Bronchial Asthma Dr Adnan

G lobal INitiative for A sthma By: bo_3eza (not bo_3azeez) Program Objectives  Increase appreciation of asthma as a global public health problem  Present key recommendations for diagnosis and management of asthma  Provide strategies to adapt recommendations to varying health needs, services, and resources  Identify areas for future investigation of particular significance to the global community Definition of Asthma    A chronic inflammatory disorder of the airways Many cells and cellular elements play a role Chronic inflammation leads to an increase in airway hyperresponsiveness with recurrent episodes of wheezing, coughing, and shortness of breath Widespread, variable, and often reversible airflow limitation  Definition of Asthma  Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role Chronic inflammation causes an associated increase in airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment   You have to know the definition of asthma as in the 2 slides above. Chronic Inflammatory disorder Of the airway Involving many cells episodes of wheezing, breathlessness, chest tightness, and coughing. Mechanisms Underlying the Definition of Asthma This will make it easier for u Risk Factors (for development of asthma) INFLAMMATION Airway Hyperresponsiveness Airflow Obstruction Risk Factors (for exacerbations) Symptoms Burden of Asthma  Asthma is one of the most common chronic diseases worldwide Prevalence increasing in many countries, especially in children A major cause of school/work absence    An overall increase in severity of asthma increases the pool of patients at risk for death • One of the most common chronic diseases • Increasing in prevalence, morbidity, and mortality. 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   Worldwide Variation in Prevalence of Asthma Symptoms International Study of Asthma and Allergies in Children (ISAAC) Lancet 1998;351:1225 prevalence of asthma in Kuwait is one of the most common in the world Increasing Prevalence of Asthma in Children/Adolescents {1966 1989 Sweden {1979 1991 Japan {1982 1992 Scotland {1982 1992 UK {1989 1994 USA {1982 1992 New Zealand 1975 {1989 Australia {1982 1992 Finland (Haahtela et al) (Aberg et al) (Nakagomi et al) (Rona et al) (Omran et al) (NHIS) (Shaw et al) (Peat et al) 0 5 10 15 20 25 30 35 Prevalence (%) Countries should enter their own data on burden of asthma. The following three slides are US data on prevalence, hospitalization rates and mortality. Trends in Prevalence of Asthma By Age, U.S., 1985-1996 80 70 60 Rate/1,000 Persons Age (years) <18 18-44 45-64 50 40 65+ Total (All Ages) 30 20 85 86 87 88 89 90 91 92 93 94 Year 95 96 Hospitalization Rates for Asthma by Age, U.S., 1974 - 1997 Rate/100,000 Persons 40 35 30 25 20 <15 15-44 45-64 65+ 15 10 5 0 74 76 78 80 82 84 86 Year 88 90 92 94 96 Death Rates for Asthma By Race, Sex, U.S., 1980-1998 Rate/100,000 Persons 5 Black Female 4 3 Black Male White Female 2 1 0 1980 White Male 1985 1990 1995 2000 Year More common in Africans and low class. 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 Air Pollutants Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs     Risk Factors that Lead to Asthma Development Host Factors  Genetic predisposition  Atopy  Airway hyperresponsiveness  Gender  Race/Ethnicity Environmental Factors Indoor allergens  Outdoor allergens  Occupational sensitizers  Tobacco smoke  Air Pollution  Respiratory Infections  Parasitic infections  Socioeconomic factors  Family size  Diet and drugs  Obesity  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 (the dr. said many patients comes with this complaint)  Asthma Diagnosis   History and patterns of symptoms Physical examination Measurements of lung function Measurements of allergic status to identify risk factors   Classification of Severity This is a very important slide that u have to know CLASSIFY SEVERITY Clinical Features Before Treatment Symptoms STEP 4 Continuous Nocturnal Symptoms FEV1 or PEF  60% predicted Severe Persistent STEP 3 Moderate Persistent Limited physical activity Daily Attacks affect activity Frequent Variability > 30% 60 - 80% predicted > 1 time week Variability > 30%  80% predicted STEP 2 Mild Persistent > 1 time a week but < 1 time a day < 1 time a week > 2 times a month Variability 20 - 30% STEP 1 