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New asthma ppp modified 2011
 

New asthma ppp modified 2011

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    New asthma ppp modified 2011 New asthma ppp modified 2011 Presentation Transcript

    • KENYA MEDICAL ASSOCIATION
      CME: SAROVA PANAFRIC HOTEL
      ASTHMA UPDATE
      DR. JOSEPH A ALUOCH F.R.C.P., E.B.S.,
      2nd JUNE 2011
    • ASTHMA
      Less understanding of Aetiology/Pathogenesis
      Genetics complex
      Control of Airway Tone?
      Reversible AWO: variability
      BHR
      Asthma no single aetiology
      Chronic Inflammation
      Dynamic Process
      Healing and Repair (Remodelling)
    • ASTHMA THE DISEASE
      No clear concept of normality
      Disease variation
      Lack of correlation between disease and outcome
      Patient understanding the severity.
      Lack of correlation between FEV and other outcome.
    • Defining asthma can be difficult !
    • Defining Asthma
      Bronchial hyperresponsiveness
      Airway inflammation
      Central features, but not defining for individual characteristics of phenotypes
    • DEFINITION
      Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role
      The ability to synthesize IgE antibody to environmental allergens (i.e., atopy) remains a major risk factor in asthma pathogenesis.
    • INFLAMMATION IN ASTHMA
      MECHANISM:
      CHANGES
      PROCESS
      ASSESSMENT
      HISTOLOGICAL CHANGES
      INFLAMMATORY CELLS
      LOCAL FACTOR
      FACTORS
      :STILL LARGELY UNCLEAR
      : PRIMARY OR SECONDARY
      : INITIATION
      :PERSISTENCE PROGRESS
      E.C.P, N.O, PEFR;
      RELATION TO SEVERITY
      : NON-ALLERGIC
      :ATOPY
      :EXERCISE INDUCED
      :PRIMARY
      :SECONDARY
      :LUNG TRANSPLANT
      :ATOPY
      :ENVIRONMENT
    • INDUCERS
      Allergens,Chemical sensitisers,
      Air pollutants, Virus infections
      INFLAMMATION
      Airway
      Hyper-responsiveness
      Airflow Limitation
      SYMPTOMS
      Cough Wheeze
      Chest tightness
      Dyspnoea
      TRIGGERS
      Allergens,
      Exercise
      Cold Air, SO2
      Particulates
    • ASTHMA UPDATE
      OTHER FACTORS LIMITING AIRFLOW
      Airway edema secondary to eosinophilic inflammation
      Mucus hypersecretion
      Structural changes i.e. hypertrophy and hyperplasia of smooth muscular tissue; tissue fibrosis as part of remodeling.
    • Inflammatary Cells
      Mast Cells
      Eosinophils
      Th2 Cells
      Basophils
      Platelets
      Structural Cells
      Epithelial Cells
      Smooth Muscles Cells
      Fibroblast
      Nerves
      Mediators
      Histamine
      Leukotrienes
      Prostanoids
      PAF
      Kinins
      Adenosine
      Endothelins
      Nitric Oxide
      Cytokines
      Chemokines
      Growth Factors
      Effects
      Bronchospasm
      Plasma exudation
      Mucus secretion
      AHR
      Structural Changes
    • IgE PATHOGENESIS
      IgE antibodies are synthesized to environmental allergens (atopy)
      Synthesized IgE binds to mast cells and basophils via high-affinity IgE receptors
      These cells are signaled to release preformed and newly generated mediators, including histamine & cysteinyl leukotrienes to rapidly contract airway smooth muscle
      Mast cells also produce a variety of cytokines (pro-inflammatory proteins) including interleukin (IL 1,2,3,4 &5), granulocyte-macrophage colony-stimulating factor, interferon and tumor necrosis factor-α
    • ATOPY
      Atopy is the genetic susceptibility to produce IgE ABs directed toward common environmental allergens, including house-dust mites, animal proteins, and fungi.
      With the production of IgE ABs, mast cells and possibly other airway cells (e.g., lymphocytes) are sensitized and become activated when they encounter specific antigens.
