Kronik Astim Tedavisi by HC120918073847

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									  Genetic         Enviromental risk
susceptibility          factors




       Triggers    Triggers
  AIM OF THE TREATMENT

Prevent of the symptoms
Normal pulmonary function
Normal dailly activity
Prevent of the attacks
Avoiding of the drugs side effects
Needs the expectations of patients and families
       Asthma Management


   Education
               +     Avoidance
                                   ±   Prevention


Severity of the disease                    Drugs



                Long term treatment plan
  Difficulties in evaluation of
        asthma severity
Severity evaluation is diffucult during pharmacologic
treatment
Asthma is a variable disease.It is difficult to assess
the asthma severity in only one visit
Symptoms are not associated with asthma severity.
Response to treatment is variable. There is no similar
response in same severity patients.



                  Li JT. Attaining Optimal Asthma Control: A Practice Parameter JACI 2005; 116: S3-11
The problem of perception in airway
           obstruction

  Metacholine test in 82 asthmatic patients

  %15 of the patients were unpercepted in
  %50 decrease of FEV1

  Weak perception in 1/7 of asthmatic
  patients

                           Rubinfeld & Pain. Lancet. 1976.R
Asthma Control Studies




                                            INS PI RE
          FACET




                                 AI R E T
                        AI R E
               OPTIMA
    Woolcock



                                            2005
  % 50 of the patients were
        uncontrolled
   Controlled                     Uncontrolled

20-24                                   5-14

  25
                           18%          15-19




                44%
                            31%

                      7%

                                        Neffen et al, ATS 2006
Asthma Diagnosis and Treatment
          Guidelines
             1991                                          2006-2007




        SEVERITY                                           CONTROL




  Global Initiative for asthma. Global strategy for asthma management and prevention. NHLBI/WHO workshop report
           National Asthma Education and Prevention Program Expert panel report: Guidelines for the Diagnosis and
                                                                                         Management of Asthma.
GINA 2006:

  STEP TREATMENT
ACCORDING CONTROL
What is changed in Asthma Treatment?
 AIM:Achieve control and maintainance

 Treatment for achieving control


  American Academy of Asthma Allergy and Clinical
  Immunology Practice Standards 2005

 French guidelines 2005

 ERS/ATS Task Force on Asthma Severity and Control 2006

 GINA 2006
     Management of the
         Asthma

Education
            +     Avoidance
                               ±   Prevention



 Control level                         Drugs
 of the disease


            Long term treatment plan
            Total Control
No symptom
No rescue medication
No nocturnal symptom and awakening
No limitation exercise ,loss of the school and
work
Asthma is controlled according to physician
and patient
FEV1 and PEF normal or in the personal best
value

                Li JT. Attaining Optimal Asthma Control: A Practice Parameter JACI 2005; 116: S3-11
 Valided Asthma Control Tests
ACT   http://www.asthmacontrol.com

ACQ http://www.qoltech.co.uk/Asthma1.htm

ATAQ http://www.ataqinstrument.com
       GINA 2006 :Levels of asthma controls
Characteristics   Controlled       Partly controlled        Uncontrolled
                  (must be all)    (any measure present any
                                   week)

Day time          None             Twice or more/week      Three or more
symptoms          ( 0-2 / week)                            present in any
Nocturnal         None             Any                         week
symptoms
Limitation of     None             Any
activities
Need for rescue None or minimal    Twice or more/week
reliever treatment ( 0-2 / week)

FEV1 - PEF        Normal           < %80 predicted or
                                   personal best
Exacerbations     None             One or more/yearl      One in any week
 Management approach based on
           control




                         Reduce
Level of control                         Treatment action
                                      Maintain and fine lowest
   Controlled                             controlling step

                                      Consider stepping up to




                         Increase
Partly controlled                          gain control

  Uncontrolled                        Step up until controlled

  Exacerbation                         Treat as exacerbation




Reduce              Treatment steps            Increase

                                                          GINA Workshop Report 2006
                                       GINA 2006 : Asthma Treatment

    Step 1           Step 2                     Step 3                   Step 4                      Step 5

                          Asthma education Environmental control
As needed
rapid-acting
ß 2 -agonist
                                  As needed rapid-acting ß 2 -agonist
                  Select one                 Select one             Add one or more            Add one or more


                                                                  Medium-or high-dose ICS   Oral corticosteroid (lowest
                  Low-dose ICS          Low-dose ICS plus LABA
                                                                        plus LABA                      dose)


               Leukotriene modifier*    Medium-or high-dose ICS     Leukotriene modifier             Anti IgE
 Controller
  options
                                          Low-dose ICS plus          Sustained release
                                          leukotriene modifier         theophylline


                                           Low-dose ICS plus
                                            sustained release
                                              theophylline


                                                                                                          www.ginasthma.org
    National Childhood Asthma
      Control and Cost Study
     • Multicenter study (12
       centers)April 2006
     • 6-18 years of ages asthmatic
       children, n: 618, followed 1 year
•     study moderator; BE.Şekerel
    National Childhood Asthma Control Study

Aim                         Results
Loss of school due to       At least 1 day: 461 (74.6%)
asthmaı                     mean: 7.6 ± 9.5 gün
Emergency department        At least unplanned visit: 273 (44.2%)
and /or hospitalty          mean: 2.4 ± 0.2
                            At least 1 emergency visit: 185 (29.9%)
                            Mean: 2.5 ± 2.2
                            At least 1 hospitality: 84 (13.6%)
Effect of quality of life    Dailly activities (%)
                               No: 31.4
                               Yes mild/moderate/severe: 38.3/ 24.6/ 5.7
                            The effect on the school performance(%)
                               No64.4
                               Yes mild,moderate,severe: 21.9/ 11.2/ 2.5
                            At least one day work lost of father: 38.5%
                            At least one day work lost of mother: 12.8%
National Childhood Asthma Control Study

•Decreasing factors in asthma control during
 last 4 weeks
  Moderate/severe asthma
  Hospitality in last one year
  No inhaled steroids
  Female
•The most important problem in therapy
  Unappropriate asthma step treatment
Cost          Mean             Median
Medical       1054,9 ± 82,1    692,8


Non-medical   1130,6 ± 311,7   140,0


Total         2185,6 ± 321,5   1023,9
USD coast




            Mild asthma   Modarate / severe asthma
            Annual direct cost per one patient




      Adana




Centers
      Mersin




          Bursa
Direct medical cost of asthma in
            Ankara




     Celik GE et al. Direct medical cost of asthma in Ankara, Turkey.
     Respiration 2004 Nov-Dec;71(6):587-93.
       Cost difference according the
               asthma severity
100%
 90%
 80%
 70%                                         other health
 60%                                         support
 50%                                         tests
 40%                                         visits
 30%
 20%                                         Hospital
 10%
                                             treatment
  0%
         HI      HP       OP       AP

          65     324.8    630.8     1317              P<0.001
        ±19.5$   ±26.5$   ±53.5$   ±157.6$

								
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