Intermittent Asymptomatic and normal PEF between attacks  2 times a month  80% predicted Variability < 20% The presence of one feature of severity is sufficient to place patient in that category. Six-Part Asthma Management Program 1. Educate Patients 2. Assess and Monitor Severity 3. Avoid Exposure to Risk Factors 4. Establish Medication Plans for Chronic Management: Adults and Children 5. Establish Plans for Managing Exacerbations 6. Provide Regular Follow-up Care Six-Part Asthma Management Program 1. Educate patients to develop a partnership in asthma management 2. Assess and monitor asthma severity with symptom reports and measures of lung function as much as possible 3. Avoid exposure to risk factors 4. Establish medication plans for chronic management in children and adults 5. Establish individual plans for managing exacerbations 6. Provide regular follow-up care Six-part Asthma Management Program Goals of Long-term Management        Achieve and maintain control of symptoms Prevent asthma episodes or attacks Maintain pulmonary function as close to normal levels as possible Maintain normal activity levels, including exercise Avoid adverse effects from asthma medications Prevent development of irreversible airflow limitation Prevent asthma mortality Six-part Asthma Management Program Control of Asthma    Minimal (ideally no) chronic symptoms Minimal (infrequent) exacerbations No emergency visits Minimal (ideally no) need for “as needed” use of No limitations on activities, including exercise PEF circadian variation of less than 20 percent (Near) normal PEF Minimal (or no) adverse effects from medicine  β2-agonist     Six-Part Asthma Management Program .  The most effective management is to prevent airway inflammation by eliminating the causal factors Asthma can be effectively controlled in most patients, although it can not be cured The major factors contributing to asthma morbidity and mortality are underdiagnosis and inappropriate treatment   Six-Part Asthma Management Program  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 Six-part Asthma Management Program Part 1: Educate Patients to Develop a Partnership  Patient education involves a partnership between the patient and health care professional(s) with frequent revision and reinforcement  Aim is guided self-management – giving patients the ability to control their asthma  Interventions, including use of written action plans, have been shown to reduce morbidity in both children and adults Six-part Asthma Management Program Part 1: Educate Patients to Develop a Partnership  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 Six-part Asthma Management Program Part 1: Educate Patients to Develop a Partnership    Educate continually Include the family (children) Provide information about asthma   Provide training on self-management skills Emphasize a partnership among health care providers, the patient, and the patient’s family Six-part Asthma Management Program Factors Associated with Non-Compliance in Asthma Care Medication Usage  Patient/Physician Misunderstanding/lack of information      Difficulties associated with inhalers Complicated regimens Fears about, or actual side effects Cost   Underestimation of severity Attitudes toward ill health Cultural factors Poor communication  Six-part Asthma Management Program Part 2: Assess and Monitor Asthma Severity with Symptom Reports and Measures of Lung Function  Symptom  reports   Use of reliever medication Nighttime symptoms Activity limitations  Spirometry for initial assessment. Peak Expiratory Flow for follow-up:   Assess severity Assess response to therapy  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  Arterial blood gas for severe exacerbations Typical Spirometric (FEV1) Tracings Volume FEV1 Normal Subject Asthmatic (After Bronchodilator) Asthmatic (Before Bronchodilator) 1 2 3 4 Time (sec) 5 Note: Each FEV1 curve represents the highest of three repeat measurements A Simple Index of PEF Variation 800 700 600 500 Highest PEF (670) PEF (L/min) Lowest morning PEF (570) 400 300 Morning PEF Evening PEF 14 0 7 Days Minimum morning PEF ( % recent best): 570/670 = 85% (From Reddel, H.K. et al. 1995) Six-part Asthma Management Program Part 3: Avoid Exposure to Risk Factors  Methods to prevent onset of asthma are not yet available but this