levels of Asthma Control

Characteristic Controlled(All of the following)

Partly controlled(Any present in any

week)Uncontrolled

Daytime symptoms None (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 Partnership2. Identify and Reduce Exposure to Risk

Factors3. Assess, Treat and Monitor Asthma4. Manage Asthma Exacerbations5. Special Considerations

Asthma 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

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 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

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

Component 1: Develop Patient/Doctor Partnership

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 ControlYour 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-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 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 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 Factors

Influenza 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 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

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

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 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 considerationsCultural preferences and differing health caresystems need to be considered

Component 3: Assess, Treat and Monitor Asthma

Controller Medications

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 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

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 Medications

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids Anticholinergics Theophylline

Short-acting oral β2-agonists

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

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

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.

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

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

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

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

Component 4: Manage Asthma Exacerbations

Primary therapies for exacerbations:• Repetitive administration of rapid-acting inhaled

β2-agonist• Early introduction of systemic

glucocorticosteroids• Oxygen supplementationClosely monitor response to treatment with serialmeasures of lung function

Component 4: Manage Asthma Exacerbations

Special 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

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