      Atopy has been found in 30 to 50% of the general population, therefore frequently found in the absence of asthma.
      Atopy is one of the strongest predisposing factors in the development of asthma.
    • EOSINOPHIL PATHOGENESIS
      Infiltration seen in all acute inflammation & many patients with chronic persistent asthma
      The granules are the source of inflammatory mediators
      Injure airway epithelium
      Enhance bronchial responsiveness
      Affect acetylcholine release
      Release cysteinyl leukotrienes to contract airway smooth muscle
      Eosinophils are produced & released from bone marrow via IL-5, migrate to airway via a number of factors
    • EOSINOPHIL PATHOGENESIS
      Although its role in pathophysiology is less clear, it is affected by anti-inflammatory therapy.
    • Reversible and variable airflow limitation
      Reversibility of airways’ obstruction
      Increased PEF >15% 15-20 minutes after inhaling ß2-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
      GINA Guidelines 1998
    • ASTHMA UPDATE
      AIRFLOW LIMITATION
      Bronchoconstriction occurs secondary to release of multi-mediators (histamine, leukotrienes, prostaglandins, PAF etc.
      Aeroallergen sensitivity
      Aspirin ( Non-IgE)
      Multi-factorial (exercise and cold air-osmotic; airborne irritants, laughing, GERD & sinusitis via neurogenic reflex; infections)
    • GOAL OF MANAGEMENT
      Minimal (ideally no) chronic (inc. nocturnal) symptoms
      Minimal (infrequent ) exacerbations
      No emergency visits
      Minimal need for prn Beta2-agonists
      No limitations on activities (inc. exercise)
      Near normal PEFR & variability <20%
      Minimal (or no ) adverse effects from medicine
    • Control
      Day time symptoms
      Limitation of activities
      Nocturnal symptoms
      Nocturnal awakenings
      Use of rescue medications
      Objective Ass. Lung F.Test
    • ASTHMA UPDATE
      • NEW DIRECTIONS
      CHANGES IN GUIDELINES
      CONTROL VS. SEVERITY
      HETEROGENEITY REGARDING ETIOLOGY
      DIFFERENT PHENOTYPES
      DIFFERENTIAL DIAGNOSIS- MASQUERADERS
      BETTER MONITORING
      ASTHMA EDUCATION
      BETTER SELF MONITORING
      MEDICAL MONITORING:SPIROMETRY
      NEW THERAPIES
      INHALED STEROIDS WITH NO OR MINIMAL BIOVAILABILITY
      OTHER NEW MOLECULES
      IMPROVED IMMUNOTHERAPIES
      IMPROVED EMPHASIS ON SELF-IMPROVEMENT: NUTRITION; PERSONAL HABITS; HOME ENVIRONMENT
    • ASTHMA UPDATE
      EARLY IDENTIFICATION OF HIGH RISK PATIENTS:
      IMMEDIATE CONCERNS:
      Improve quality of life
      Reduce risk for hospitalizations and death.
      LONG TERM CONCERNS:
      Prevent irreversible changes in airway structure i.e. remodeling with sub-basement fibrosis, mucus hypersecretion, s.m hypertrophy, & injury of lining (epithelium).
    • SYMPTOM CLASSIFICATION
      Severe Persistent
      Moderate Persistent
      Mild Persistent
      Mild Intermittent
    • SYMPTOM CLASSIFICATION
      Severe Persistent
      Day: continual
      Night: frequent
      Moderate Persistent
      Day: daily
      Night: >1/week
      Mild Persistent
      Day: >2/week (<1/day) [3-6/week]
      Night: >2/month
      Mild Intermittent
      Day: 2/week
      Night: 2/month
    • ASTHMA UPDATE
      AIRWAY HYPER-RESPONSIVENESS (TWITCHY LUNGS)
      Exaggerated bronchoconstrictor response to stimuli- triggers such as exercise, cold air, laughing, stress.
