asthma fan huizhen pulmonary medicine zhujiang hospital southern medical university

Asthma

Fan HuizhenPulmonary MedicineZhujiang Hospital Southern medical university

Definition of AsthmaDefinition 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

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, MDSource: Peter J. Barnes, MD

Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, Source: Peter J. Barnes, MDMD

Mechanisms: Asthma Inflammation

Source: Peter J. Barnes, Source: Peter J. Barnes, MDMD

Asthma Inflammation: Cells and Mediators

哮喘病理生理学

• 支气管高反应性• 平滑肌增生 /体积增大

• 炎症介质释放增多

• 炎症细胞数增加• 黏膜水肿• 支气管高反应• 气道分泌物增加• 上皮损伤

• 细胞增生（平滑肌细胞、黏液腺）• 基质蛋白沉积增加• 基底膜增厚• 血管新生

平滑肌功能障碍平滑肌功能障碍

气道炎症气道炎症

气道重塑气道重塑

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 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

Burden of Asthma

Health care expenditures very high

Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma. Developing economies likely to face increased demand

Poorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care

Health care expenditures very high

Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma. Developing economies likely to face increased demand

Poorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care

Asthma Prevalence and Mortality

SourceSource: Masoli M et al. Allergy 2004: Masoli M et al. Allergy 2004

中国是哮喘病死率最高的国家之一5~34 岁年龄组患者哮喘病死率（ case-fatality rates )

36.7/10 万

( >10.0/10 万，处于高水平 )

Masoli M (2004). The global burden of asthma GINA report. Masoli M (2004). The global burden of asthma GINA report.

在中国，每 100,000 位哮喘患者中有 36.7 位哮喘患者会因哮喘死亡。 GINA2004

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

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 AsthmaFactors 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

Host Factors Genetic - Atopy - Airway

hyperresponsiveness Gender Obesity

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

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

Is it Asthma?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

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) TracingsTypical Spirometric (FEV1) Tracings

11Time (sec)Time (sec)22 33 44 55

FEV1FEV1

VolumeVolume

Normal SubjectNormal Subject

Asthmatic (After Bronchodilator)Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)Asthmatic (Before Bronchodilator)

Note: Each FEV1 curve represents the highest of three repeat measurementsFEV1 increased ≥12% and ≥200ml

Measuring Airway Responsiveness

FEV1 decreased ≥20%

Clinical Control of Asthma

No (or minimal)* daytime symptoms

No limitations of activity

No nocturnal symptoms

No (or minimal) need for rescue medication

Normal lung function

No exacerbations_________* Minimal = twice or less per week

Levels of Asthma Control

CharacteristicControlled

(All of the following)Partly controlled

(Any present in any week)Uncontrolled

Daytime symptomsNone (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 Partnership

2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations

5. Special Considerations

1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations

5. Special Considerations

Asthma Management and PreventionProgram: Five ComponentsAsthma Management and PreventionProgram: Five Components

Revised 2006

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

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

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

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







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

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





Key factors to facilitate communication:

Friendly demeanor

Interactive dialogue

Encouragement and praise

Provide appropriate information

Feedback and review

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 Control

Your 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.


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 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

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





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

基于哮喘临床控制的哮喘管理

评估评估哮喘控制水平水平

治疗并达到治疗并达到哮喘控制

监测并维持监测并维持哮喘控制

2006 GINA2006 GINA2006 GINA2006 GINA

哮喘管理模式

A stepwise approach to pharmacological therapy is recommended

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

A stepwise approach to pharmacological therapy is recommended

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





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 considerations

Cultural preferences and differing health caresystems need to be considered

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 considerations

Cultural preferences and differing health caresystems need to be considered





Component 4: Asthma Management and Prevention Program

Controller MedicationsComponent 4: Asthma Management and Prevention Program

Controller Medications

Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists Systemic glucocorticosteroids Theophylline Hormones Long-acting oral β2-agonists Anti-IgE

Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists Systemic glucocorticosteroids Theophylline Hormones Long-acting oral β2-agonists Anti-IgE

