1 1 bronchial asthma introduction to primary care: a course of the center of post graduate studies...
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BRONCHIAL ASTHMABRONCHIAL ASTHMA
Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847
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ObjectivesTo describe how to make the diagnosis of
asthma utilizing the Saudi Asthma Guidelines.To discuss the efficacy of nebulizers versus
metered dose inhalers and other medications in the treatment of asthma
To describe the following methods for monitoring disease severity and any evidence supporting one method over the otherSymptoms based (i.e. medication frequency and dose
based upon symptoms)Daily peak flow meter monitoring (i.e. red,
yellow, green zones)
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DEFINITION OF ASTHMA
• CHRONIC INFLAMATORY DISORDER OF THE AIRWAY ASSOCIATED WITH WIDESPREAD BUT
VARIABLE AIRFLOW LIMITATION (PARTLY REVERSIBLE WITH OR WITHOUT TREATMENT )
• AND WITH INCREASED AIRWAY HYPERRESPONSIVENESS TO VARIETY OF
STIMULI
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WHAT IS THE PREVALENCE IN SAUDI ARABIA ?
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The prevalence of asthma among school children in KSA
• Range
4%-23% • Riyadh 10%• Jeddah 12%
( AL Frayh, et al, 2001 )
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history
• Required a full detailed medical history and clinical exam. Including peak expiratory flow (PEF)rate.
• 1-Symptoms:– Cough– Wheezing– Shortness of breath
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• How frequent, how severe, what intervention needed.
• Interfere with sport or normal physical activity• Trouble some cough between attacks• Symptoms improve by asthma medication
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• 2- atopy :skin eczema ,itchy eye,frequent nasal blockage,discharge or sneezing especialy in the morning
• 3- family history of atopic diseases.• 4- environmental history• 5- exclusion of other medical conditions
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Physical examination• Hight and weight(growth in childern)• Nose,throat, sinusis(polyps,deviated nasal
septum,post nasal drip,pale-pink or congested nasal turbinate.
• Feature of atopy• Examination of the respiratory system
– May be normal between attacks– wheeze brochi,tachypnea,chest deformity suggest
asthma– Stridor,clubbing,heart murmers ----other than
bronchial astha
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• Peak expiratory flow rate (PEF):• Should be performed in every patient>5 yrs• In certain patient measuring PEF prior to and
after a bronchodilator may help in confirming the diagnosis.
• Measuring PEF variability comparing the morning and evening PEF over a period of 2 weeks
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• Variability over 15% conferms but not essential for diagnosis
• PEF may be normal between attacks
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Investigation
• Usually not necessary• CXR Usually not necessary except in
• Severe cases• Foreign body • Infection
• Arterial blood gases in severe cases
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Differential diagnosis
In children < 5 yrs :• Upper airway allergies,rhinitis, sinusitis• GERD• Foreign body aspiration• Recurrent viral LRTI• Cystic fibrosis• Congenital heart disease
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Differential diagnosisIn older children and adults:
• Upper airway allergies, rhinitis, sinusitis• GERD• Heart disease • COPD• Vocal cord dysfunction• Inhalation of foreign body• Hyperventilation and panic attack• Cough secondary to drugs(β-blockers and ACE inhibtors)• Bronchiachtiasis• Laryngeal dysfunction
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classification
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classification
• Etiology:– Allergic and non allergic asthma– Help in determining prognosis and in determining
allergen to be avoided • Severity:
– Intermittent, mild persistent, moderate persistent, severe persistent.
– Management at the initial assessment of a patient• Control:
– Useful for ongoing therapy
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Classification: asthma Severity:
classification intermittent Mildpersistent
Moderatepersistent
Severe persistent
Minor symptoms
<1/week 1-3/week 4-5/week continuous
Exacerbations/nocturnal
<1/month 1/month 2-3/month >4/month
PEF between attacks
>80% >80% 60-80% <60%
Pharmacological therapy
step1 step2 step3 step4
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Classification: asthma controlcharachtarstic controlled(all the
following)Partly controlled(any in any week)
uncontrolled
Day time symptoms None(twice or less/week)
More than twice/week
Three or more Feature of partly controlled asthma present in any weekLimitation of
activityNone Any
Nocturnal symptoms /awaking
None Any
Need for reliever /rescue treatment
None (twice or less/week)
More than twice/week
Lung function (PEF or FEV1)
Normal <80 % predicted or Personal best
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Management
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Goals of successful management
• Achieve and maintain control of symptoms• Maintain normal activity level ,including
exercise• Maintain (near) "normal" pulmonary
function. • Prevent recurrent exacerbations of asthma• Avoid adverse effects from asthma medication• Prevent asthma medication
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Component of asthma therapy
1) Develop patient /doctor partenership asthma education
2) Identify and reduce exposure to risk factors3) Assess treat and monitor asthma4) Manage asthma exacerbation emergencies5) Special consideration coexisting and related
condition
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Component 1:Develop patient /doctor partnership asthma education
• Asthma education• Asthma follow up and referal
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Component 1:Develop patient /doctor partnership asthma education
Asthma educationObjectives:1- improving knowledge of
asthma2-changing attitude and
behavior3-Improving management
skills4- improving satisfaction and
overall quality of life
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Component 1:Develop patient /doctor partnership asthma education
Elements of patient education :1- basic facts about asthma:Disease, medication and goal of therapy2- socio-cultural misconception:Asthma as infectious disease,asthma medication