      Defined by methacholine/adenosine/mannitol responsiveness
      Rx directed towards reducing inflammation can reduce airway hyper-responsiveness.
    • ASTHMA UPDATE
      HETEROGENOUS PHENOTYPES OF ASTHMA:
      Different patterns of inflammation-targets for eventual treatment
      Many patients have overlapping phenotypes.
      Intermittent; Persistent
      Atopic (extrinsic) vs. Intrinsic
      Exercise induced
      Aspirin sensitive
      Late Onset
      Infection induced (RSV; parainfluenza; adenovirus, rhinovirus)
      Cough variant asthma
      Steroid resistant
    • ASTHMA UPDATE
      ESTABLISH DIAGNOSIS OF ASTHMA:
      History, physical and PFT to establish there are symptoms of airflow obstruction and/or airway hyperresponsiveness;
      At least evidence for reversibility
      Value of history
      What are the triggers in the home?
      Outdoor triggers?-pollens, time of year
      What else triggers asthma- aspirin, NSAIDs, URI’s cold air exercise, forest fires, smoking; positioning, foods,
      Family history
    • ASTHMA UPDATE
      Differential diagnosis:co-morbidities
      GERD;
      vocal cord dysfunction;
      foreign body;
      anatomical abn;
      hypersensitivity bronchopulmonary aspergillosis;
      Chronic sinusitis
      Churg’s syndrome;
      Samter’s syndrome;
      Cystic Fibrosis
      bronchiectasis;
      sleep apnea with aspiration;
      occupation and hobbies (birds);
      wheezing” with COPD
    • ASTHMA UPDATE
      PHYSICAL EXAM:
      Nasal exam- polyps
      Level of wheezing (high, low)
      High level over trachea: consider vocal cord dysfunction
      Hyperexpansion of chest
      Signs of chronicity i.e.(clubbing); consider bronchiectasis, COPD, C.F.
      Signs of hypoxemia (cyanotic nail beds)
      Lymphadenopathy or lack of with history of recurring respiratory infections (consider ID workup)
      Keep in mind undiagnosed adult CF (sweat test is not useful in adults)
    • ASTHMA UPDATE
      LABORATORY EVALUATION:
      r/o Atopy: skin tests properly applied and interpreted;
      Properly performed PFT pre and post BD
      PEF > FEV1; Expiration plateau for at least 6 seconds
      Reproducibility with BD- at least 2 measurements with FEV1 within 0.15 L.
      Reversibility in adults: >250 ml; FEV1> 12% or
      > 10% increase of pred FEV1% for adults. Later may separate COPD from asthma. May need oral steroids for reversibility.
      FEV1/FVC% should be included for children .
    • ASTHMA UPDATE
      Laboratory evaluation:
      • Other PFT:
      • Inspiratory loop for VCD
      • Methacholine challenge
      • Nasal exam/endoscopy- polyps; sinusitis;VCD
      • Chest Xray/ CT of chest on rare occasion
      Sinus CT
      Trial with protonics as a diagnostic tool (pH studies)
      Consider bronchoscopy and lung biopsy for difficult to diagnose and/or treat.
    • ASTHMA UPDATE
      NIH Guidelines: asthma classification
      Initially severity assessment:
      Based on medication usage; history of recent exacerbations, PFT; night time awakenings; persistent or intermittent.
      Initial Rx based on classification of severity
      Manage based on control of symptoms i.e. more functional emphasis:
      Use of rescue meds
      Night time awakenings
      Exacerbation rate
      Objective parameters –PFT; NO measurements
    • ASTHMA UPDATE
      Goals of Therapy
      Reduce impairment (current)
      Prevent troublesome symptoms (cough, breathlessness with exertion and at night)
      Reduce frequent use of SABA to < 2 days a week
      Maintain near normal PFT
      Maintain normal activity
      Reduce risk (future)
      Exacerbations
      Prevent ER visits and hospitalizations
      Prevent loss of lung function; children-prevent reduced lung growth
    • Managing asthma needs brains !
