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  1. 1. Guidelines for management ofasthma GlobalINitiative for Asthma (updated Dec 2008)
  2. 2. Guidelines for management ofasthma The British Thoracic Society/Scottish Intercollegiate Guidelines Network British Guideline on the Management of Asthma (updated May 2008)
  3. 3. About asthma…One of the most chronic diseases, with an estimated 300 million individuals affected worldwidePrevalence is increasing especially among children
  4. 4.  Asthma is a chronic inflammatory disorder of the airways Chronically inflamed airways are hyperresponsive, they become obstructed and airflow is limited by  Bronchoconstriction  Mucus plug  Increased inflammation when airways are exposed to various risk factors
  5. 5. A stepwise approach to pharmacologic treatment to achieve and maintain control of asthma should take into account the safety of treatment, potential for adverse effects and the cost of treatmentController medication must be taken daily and reliever medication may occasionally be used to treat acute symptoms
  6. 6. Diagnosis GINA 2008
  7. 7. DiagnosisSpirometrypreferred method of measuring airflow limitation and its reversibility to establish a diagnosis of asthma.An increase in FEV of >12% and 200 ml 1 after administration of a bronchodilator indicates reversible airflow limitation consistent with asthma. GINA 2008
  8. 8. Diagnosis of asthma in children Initial clinical assessment  Clinical features that increase the probability of asthma:  >1 of these symptoms: wheeze, cough, difficulty breathing, chest tightness  Personal history of atopy  FH of atopy  Widespread wheeze on auscultation  History of improvement in symptoms or lung function in response to adequate therapy BTS guideline 2008
  9. 9. Diagnosis of asthma in children Initial clinical assessment:  Clinical features that lower the probability of asthma  Symptoms with colds only with no interval symptoms  Isolated cough in the absence of wheeze/difficulty breathing  History of moist cough  Prominent dizziness, light-headedness, peripheral tingling  Repeatedly normal physical exam of chest when symptomatic  Normal PEF or spirometry when symptomatic  No response to trial of asthma therapy  Clinical features pointing to alternative diagnosis BTS guideline 2008
  10. 10.  The child can be classified into  High probability of asthma  start a trial of treatment  Low probability of asthma  consider more detailed investigation and specialist referral  Intermediate probability of asthma  perform spirometry and assess the change in FEV1 or PFR in response to an inhaled bronchodilator (reversibility) If the child cannot perform spirometry, consider treat as asthma and review, consider other condition +/- refer to specialist BTS guideline 2008
  11. 11. Remember…The diagnosis of asthma in children is a clinical one.Based on recognizing a characteristic pattern of episodic symptoms in the absence of an alternative explanation BTS guideline 2008
  12. 12. BTS guideline 2008
  13. 13. Classification of asthma control GINA 2008
  14. 14. 4 components of asthma care1. develop doctor/patient relationship2. identify and reduce exposure to risk factors3. Assess, treat and monitor asthma4. Manage asthma exacerbations GINA 2008
  15. 15. Component 1: develop doctor-patient relationship Patients should learn to: Avoid risk factors Take drugs regularly Understand the difference between “controller” and “reliever” medications Monitor the status using symptoms and if relevant, PFR recognize signs that asthma is worsening and take action Seek medical help as appropriate
  16. 16. Component 2: identify and reduceexposure to risk factorsExercise may lead to asthmatic symptoms but patients should not avoid exercise but use beta agonist as prophylaxis insteadAdvice patient with moderate to severe asthma to have influenza vaccine every year
  17. 17. Component 2: identify and reduceexposure to risk factors Avoidance that improve the control of asthma:  Tobacco smoke  Drugs, food and addictives  Occupational sensitizers Reasonable avoidance measures can be recommended but have not been shown to have clinical benefit:  House dust mites, animals with fur, cockroaches, outdoor pollens and mild, indoor mold
  18. 18. Component 3: assess, treat andmonitor asthmaAssess:
  19. 19. Component 3: assess, treat andmonitor asthmaTreatment: GINA 2008
  20. 20. Stepwise treatmentStep 1:No need for controllerReliever: rapid acting beta 2 agonist