are addictive,3- medicationAdvantage of inhaled over systemic medications The need for more than one inhaler
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Component 1:Develop patient /doctor partnership asthma education
• 4- management skillsTechnique:• Inhalation devices,spacer, PEFAsthma self management:• Name and dose of the medication• Monitoring of asthma• Sign suggest worsening of asthma• Action in exacerbation• How and when adjust medication• How and when to seek medical attention
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Component 1:Develop patient /doctor partnership asthma education
Follow upInitial phase:• Last until asthma control is
optimum• The diagnnosis is
established• Patient need to be seen at
least every 3-6 weeks during this phase
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Component 1:Develop patient /doctor partnership asthma education
• Second phase:• The asthma is well controlled• Interval history, examination ,medication • Special attention include:1-need for emergency care2-loss of time in work or school3-freq. of β2 agonist usage4-wheezing interfere with normal physical activity
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Component 1:Develop patient /doctor partnership asthma education
5-use of oral steroid6-Perform spirometry or PEF in clinic7-go over PEF chart with the patient 8- observe inhalation technique 9- step up or down anti-inflammatory therapy10-provide written instruction to certain patients Patient need to be seen every 3-6 monthsOr earlier if patient deteriorate
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Component 1:Develop patient /doctor partnership asthma education
Referral Primary health care centers:Manage asthma whose
diagnosis is striaght forward and are easily controlled
If asthma is partialy controlled or uncontrolled --refer to secondary care
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Component 2: Identify and reduce exposure to risk factors
• Domestic dust mites• Air pollution• Tobacco smoke• Occupational irritants• Cockroach • Animal with fur• Pollen
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• Respiratory (viral) infections• Chemical irritants• Strong emotional expressions• Drugs ( aspirin, beta blockers)
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Component 3:Assess treat and monitor asthma
• asthma Severity• asthma control
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Asthma control test
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step1 step2 step3 step4 step5
As needed rapid –acting β2 agonist
Low dose ICS
Low dose ICS+LABA Medium to high dose ICS +LABA
Step 4 +steriods
Leukotriene modifier
Low –dose ICS + Leukotriene modifier
Medium to high dose ICS+ Leukotriene modifier
STEP 4+anti IgE
Medium to high dose ICS
Medium to high dose ICS +LABA+ Leukotriene modifier
Addition of sustained release theophylline may be considered
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LEVEL OF CONTROL TREATMENT OPTION
controlled Step down therapy
Maintain therapy
Partly controlled Maintain therapy
Step up therapy
Uncontrolled Step up therapy
Look up for reasons
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Component 4:Manage asthma exacerbation emergencies
• Home management:• Frequent β2 agonist
preferaply via spacer device q 4h
• Dose of ICS to be increased 4 folds
• Action plan
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Management of severe attack
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Peak Flow Meter ZonesGreen ZoneGreen Zone (80 to 100 percent of your personal best) signals
good control. Take your usual daily long-term-control medicines, if you take any. Keep taking these medicines even when you are in the yellow or red zones.
Yellow ZoneYellow Zone (50 to 79 percent of your personal best) signals caution: your asthma is getting worse. Add quick-relief
medicines. You might need to increase other asthma medicines as directed by your doctor.
Red ZoneRed Zone (below 50 percent of your personal best) signals medical alert! Add or increase quick-relief medicines and call your doctor now.
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Component 5:special consideration
• Rhinitis• Sinusitis• Nasal polyps• Respiratory infection• GERD• Asprin induced asthma(AIA)• Pregnancy • surgery
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• B. This patient has mild persistent asthma, which is defined as having asthma symptoms more than two times a week but less than one time a day. These patients also have nocturnal
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Is the asthma of the patient in the previous question controlled or not? What recommendations might you give her regarding her therapy?
• A. Controlled, do not change her therapy• B. Controlled, educate regarding triggers• C. Not controlled, give a short burst of oral prednisone• D. Not controlled, add a long-acting bronchodilator such as
salmeterol• E. Not controlled, add a low-dose inhaled corticosteroid or
leukotriene antagonist
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• E. This patient is not well controlled since she is using her inhaler more than twice a week and experiencing symptoms so frequently. Addition of a low-dose inhaled corticosteroid or a leukotriene antagonist are appropriate options for mild persistent asthma.
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The same 23-year-old patient comes in to your office 2 months later after having a kitchen fire at home and is complaining of shortness of breath. What factor on your history and physical might make you consider admitting her to the hospital?
• A. Wheezing on lung exam• B. Pulse oximetry less than 93%• C. Respiratory rate of 30 breaths per minute• D. No response to one treatment with an albuterol nebulizer• E. PaCO2 of 25
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• C. A respiratory rate of greater than 28 or pulse of greater than 110 beats per minute would both indicate a severe episode. Wheezing is an unreliable indicator of the severity of attack. A pulse oximetry measurement of 90% is the goal unless the patient is pregnant or has cardiac disease. A PaCO2 of 25 is expected in a patient who is hyperventilating. A PaCO2 that is normal or elevated may be a sign of impending respiratory failure and such patients should be monitored closely in the intensive care unit
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Thanks
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