    • UPDATE ON ASTHMA
      Therapeutic Strategies to Improve Control:
      Education: preferably by experienced or certified asthma educator:
      Peak flows- setting parameters of when to call.
      Awareness of questions to ask: nocturnal awakenings, use of rescue meds.
      Asthma treatment plan: what to do when sx develop.
      How to use medications and when- very important
      Compliance checks
    • ASTHMA UPDATE
      Environmental & Personal Health Strategies
      Eliminate tobacco smoke ( in utero and passive)
      Associated with severity and dec. response to steroid Rx.
      Air pollution- forest fires
      Wood burning stoves
      Use of air purifier (HEPA) especially near open windows during pollen seasons
    • UPDATE ON ASTHMA
      Environmental & Personal Health Strategies
      Encourage breast feeding up to 6 months to minimize food allergy induction
      Home environmental control
      Individualize recommendations for aerobics in cold weather and during peak pollen counts.
      Speculative HYGIENE THEORY but worth noting:
      early exposure to daycare; rural environment; early exposure to animals- Favor immune responses away from allergy development;
      antibiotic use; Western lifestyle- Favor immune responses towards allergy responses.
    • UPDATE ON ASTHMA
      Environmental & Personal Health Strategies
      Control co-morbidities that can increase asthma:
      Allergic rhinitis/sinusitis –studies demonstrate that regular use of nasal steroids and/or AH reduce asthma flares and ER visits
      GERD- use of protonics decreases asthma.
      Obesity-dieting is important
      Leptin increases in obesity: inc. IgE sensitization
      Adiponectin decreases in obesity: enhancing remodeling and increased inflammation.
      CPAP for sleep apnea can help control obesity, aspiration
      New concerns: overuse of vitamins, folic acid in pregnancy may be increase incidence of asthma: based on mice studies.
    • ASTHMA UPDATE
      MONITORING ASTHMA TO ASSESS CONTROL:
      Symptom retrieval- ACT
      Spirometrics- frequency
      Other Monitoring Parameters
      Peak flow measurements
      Sputum Eosinophils
      Nitric Oxide and pH Measurements on Exhaled Air
    • ASTHMA UPDATE
      Sputum eosinophils : correlates with inflammatory response but impractical
      NO produced by epithelial and alveoli cells. Correlates with eosinophil bronchial lavage studies
      Many convincing studies that suggest NO can be used to reflect status of eosinophilic inflammation in asthma.
      May be best used as a compliance check with inhaled steroids.
    • ASTHMA UPDATE
      Medications:
      Rescue medications and long term beta agonists:
      Controversy re’ LABA. New data supports use with ICS.
      Xopenex® vs. albuterol
      Inhaled corticosteroids- reduced decline in lung function (FEV1)
      Mometasone and ciclesonide –both have minimal or no bioavailability (absorption)
      Dynamic dosing- use of ICS as a burst to treat exacerbations in well controlled asthma patients and normal lung function
    • ASTHMA UPDATE
      TARGETED THERAPY:
      IgE- anti-IgE (Xolair)
      Leukotrienes (anti-leukotrienes – Singulair; Zyflo
      Trials with Anti-IL-5- reduce eosinophils
      Anti- IL-4 trials-reduce IgE
    • ASTHMA UPDATE
      • Monoclonal anti-IgE (Xolair)
      Must be used for difficult to manage severe and persistent asthmatics
      Resistant to high dose inhaled steroids
      Require oral steroids
      Must have IgE levels in a certain range
      Expensive
      Does it work –in some cases, noticeable reduction in exacerbations
      Side effects-anaphylaxis-very rare but requires close observation for 2 hours after dose.