remains an important goal  Measures to reduce exposure to causes of asthma exacerbations (e.g. allergens, pollutants, foods and medications) should be implemented whenever possible Six-part Asthma Management Program Part 3: Avoid Exposure to Risk Factors     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  Six-part Asthma Management Program 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 inhaled glucocorticosteroids markedly reduces the frequency and severity of exacerbations Six-part Asthma Management Program Part 4: Establish Medication Plans for Long-Term Asthma Management  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 Part 4: Long-term Asthma Management Stepwise Approach to Asthma Therapy The choice of treatment should be guided by:    Severity of the patient’s asthma Patient’s current treatment Pharmacological properties and availability of the various forms of asthma treatment Economic considerations  Cultural preferences and differing health care systems need to be considered. Part 4: Long-term Asthma Management Pharmacologic Therapy Controller Medications: Inhaled glucocorticosteroids  Systemic glucocorticosteroids  Cromones  Methylxanthines  Long-acting inhaled β2-agonists  Long-acting oral β2-agonists  Leukotriene modifiers  You have to You have to know the difference between each class, (controllers, relievers) U have to know each drug belong to which class. Synergestic affect: B blocker (increase steroids affect) + steroids (increase B receptors, side affects candida and voice Part 4: Long-term Asthma Management Pharmacologic Therapy Reliever Medications:  Rapid-acting inhaled β2-agonists Systemic glucocorticosteroids Anticholinergics Methylxanthines Short-acting oral β2-agonists     • The dr. said to concentrate on the first 39 slides and forget about the rest. • They are for u nerds (etc:.MuzMuz). Part 4: Long-term Asthma Management Stepwise Approach to Asthma Therapy - Adults Outcome: Asthma Control Outcome: Best Possible Results Controller:  Controller: Controller: None  Controller: Daily inhaled corticosteroid    Daily inhaled corticosteroid Daily longacting inhaled β2-agonist  Daily inhaled corticosteroid Daily long – acting inhaled β2-agonist plus (if needed)  When asthma is controlled, reduce therapy Monitor -Theophylline-SR -Leukotriene -Long-acting inhaled β2- agonist -Oral corticosteroid  Reliever: Rapid-acting inhaled β2-agonist prn STEP 1: Intermittent STEP 2: Mild Persistent STEP 3: Moderate Persistent STEP 4: Severe Persistent STEP Down Alternative controller and reliever medications may be considered (see text). Recommended Asthma Medications Step 1: Adults Severity Daily Controller Medications Other Options (in order of cost) • None Step 1: • None Intermittent Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried. Recommended Asthma Medications Step 2: Adults Severity Step 2: Mild Persistent Daily Controller Medications • Inhaled glucocorticosteroid (< 500 μg BDP or equivalent) Other Options (in order of cost) • Sustained-release theophylline, or • Cromone, or • Leukotriene modifier Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried. Recommended Asthma Medications Step 3: Adults Severity Step 3: Moderate persistent Daily Controller Medications • Inhaled glucocorticosteroid (200 – 1000 μg BDP or equivalent) plus long-acting inhaled β2- agonist Other Options (in order of cost) • Inhaled glucocorticosteroid (500 – 1000 μg BDP or equivalent) plus sustainedrelease theophylline, or • Inhaled glucocorticosteroid (500 – 1000 μg BDP or equivalent) plus long-acting inhaled β2- agonist, or • Inhaled glucocorticosteroid at higher doses (> 1000 μg BDP or equivalent), or • Inhaled glucocorticosteroid (500 – 1000 μg BDP or equivalent) plus leukotriene modifier Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried. Recommended Asthma Medications Step 4: Adults Severity Step 4 Severe persistent Daily Controller Medications • Inhaled glucocorticosteroid ( > 1000 μg BDP or equivalent) plus long-acting inhaled β2- agonist • plus one or more of the following, if needed: - Sustained-release theophylline - Leukotriene modifier - Long-acting inhaled β2- agonist - Oral glucocorticosteroid Other Options Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried. Part 4: Long-term Asthma Management Allergen-specific