asthma; basis of current management

8/14/2019 Asthma; Basis of Current Management

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Basis of Current Management in

Asthma

AE Orimadegun AE Orimadegun



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OUTLINE…

DefinitionDefinitionEpidemiologyEpidemiologyPathogenesis/PathophysiologyPathogenesis/PathophysiologyRisk FactorsRisk FactorsMechanismsMechanisms

Diagnosis and ClassificationDiagnosis and ClassificationEducation and Delivery of CareEducation and Delivery of CareSix Part Asthma Management PlanSix Part Asthma Management Plan



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Definition of Asthma

Asthma is a chronic inflammatory disorder of theAsthma is a chronic inflammatory disorder of theairways in which many cells and cellular elements playairways in which many cells and cellular elements playa rolea role

Chronic inflammation causes an associated increase inChronic inflammation causes an associated increase inairway hyperresponsiveness that leads to recurrentairway hyperresponsiveness that leads to recurrentepisodes of wheezing, breathlessness, chest tightness,episodes of wheezing, breathlessness, chest tightness,and coughing, particularly at night or in the earlyand coughing, particularly at night or in the early

morningmorningThese episodes are usually associated withThese episodes are usually associated withwidespread but variable airflow obstruction that is oftenwidespread but variable airflow obstruction that is oftenreversible either spontaneously or with treatmentreversible either spontaneously or with treatment



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Most common chronic illness in childhoodworldwide

Between 100 - 150 million people suffer fromasthma worldwide 1

Worldwide prevalence rates are increasing, onaverage, by 50% per decade 1

Worldwide costs of asthma greater is than HIV /AIDS and tuberculosis combined 1

1. WHO, Bronchial Asthma Fact Sheet 20002. GINA Guidelines 1998

Facts and figures



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Facts and figures…Prevalence rates in Nigeria:

Sofowora & Clark - 2.4% in a school survey at Ibadan.

Falade et al using ISAAC Questionnaire found 16.7%(13-14yrs) and 7.2% (6-7yrs) in Ibadan.

Okoromah reported 3% in Enugu (6-13yrs)

Oviawe - 0.7% in a rural community at Edo

Highest prevalence reported from UK, New Zealand,and Australia (Isaac)



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7070

6060

5050

4040

3030

20208585 8686 8787 8888 8989 9090 9191 9292 9393 9494

Rate/1,000 PersonsRate/1,000 Persons

Year Year

<18

18-44

45-64

65+

Total (All Ages)

Age (years)Age (years)

Trends in Prevalence of AsthmaTrends in Prevalence of Asthma By Age, U.S., 1985-1996By Age, U.S., 1985-1996

9595 9696

8080



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44

33

11

19801980

Rate/100,000 PersonsRate/100,000 Persons

Year Year

22

0019851985 19901990 19951995 20002000

Black MaleBlack Male

White FemaleWhite Female

White MaleWhite Male

Black FemaleBlack Female

Death Rates for AsthmaDeath Rates for AsthmaBy Race, Sex,By Race, Sex, U.S., 1980-1998U.S., 1980-1998

55



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Pathogenesis/PathophysiologyPathogenesis/Pathophysiology

Complex, chronic inflammatory disorder of the airwayComplex, chronic inflammatory disorder of the airwayImmunopathologic features include:Immunopathologic features include:

Denudation of airway epithelium

Collagen deposition beneath the basement membraneOedema

Mast cell activation

Inflammatory cell infiltration Neutrophils

Eosinophils

Lymphocytes (TH2-like cells)



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Airway inflammation results in:Airway inflammation results in:HyperresponsivenessHyperresponsiveness

Limitation of airfowLimitation of airfow

Airway oedemaAirway oedema

Acute bronchoconstrictionAcute bronchoconstriction

Mucus plug formationMucus plug formation

Disease chronicityDisease chronicity

Atopy is the strongest predisposing factor Atopy is the strongest predisposing factor for asthmafor asthma



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MucushypersecretionHyperplasia

Eosinophil

Mast cell

Allergen

Th2 cell

VasodilatationNew vessels

Plasma leakOedema

Neutrophil

Mucus plug

Macrophage/ dendritic cell

BronchoconstrictionHypertrophy / hyperplasia

Cholinergicreflex

Epithelial shedding

Subepithelialfibrosis

Sensory nerveactivation

Nerve activat ion

Modern view of pathophysiology…



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Inflammatory processes



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Risk FactorsRisk Factors(for development of asthma)(for development of asthma)

INFLAMMATIONNFLAMMATION

AirwayAirway

HyperresponsivenessHyperresponsivenessAirflow ObstructionAirflow Obstruction

Risk FactorsRisk Factors(for exacerbations)(for exacerbations)

SymptomsSymptoms



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Risk Factors for AsthmaRisk Factors for Asthma