      Leukotriene modifiers:
      Montelukast ( prevents exercise induction up to 24 hrs- single dose)
      Zyflo ( aspirin sensitive asthmatics)
    • ASTHMA UPDATE
      Approaches Based on Hygiene Theory
      Shifting Th2 to Th1 to modify asthma. The shift to Th1 induces IL-2 and IFN critical in defense against infection
      Alter balance between Th1 and Th2- towards Th1 by immunotherapies
      SLIT vs. SCIT
      Factors favoring Th1:
      Older siblings; early exposure to daycare; rural environment; certain infections (TB, measles, hep A); early exposure to animals;
      Factors favoring Th2:
      Antibiotic use; Western lifestyle; urban environment; diet; house dust mite and cockroach sensitization; RSV
    • Potential Treatments for Acute Asthma
      B-agonists
      Corticosteroids
      Oxygen
      Intubation & Mechanical Ventilation
      Methylxanthines
      Ipratropium Bromide
      BiPAP
      Heliox
      MgSO4 Infusion
      Mucolytics
      Chest Physical Therapy
      Aggressive Hydration
      Antibiotics
      Inhalational Anesthetics
      ECMO
      Inhalational Furosemide
      Inhalational MgSO4
    • Methylxanthines (Theophylline)
      Used for over 50 years to treat asthma
      Poorly understood mechanism of action
      Physiologic effects thought to include bronchodilation, stimulation of diaphragmatic contractility, mucocilliary clearance, and possibly some anti-inflammatory effect.
      Dose related toxicities include nausea, vomiting, headache, CNS stimulation, seizure, hematemasis, hyperglycemia, and hypokalemia
    • Bottom Line on Methylxanthines
      "theophylline/aminophylline is not recommended because it appears to provide no additional benefit to optimal inhaled B2-agonist therapy and may increase adverse effects.”
      Use after admission remains controversial
    • Ipratropium Bromide
      A synthetic anticholinergic compound
      Anticholinergic compounds are known to cause bronchodilation
      Atropine has been used, but often limited due to side effects such as tachycardia, dry mouth, disturbances of visual accommodation, etc.
      Ipratropium thought to be relatively free of side effects, but with preservation of bronchodilatory properties
    • Ipratropium Bromide Bottom Line
      Small, early studies tend to favor its use
      More recent, larger studies fail to find benefit
      Given ipratropium’s relative lack of toxicity, one “safely” can use it
    • Noninvasive Positive-Pressure Ventilation (BiPAP)
      Literature is extensive in treatment of COPD, but sparse in treatment of acute asthma
      Studies using CPAP in asthma have shown it to improve symptoms, but not gas exchange
    • BiPAP
      BiPAP theoretical benefits:
      Decreased work of breathing (and CO2 production)
      Ameliorating large negative intrapleural pressures and accompanying potential for hemodynamic compromise
      Bronchodilation with decreased airway resistance (due to “splinting” airways open with air pressure)
      Improved delivery of inhalational medication
      Problems include:
      Discomfort with facemask and pressure apparatus
      Requires very close observation by trained personnel
    • BiPAP Bottom Line
      Little evidence to guide us
      Existing evidence seems to support its use
      Given few known risks with an attempt, would consider BiPAP in patients refractory to conventional therapy (B-agonists and corticosteroids), or facing impending intubation
    • Magnesium Sulfate (Infused)
      Mechanism of action not well understood but may inhibit bronchial smooth muscle contraction by inhibiting intracellular influx of calcium
      Side effects are dose and rate related:
      facial warmth, flushing, decrease in BP, sweating, nausea, emesis, CNS effects (including coma)
    • Bottom Line on MgSO4
      Lower doses (2g in 20 min) well tolerated but probably only helpful in severe asthma if at all
      Weak evidence that higher doses (2g in 2 min or 10-20 g in 1 hour) more effective, but side effects may be more of a problem
      Doses on the order of 2g in 2 min shown to be safe in obstetrical literature
    • Heliox
      As described by Gluck: “Helium-oxygen mixtures improve ventilation by reducing the Reynolds number and reducing density dependent resistance. Helium’s beneficial effects are due to its high kinematic viscosity, high binary diffusion coefficient for CO2, and high diffusivity.”