Immunotherapy Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis  A number of questions must be addressed regarding the role of specific immunotherapy in asthma therapy  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 Six-part Asthma Management Program 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. Six-part Asthma Management Program Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and Children  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 Six-part Asthma Management Program Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and Children  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 Six-part Asthma Management Program Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and Children  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 Recommended Asthma Medications Step 1: Children Severity Daily Controller Medications Other Options (in order of cost) • None Step 1: • None Intermittent Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried. Recommended Asthma Medications Step 2: Children Severity Step 2: Mild Persistent Daily Controller Medications • Inhaled glucocorticosteroid (100 – 400 μg budesonide or equivalent) Other Options (in order of cost) • Sustained-release theophylline, or • Cromone, or • Leukotriene modifier Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried. Recommended Asthma Medications Step 3: Children Severity Daily Controller Medications Other Options (in order of cost) Step 3: • Inhaled glucocorticosteroid • Inhaled glucocorticosteroid (< 800 μg Moderate ( 400 – 800 μg budesonide budesonide or equivalent) plus sustained-release theophylline, or persistent or equivalent) • Inhaled glucocorticosteroid (< 800 μg budesonide or equivalent) plus longacting inhaled β2- agonist, or • Inhaled glucocorticosteroid at higher doses (> 800 μg budesonide or equivalent), or • Inhaled glucocorticosteroid (< 800 μg budesonide or equivalent) plus leukotriene modifier Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried. Recommended Asthma Medications Step 4: Children Severity Step 4 Severe persistent Daily Controller Medications • Inhaled glucocorticosteroid ( > 800 μg budesonide or equivalent) • plus one or more of the following, if needed: - Sustained-release theophylline - Leukotriene modifier - Long-acting inhaled β2- agonist - Oral glucocorticosteroid Other Options Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried. Six-part Asthma Management Program Part 5: Establish Plans for Managing Exacerbations Treatment of exacerbations depends on:  The patient  Experience of the health care professional  Therapies that are the most effective for the particular patient  Availability of medications  Emergency facilities Six-part Asthma Management Program Part 5: Establish Plans for Managing Exacerbations 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 serial measures of lung function Six-part Asthma Management Program Part 5: Managing Severe Asthma Exacerbations  Severe exacerbations are lifethreatening medical emergencies  Care must be expeditious and treatment is often most safely undertaken in a hospital or hospital-based emergency department Emergency Department Management Acute Asthma Initial Assessment History, Physical Examination, PEF or FEV 1 Initial Therapy Bronchodilators; O2 if needed Good Response Incomplete/Poor Response Add Systemic Glucocorticosteroids Good Response Poor Response Admit to Hospital Respiratory Failure Observe for at least 1 hour If Stable, Discharge to Home Discharge Admit to ICU Six-part Asthma Management Program Part 6: Provide Regular Follow-up Care Continual monitoring is essential to assure that therapeutic goals are met. Frequent follow-up visits are necessary to review:  Home PEF and symptom records  Techniques in use of medications  Risk factors and their control Once asthma control is established, follow-up visits should be scheduled (at 1 to 6 month intervals as appropriate) Six-part Asthma Management Program Special Considerations Special considerations are required to manage asthma in relation to:  Pregnancy  Surgery  Physical activity  Rhinitis, sinusitis, and nasal polyps  Occupational asthma  Respiratory infections  Gastroesophageal reflux  Aspirin-induced asthma Six-part Asthma Management Program: Summary  Asthma can be effectively controlled, although