Host factors: predispose individuals to,or protect them from, developing

asthmaEnvironmental factors: influencesusceptibility to development of asthma

in predisposed individuals, precipitateasthma exacerbations, and/or causesymptoms to persist



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Risk Factors for AsthmaRisk Factors for AsthmaHost Factors

Genetic predispositionAtopy – IgE mediated response to allergenAirway hyperresponsivenessGender

Race/EthnicityEnvironmental Factors• Indoor allergens – dust mites, animal dander,

cockroaches, fungi• Outdoor allergens – pollens, fungi• Occupational sensitizers• Tobacco smoke – passive, active



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Risk Factors that Lead toRisk Factors that Lead toAsthma DevelopmentAsthma Development

Environmental Factors (cont’d)• Air Pollution – outdoor, indoor • Respiratory Infections

• Parasitic infections• Socioeconomic factors• Family size

• Diet and drugs• Obesity



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Factors that Exacerbate AsthmaFactors that Exacerbate Asthma

AllergensAllergens

Air PollutantsAir Pollutants

Respiratory infectionsRespiratory infections

Exercise and hyperventilationExercise and hyperventilation

Weather changesWeather changesSulfur dioxideSulfur dioxide

Food, additives, drugsFood, additives, drugs



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Is it Asthma?Is it Asthma?

Recurrent episodes of wheezingRecurrent episodes of wheezing

Troublesome cough at nightTroublesome cough at night

Cough or wheeze after exerciseCough or wheeze after exercise

Cough, wheeze or chest tightness after Cough, wheeze or chest tightness after exposure to airborne allergens or exposure to airborne allergens or pollutantspollutantsColds “go to the chest” or take moreColds “go to the chest” or take morethan 10 days to clear than 10 days to clear



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Asthma DiagnosisAsthma Diagnosis

History and patterns of symptoms

Physical examination

Measurements of lung function

Reversibility test

Diurnal variation

Measurements of allergic status toidentify risk factors



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Reversibility of airways’ obstruction – increased PEF >15% 15-20 minutes after inhaling ß 2-agonist

Variability of airways’ obstruction – PEF varies between morning and evening

>20% in patients taking bronchodilator >10% in patients not taking bronchodilator

Exercise-induced airways’ obstruction – decreased PEF >15% after 6 minutes of exercise

**Bronchoprovocative challenge test – Pc 20 FEV 1 methacholine and histamine

GINA Guidelines 1998 **not covered by GINA

v v wlimitation



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Classification of SeverityClassification of Severity

CLASSIFY SEVERITYClinical Features Before Treatment

SymptomsSymptoms NocturnalNocturnalSymptomsSymptoms

FEVFEV 11 or PEFor PEF

STEP 4STEP 4

SevereSeverePersistentPersistent

STEP 3STEP 3

ModerateModeratePersistentPersistent

STEP 2STEP 2

MildMildPersistentPersistent

STEP 1STEP 1IntermittentIntermittent

ContinuousContinuous

Limited physicalLimited physicalactivityactivity

DailyDailyAttacks affect activityAttacks affect activity

> 1 time a week> 1 time a week

but < 1 time a daybut < 1 time a day

< 1 time a week< 1 time a week

AsymptomaticAsymptomaticand normal PEFand normal PEFbetween attacksbetween attacks

FrequentFrequent

> 1 time week> 1 time week

> 2 times a month> 2 times a month

≤ 2 times a2 times amonthmonth

≤ 60% predicted60% predicted

Variability > 30%Variability > 30%

60 - 80% predicted60 - 80% predicted

Variability > 30%Variability > 30%

≥ 80% predicted80% predicted

Variability 20 - 30%Variability 20 - 30%

≥ 80% predicted80% predicted

Variability < 20%Variability < 20%

The presence of one feature of severity is sufficient to place patient in that category.



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1. Educate Patients

2. Assess and Monitor Severity

3. Avoid Exposure to Risk Factors4. Establish Medication Plans for Chronic

Management

5. Establish Plans for Managing Exacerbations

6. Provide Regular Follow-up Care

Six-Part Asthma ManagementProgram



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Six-part Asthma Management ProgramSix-part Asthma Management Program

Goals of Long-term ManagementGoals of Long-term Management

Achieve and maintain control of symptomsPrevent asthma episodes or attacksMaintain pulmonary function as close to normallevels as possibleMaintain normal activity levels, includingexercise

Avoid adverse effects from asthma medicationsPrevent development of irreversible airflowlimitationPrevent asthma mortality



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Six-Part Asthma ManagementSix-Part Asthma ManagementProgramProgram

The most effective management is toprevent airway inflammation byeliminating the causal factors

Asthma can be effectively controlled inmost patients, although it can not becured

The major factors contributing to asthmamorbidity and mortality are under-diagnosis and inappropriate treatment

.