      In English: Helium flows through airways more “easily” that nitrogen, decreasing work of breathing
      Not thought to directly promote bronchodilation
    • Heliox: an Ethereal Treatment
      Few clinical trials mostly consisting of case series, uncontrolled studies, and some pediatric literature
      No “definitive” study, but seems to be a consensus in the literature supporting its use in some cases - particularly severe asthma
    • Heliox Bottom Line
      Little available evidence
      May be helpful (at least in very severe asthma) in “buying time” until other treatments become effective
      Use unlikely to cause harm unless it delays other necessary treatment such as B-agonists or necessary intubation
    • The Bottom, Bottom Line
      B-agonists and corticosteroids remain the mainstay treatments for asthma exacerbation
      Methylxanthines not helpful acutely, but may play a role subacutely and/or in chronic management
      Ipratropium Bromide not harmful, may help
      BiPAP and Heliox may spare a patient from more morbid treatments such as intubation
      MgSO4 is without good evidence of benefit, but high doses may be helpful in severe asthma
    • ASTHMA MEDICATIONS
      Beta2-Agonists
      • Injected
      • Short-acting inhaled
      • Long-acting inhaled
      Corticosteroids
      • Inhaled
      • Systemic (oral)
      Leukotriene Modifiers
      Methyl Xanthines
      Cromolyn and Nedocromil
      Anticholinergics
    • COMORBID INFECTIONS
      Most asthma exacerbations are associated with infection by a respiratory virus, especially rhinovirus.
      Only a small percentage of exacerbations are associated with infection by an atypical bacterium, like Mycoplasma pneumoniae or Chlamydia pneumoniae.
      It is widely believed that coincident bacterial sinusitis contributes to asthma exacerbations.
      Airway obstruction due to mucus plugging possibly predisposes patients to bacterial infection of non-draining regions of the lungs.
      Viral and bacterial infections are both associated with neutrophilic inflammation of the upper and lower airways.
    • RECOMMENDATION
      Antibiotics are not recommended for the treatment of acute asthma exacerbations except as needed for comorbid conditions – e.g., for the patients with fever and purulent sputum, evidence of pneumonia, or suspected bacterial sinusitis.
    • PROPELLENTS
      CFC: chlorofluorocarbons
      Safe to inhale but damaging to the earth’s ozone layer
      MDIs with CFC are being phased out
      HFA: hydrofluoroalkane
      Safe for the environment and the patient
      Delivers nearly twice as much medication to the patient
    • ORAL CORTICOSTEROIDS
      Only prednisone needed for PO use
      Once per day about equivalent to BID
      May stop med abruptly after ~5 days
      Used almost exclusively for quick relief, not for supplementing (long term) inhaled steroids or long acting beta2-agonists in step 4
    • INHALED STEROIDSCOMMON PRACTICES
      Beclomethasone (Beclovent) not in common use in some medical centers
      Budesonide (Pulmicort)~20% absorbed, but used mostly in nebulizer for children
      Flunisolide (Aerobid) not used much
      Fluticasone (Flovent) ~1% absorbed, commonly used & available in 3 strengths
      Triamcinolone acetonide (Azmacort) not in common use in some medical centers
    • Keep asthma medicine cool !