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by AgeEstimate 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

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

倍氯米松 200-500 100-200 >500-1000 >200-400 >1000 >400

布地奈德 200-600 100-200

600-1000 >200-400 >1000 >400

布地奈德混悬液 250-500

>500-1000

>1000

环索奈德 80 – 160 80-160 >160-320 >160-320 >320-1280 >320

氟尼缩松 500-1000 500-750

>1000-2000 >750-1250 >2000 >1250

氟替卡松 100-250 100-200

>250-500 >200-500 >500 >500

糠酸莫米松 200-400 100-200

> 400-800 >200-400 >800-1200 >400

曲安奈德 400-1000 400-800

>1000-2000 >800-1200 >2000 >1200

Component 4: Asthma Management and Prevention Program

Reliever MedicationsComponent 4: Asthma Management and Prevention Program

Reliever Medications

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids

Anticholinergics

Theophylline

Short-acting oral β2-agonists

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids

Anticholinergics

Theophylline

Short-acting oral β2-agonists

Component 4: Asthma Management and Prevention Program Allergen-specific Immunotherapy

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

Perform only by trained physician

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 CONTROLLEVEL OF CONTROL

maintain and find lowest controlling step

consider stepping up to gain control

step up until controlled

treat as exacerbation

TREATMENT OF ACTIONTREATMENT OF ACTION

TREATMENT STEPSREDUCE INCREASE

STEP

1STEP

2STEP

3STEP

4STEP

5

RE

DU

CE

INC

RE

AS

E

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


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)


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)


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)



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


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)


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)


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

MDI使用方法

贮雾罐使用方法

雾化吸入方法


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)

大多数哮喘患者可以达到哮喘控制

控制改善良好控制完全控制

(~40%)

(~40%)

(~20%)

Bateman ED et al. AJRCCM 2004

哮喘控制



使用哮喘管理工具评估哮喘控制

哮喘控制测试 (ACT) 、哮喘控制问卷 (ACQ) 、哮喘治疗评估问卷（ ATAQ ）是：

经验证的、用于评估哮喘控制的工具，通过提供具体数值区分哮喘控制的不同水平

不仅被推广用于研究，也用于基层医疗单位中患者哮喘控制评估

可改善对哮喘控制的评估，并提供可反复使用的客观指标，有助于改善医生和患者间的交流

Schatz et al. 2004.


25 分：哮喘完全控制20 － 24 分：哮喘良好控制<20 分：哮喘未得到控制

需要改变治疗方案，以达到哮喘控制

ACT 评分的使用


控制：确定维持哮喘控制所需最低治疗级别

部分控制：考虑升级治疗以达到哮喘控制

未控制：升级治疗直至达到哮喘控制


为达到哮喘控制的治疗方案

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

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







Treatment of exacerbations depends on: The patient Experience of the health care professional Availability of medications Emergency facilities

Treatment of exacerbations depends on: The patient Experience of the health care professional Availability of medications Emergency facilities

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

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





Emergency Department Management

Acute AsthmaEmergency Department Management

Acute Asthma

Good Response

Observe for at least 1

hour

If Stable, Discharge to

Home

Initial AssessmentHistory, Physical Examination, PEF or FEV1

Initial TherapyBronchodilators; O2 if needed

Incomplete/Poor Response

Add Systemic Glucocorticosteroids

Good Response

Discharge

Poor Response

Admit to Hospital

Respiratory Failure

Admit to ICU


Special ConsiderationsAsthma Management and Prevention Program

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

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

Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms

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

Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms

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

Asthma Management and Prevention Program: SummaryAsthma Management and Prevention Program: Summary

A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication

The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered

A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication

The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered

Asthma Management and Prevention Program: SummaryAsthma Management and Prevention Program: Summary

asthma fan huizhen pulmonary medicine zhujiang hospital southern medical university

Documents

burden of asthma asthma

asthma inflammation

development of asthma

asthma development

asthma prevalence

controlled asthma

asthma host factors

definition of asthma