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Six-Part Asthma ManagementSix-Part Asthma ManagementProgramProgram

Any asthma more severe than intermittent

asthma is more effectively controlled by

treatment to suppress and reverse airway

inflammation than by treatment only of acute bronchoconstriction and symptoms



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Six-part Asthma Management Program

Part 1: Educate Patients toDevelop a Partnership

Patient education involves a partnershipbetween the patient and health care

professional(s) with frequent revision andreinforcement

Aim is guided self-management – givingpatients the ability to control their asthma

Interventions, including use of writtenaction plans, have been shown to reducemorbidity in both children and adults



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Part 1: Educate Patients toDevelop a Partnership

Guidelines on asthma management shouldbe available but adapted and adopted for

local use by local asthma planning teamsClear communication between health careprofessionals and asthma patients is key toenhancing compliance

Educate continually



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Part 2: Assess and Monitor Asthma Severity withSymptom Reports and Measures of Lung Function

Symptom reportsUse of reliever medicationNighttime symptomsActivity limitations

Spirometry for initial assessment. PeakExpiratory Flow for follow-up:

Assess severityAssess response to therapy



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Part 2: Assess and Monitor Asthma Severity withSymptom Reports and Measures of LungFunction

• PEF monitoring at home – Important for those with poor perception of

symptoms – Daily measurement recorded in a diary – Assesses the severity and predicts worsening – Guides the use of a zone system for asthma

self-management



Si A h M P



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Part 3: Avoid Exposure to RiskFactors

Methods to prevent onset of asthma arenot yet available but this remains an

important goalMeasures to reduce exposure to causesof asthma exacerbations ( e.g. allergens,

pollutants, foods and medications) shouldbe implemented whenever possible

Si A h M P



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Part 3: Avoid Exposure to RiskFactors

Reduce exposure to indoor allergensReduce exposure to indoor allergens

Avoid tobacco smokeAvoid tobacco smoke

Avoid vehicle emissionAvoid vehicle emission

Explore role of infections on asthmaExplore role of infections on asthma

development, especially in children anddevelopment, especially in children andyoung infantsyoung infants

Si t A th M g t P g



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Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and

Children

At present, inhaled glucocorticosteroids

are the most effective controller medications and are recommended for persistent asthma at any step of severity

Long-term treatment with inhaledglucocorticosteroids markedly reduces thefrequency and severity of exacerbations

Six part Asthma Management Program



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Part 4: Establish Medication Plans for Long-Term Asthma Management

A stepwise approach to pharmacologicalA stepwise approach to pharmacologicaltherapy is recommendedtherapy is recommended

The aim is to accomplish the goals of The aim is to accomplish the goals of therapy with the least possible medicationtherapy with the least possible medication



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Part 4: Long-term Asthma Management

Pharmacologic Therapy

Reliever Medications:

Rapid-acting inhaled β 2-agonists

Systemic glucocorticosteroids

Anticholinergics

MethylxanthinesShort-acting oral β 2-agonists



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Part 4: Long-term Asthma Management

Allergen-specific Immunotherapy

Greatest benefit of specific immunotherapyusing allergen extracts has been obtained inthe treatment of allergic rhinitis

Specific immunotherapy should beconsidered only after strict environmental

avoidance and pharmacologic interventionhave failed to control asthma

Perform only by trained physician




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Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants

and Children

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.




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Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and

ChildrenLong-term treatment with inhaledglucocorticosteroids has not been shownto be associated with any increase inosteoporosis or bone fractureStudies including a total of over 3,500children treated for periods of 1 – 13 yearshave found no sustained adverse effect of inhaled glucocorticosteroids on growth




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Part 4: Establish Medication Plans for Long-Term Asthma Management in

Infants and Children

Rapid-acting inhaled β 2- agonists are

the most effective reliever therapy for childrenThese medications are the most

effective bronchodilators available andare the treatment of choice for acuteasthma symptoms



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Recommended Asthma MedicationsRecommended Asthma MedicationsStep 1: Children Younger Than 5yrsStep 1: Children Younger Than 5yrs

• NoneNone • NoneNone Step 1:Step 1:IntermittentIntermittent

Other OptionsOther Options (in order (in order of cost)of cost)

Daily Controller Daily Controller MedicationsMedications

SeveritySeverity

Reliever Medication: Rapid-acting inhaledReliever Medication: Rapid-acting inhaled ββ 22- agonist prn, not more- agonist prn, not morethan 3-4 times a day. Once control is achieved and maintained for atthan 3-4 times a day. Once control is achieved and maintained for atleast 3 months, gradual reduction of therapy should be tried.least 3 months, gradual reduction of therapy should be tried.