it cannot be cured  Effective asthma management programs include education, objective measures of lung function, environmental control, and pharmacologic therapy A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication  Six-part Asthma Management Program: Summary (continued)  Anything more than mild, occasional asthma is more effectively controlled by suppressing inflammation than by only treating acute bronchospasm The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered  Part 4: Long-term Asthma Management Stepwise Approach to Asthma Therapy - Adults Outcome: Asthma Control Outcome: Best Possible Results Controller:  Controller: Controller: None  Controller: Daily inhaled corticosteroid    Daily inhaled corticosteroid Daily longacting inhaled β2-agonist  Daily inhaled corticosteroid Daily long – acting inhaled β2-agonist plus(if needed)  When asthma is controlled, reduce therapy Monitor -Theophylline-SR -Leukotriene -Long-acting inhaled β2- agonist -Oral corticosteroid  Reliever: Rapid-acting inhaled β2-agonist prn STEP 1: Intermittent STEP 2: Mild Persistent STEP 3: Moderate Persistent STEP 4: Severe Persistent STEP Down Alternative controller and reliever medications may be considered (see text). Stepwise Approach to Asthma Therapy: Adults Step 1: Intermittent Asthma Daily Controller Medications None required Reliever Medications Rapid-acting inhaled  2-agonist for symptoms (but < once a week) Rapid-acting inhaled  2-agonist, cromone, or leukotriene modifier before exercise or exposure to allergen     Continuously review medication technique, compliance and environmental control Review treatment every three months. Step up if control is not achieved; step down if control is sustained for at least 3 months Preferred treatments are in bold print Stepwise Approach to Asthma Therapy: Adults Step 2: Mild Persistent Asthma Daily Controller Medications Inhaled glucocorticosteroid (< 500 μg BDP or equivalent) Other options (order by cost):  sustained-release theophylline, or  Cromone, or  leukotriene modifier Reliever Medications Rapid-acting inhaled  2-agonist for symptoms (but < 3-4 times/day) Other options:  inhaled anticholinergic, or  short-acting oral  2-agonist, or  short-acting theophylline     Continuously review medication technique, compliance and environmental control. Review treatment every three months Step up if control is not achieved; Step down if control is sustained for at least 3 months Preferred treatments are in bold print Stepwise Approach to Asthma Therapy: Adults Step 3: Moderate Persistent Asthma Daily Controller Medications Reliever Medications Inhaled glucocorticosteroid, (200 – 1000 μg BDP or Rapid-acting inhaled equivalent) plus long-acting inhaled β2agonist  2-agonist for symptoms Other options (order by cost): (but < 3 - 4 times/day)  Inhaled glucocorticosteroid (500 – 1000 μg BDP equivalent) plus sustained-release theophylline, or Other options:  Inhaled glucocorticosteroid (500 – 1000 μg BDP  inhaled anticholinergic or equivalent) plus long-acting inhaled β2- agonist, or  short-acting oral  inhaled glucocorticosteroid at higher doses  2-agonist or (> 1000 μg BDP equivalent), or  short-acting theophylline  Inhaled glucocorticosteroid (500 – 1000 μg BDP equivalent) plus leukotriene modifier     Continuously review medication technique, compliance and environmental control. Review treatment every three months. Step up if control is not achieved; Step down if control is sustained for at least 3 months. Preferred treatments are in bold print. Stepwise Approach to Asthma Therapy: Adults Step 4: Severe Persistent Asthma Daily Controller Medications Inhaled glucocorticosteroid, (> 1000 μg BDP or equivalent) plus long-acting inhaled β2agonist plus one or more of the following, if needed (order by cost):  sustained-release theophylline, or  leukotriene modifier or  oral glucocorticosteroid Reliever Medications Rapid-acting inhaled  2-agonist for symptoms (but < 3-4 times/day) Other options:  inhaled anticholinergic or  short-acting oral  2-agonist or  short-acting theophylline     Continuously review medication technique, compliance and environmental control. Review treatment every three months. Step up if control is not achieved; Step down if control is sustained for at least 3 months. Preferred treatments are in bold print.