    • Ciclesonide
      Newest ICS (About 5 years in use)
      Small airways effect
      High level of efficacy of available ICS
      Safety profile
      Does not affect circadian rhythm
      High degree of serum protein binding
      Rapid clearance rate; reduced systemic effect
    • CIC
      • OPTIMAL EFFICACY
      • MINIMAL SYTEMIC ABSORPTION
      • LOW SIDE EFFECTS
      • RETENTION IN LUNG
      • DISTRIBUTION IN LYPOPHILLIC TISSUE OF THE LUNG, SLOW ABSORPTION , PROLONGED HALF LIFE
    • LONG ACTINGBETA2-AGONISTS
      Salmeterol (Serevent) off market (CFC)
      Fixed dose of salmeterol now only available in combination with 3 strengths of fluticasone as Advair (100/50, 250/50 & 500/50)
      Formoterol (Foradil) available
    • FORMOTEROL
      Available as Foradil
      It is both short acting and long acting
      12 mcg of Foradil is equivalent to 50 mcg of salmeterol (Serevent)
      Provided as 12 mcg capsules to be used in aerolizer (not PO) every 12 hours
    • CROMOLYN & NEDOCROMIL
      Cromolyn is available as Intal
      Nedocromil is available as Tilade
      Not commonly used
    • LEUKOTRIENE MODIFIERS
      Used as adjunctive therapy for asthma
      Oral treatment available
      Simultaneously treats allergic rhinits
    • LEUKOTRIENE MODIFIERS
      Leukotriene Receptor Antagonists (LTRAs)
      Montelukast is available as Singulair prescribed as one 10 mg tablet per day
      Zafirlukast is available as Accolate prescribed as 20 mg tablet BID
      5-Lipoxygenase Inhibitors
      Zileuton is available as Zyflo prescribed as 600 mg QID
    • Children and allergy in asthma
    • METHYLXANTHINES
      Theophylline used very little now and requires blood level monitoring
    • OTHERS
      Pulse oximetry – most useful in emergency rooms
      Spirometry – useful to detect degree of obstruction and if it can clear with bronchodilators and or steroids
      Asthma specialists – useful for step 3 and/or step 4 patients or difficulty with management
    • Other Drugs
      Surfactant Replacement Therapy
      New anti-inflammatory Agents
      Inhaled antibiotics
      Anticytokine Agents
      Protease inhibitors immunomodulators
    • Anti-IgE
      Recombinant humanized monoclonal antibody to treat persons over 12 years with moderate to severe asthma
      -Omalizumab - Xolair
      -Inhibits binding of IgE to receptors on mast cells and basophils
      -Prevents the release of mediators of allergic response that cause bronchospasm
      -Given subcutaneously q 2-4 weeks, very expensive but effective in reducing hospital visits and steroids use.
    • Special AdministrationTechniques
      Devices used to deliver aerosol medication
      -MDI
      -Jet Nebulizer
      -UItrasonic Nebulizer
      -Dry powder inhaler
      -Spacer
    • Inhalation devices
    • CONSEQUENCES OF POOR ASTHMA CONTROL
      Social economic waste that is preventable
      Loss in school/job absenteeism
      High morbidity
      Marginalization of Asthmatics in life
      Family life disruption (divorces and single mother hood)
      All ADDS up to poor quality of life and early demise
    • Barriers to asthma medication
    • BARRIERS IN ASTHMA
      Patient
      Healthcare system
      Health care provider
      environmental
    • BARRIERS IN ASTHMA
      Patient
      Varying cultural issues
      Complex treatment regimen
      Fear of medication
      Poor adherence – side effects of mediation – poor coping
      Embarrassment over asthma
      Low – income – lack of resources
      Lack of appreciation of severity of asthma
    • BARRIERS IN ASTHMA
      Health care provider
      Busy with other respiratory disease
      Attitude: misdiagnosis and under diagnosis
      Training and knowledge
      Managing acute attacks rather than long term control
      Limited time to give asthma education
      Lack of awareness of existence of clinical guidelines
    • BARRIERS IN ASTHMA CONT’
      Health care system
      Geographical
      Poor infrastructure
      Availability of drugs
      Low public health
      Priorities (TB/HIV malaria
      Private versus public
      Cost of hospital visits
    • BARRIERS IN ASTHMA CONT’D
      Environmental factors
      School
      Home
      Workplace
      Tobacco – smoke
      Urbanization - pollution
    • BARRIERS IN ASTHMA CONT’D
      Effects of barriers
      Socio-economic
      Frequent symptoms
      Severe symptoms
      More emergency room visits
      More absenteeism
      Frequent hospitalization
      Higher mortality
    • The challenges of asthma management
      Over-reliance on rescue medication1
      Suboptimal control1
      Poor adherence to maintenance therapy1
      Complexity of current treatments1
      Lack of education and understanding among patients1
      1FitzGerald JM, et al. Can Resp J 2006;13:253–259;2Harrison TW, et al. Lancet 2004;363:271–275.
    • THANK YOU FOR YOUR KIND ATTENTION