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Recommended Asthma MedicationsRecommended Asthma MedicationsStep 2: Children Younger Than 5 yrsStep 2: Children Younger Than 5 yrs

• Sustained-releaseSustained-releasetheophylline,theophylline, or or

• Cromone,Cromone, or or

•Leukotriene modifier Leukotriene modifier

• Low-dose inhaledLow-dose inhaledglucocorticosteroidglucocorticosteroid

Step 2:MildPersistent

Other OptionsOther Options (in order (in order of cost)of cost)

Daily Controller Daily Controller MedicationsMedications

SeveritySeverity

Reliever Medication: Rapid-acting inhaledReliever Medication: Rapid-acting inhaled ββ 22 - agonist prn, not more- agonist prn, not morethan 3-4 times a day. Once control is achieved and maintained for atthan 3-4 times a day. Once control is achieved and maintained for atleast 3 months, gradual reduction of therapy should be tried.least 3 months, gradual reduction of therapy should be tried.



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• Medium-dose inhaled glucocorticosteroidMedium-dose inhaled glucocorticosteroid plus plus sustained-release tsustained-release t heophylline,heophylline, or or

• Medium-dose inhaled glucocorticosteroidMedium-dose inhaled glucocorticosteroid plus plus long-acting inhaledlong-acting inhaled ββ 22- agonist,- agonist, or or

• High-dose inhaled glucocorticosteroidHigh-dose inhaled glucocorticosteroid ,, or or

• Medium-doseMedium-dose InhaledInhaledglucocorticosteroidglucocorticosteroid plus plus leukotrieneleukotrienemodifier modifier

• Medium-dose inhaledMedium-dose inhaledglucocorticosteroidglucocorticosteroid

Step 3:Step 3:ModerateModeratepersistentpersistent

Other Options (in order of cost)Other Options (in order of cost)Daily Controller Daily Controller MedicationsMedications

SeveritySeverity

Reliever Medication: Rapid-acting inhaledReliever Medication: Rapid-acting inhaled ββ 22- agonist prn, not more- agonist prn, not morethan 3-4 times a day. Once control is achieved and maintained for atthan 3-4 times a day. Once control is achieved and maintained for atleast 3 months, gradual reduction of therapy should be tried.least 3 months, gradual reduction of therapy should be tried.



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• High-dose inhaled glucocorticosteroidHigh-dose inhaled glucocorticosteroid plus plus one or more of the following, if one or more of the following, if

needed:needed:- Sustained-release theophylline- Sustained-release theophylline- Leukotriene modifier - Leukotriene modifier - Long-acting inhaled- Long-acting inhaled ββ 22 - agonist- agonist

- Oral glucocorticosteroid- Oral glucocorticosteroid

Step 4Step 4SevereSevere

persistentpersistent

Other Other OptionsOptions

Daily Controller MedicationsDaily Controller MedicationsSeveritySeverity

Reliever Medication: Rapid-acting inhaledReliever Medication: Rapid-acting inhaled ββ 22- agonist prn, not more- agonist prn, not morethan 3-4 times a day. Once control is achieved and maintained for atthan 3-4 times a day. Once control is achieved and maintained for at

least 3 months, gradual reduction of therapy should be tried.least 3 months, gradual reduction of therapy should be tried.




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Part 5: Establish Plans for ManagingExacerbations

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

inhaled β 2-agonist• Early introduction of systemic

glucocorticosteroids

• Oxygen supplementationClosely monitor response to treatmentwith serial measures of lung function



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Acute Asthma

Good Response

Observe for atleast 1 hour

If Stable,Discharge to

Home

Initial AssessmentHistory, Physical Examination, PEF or FEV 1

Initial TherapyBronchodilators; O 2 if needed

Incomplete/Poor Response

Add Systemic Glucocorticosteroids

Good Response

Discharge

Poor Response

Admit to Hospital

Respiratory Failure

Admit to ICU




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Part 6: Provide Regular Follow-up Care

Continual monitoring is essential to assure thattherapeutic goals are met. Frequent follow-up visitsare necessary to review:

Home PEF and symptom recordsTechniques in use of medicationsRisk factors and their control

Once asthma control is established, follow-upvisits should be scheduled (at 1 to 6 month intervalsas appropriate)



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Six-part Asthma ManagementProgram: Summary (continued)

Anything more than mild, occasional asthma isAnything more than mild, occasional asthma ismore effectively controlled by suppressingmore effectively controlled by suppressinginflammation than by only treating acuteinflammation than by only treating acutebronchospasmbronchospasm

The availability of varying forms of treatment,The availability of varying forms of treatment,cultural preferences, and differing health carecultural preferences, and differing health caresystems need to be consideredsystems need to be considered



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Thank you for listening…

asthma; basis of current management

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