  21. 21. Step 2:Controller: ◦ low dose inhaled corticosteroid ◦ Leukotriene modifierReliever: ◦ Rapid acting beta 2 agonist
  22. 22.  Step 3: Controller:  low dose inhaled corticosteroid + long acting beta 2 agonist  Medium or high dose ICS  Low dose ICS + leukotriene modifier  Low dose ICS plus SR theophylline Reliever:  Rapid acting beta 2 agonist
  23. 23.  Step 4: Controller:  Medium/high dose inhaled corticosteroid + long acting beta 2 agonist  Add one or more:  leukotriene modifier  SR theophylline Reliever:  Rapid acting beta 2 agonist
  24. 24. Step 5:Controller: ◦ Controller as in step 4, add one or more: ◦ Oral glucocorticosteriod (lowest dose) ◦ Anti-IgE treatmentReliever: ◦ Rapid acting beta 2 agonist
  25. 25. Component 3: assess, treat andmonitor asthmaMonitoring:Typicallypatients should be seen 1-3 months after the initial visit, and every 3 months thereafterAfter an exacerbation, FU within 2-4 weeks
  26. 26. Adjusting medication If asthma is not well controlled: step up treatment and improvement should be seen within 1 month Review the patient’s medication technique, compliance and avoidance of risk factors Partly controlled: consider stepping up treatment considering the safety, cost, effectiveness of treatment and the patient’s satisfaction If control is maintained for 3 months, step down with gradual stepwise approach
  27. 27. GINA 2008
  28. 28. BTS guideline: Stepwise management in adults
  29. 29. BTS guideline: Stepwise management in children 5-12 year old
  30. 30. BTS guideline:Stepwise management in children<5 year old
  31. 31. RelieversShort acting beta 2 agonistsAnticholinergicsShort acting theophylline
  32. 32. RelieverShort acting beta 2 agonistsSalbutamol (Ventolin)Terbutaline (Bricanyl) – tablet/injectionSE: ◦ Tachycardia, tremor, headache, irritability ◦ At very high dose hyperglycaemia, hypokalemia ◦ Systemic administration increase risk of SE
  33. 33. RelieverAnticholinergics:Ipratropium bromide (Atrovent)SE: minimal dry mouth or bad taste in the mouthMay provide addictive effect to beta agonist but slower onset
  34. 34. RelieverShort acting theophyllineAminophylline (7mg/kg loading over 20min then 0.4mg/kg/hr infusion)SE: ◦ Nausea, vomiting, headache ◦ Higher serum concentration: seizure, tachycardia, arrhythmia ◦ Require level monitoring
  35. 35. ControllersInhaled corticosteroid (ICS)Oral steroidSodium cromoglycateLong acting beta 2 agonistCombination ICS/LABASR theophyllineAntileukotrieneImmunomodulators
  36. 36. Inhaled corticosteroid Beclotide (beclomethasone dipropionate 50mcg/dose) Becloforte (beclomethasone dipropionate 250mcg/dose) Beclazone (beclomethasone easi-breathe 100mcg/dose or 250mcg/dose) Pulmicort (budesonide 100mcg/dose or 200mcg/dose) Flixotide (fluticasone propionate)  In accuhaler or inhaler
  37. 37. Inhaled corticosteroidSE:High daily doses may be associated with skin thinning, bruises, and adrenal suppressionHoarseness, oral candidasisGrowth delay or supression in children (average 1cm)
  38. 38. Inhaled corticosteriod
  39. 39. LABASalmeterol (serevent)Should not use as monotherapy for controller therapy, always use as adjunct to ICSNot used in acute attack
  40. 40. Combines inhalers ICS + LABA Symbicort (budesonide + formoterol turbuhaler 160/4.5mcg, 80/4.5mcg, 320/9mcg) Seretide (salmeterol + fluticasone 50/100mcg, 50/250mcg, 50/500mcg) Seretide lite (salmeterol + fluticasone 25/50mcg) Seretide medium (salmeterol + fluticasone 25/125mcg) Seretide forte (salmeterol + fluticasone 25/250mcg)
  41. 41. ControllersSRtheophyllineAminophylline ◦ Starting dose 10mg/kg/d with usual 800mg max in 1-2 doses ◦ SE:  nausea, vomiting,  high serum concentration: seizure, tachycardia, arrhythmia
  42. 42. ControllersAntileukotrienesMontelucast (Singulair)Adult: 10mg dailyChildren: 5mg dailyNo specific SE to date
  43. 43. ControllersImmunomodulatorsAntiIgEOmalizumabSubcutaneous injection every 2-4 weeks
  44. 44. How to monitor asthma control? Questions to ask the patient: Has your asthma awaken you at night? Have you needed more reliever medication as usual? Have you needed any urgent medical care? Has your peak flow been below your personal best? Are you participating in your usual physical activities?
  45. 45. How to monitor asthma control?is the patient using the inhaler, spacer or peak flow meters correctly?Is the patient taking the medications and avoiding risk factors according to the asthma management risk factors according to the asthma management plan?Does the patient have any other concerns?
  46. 46. Component 4: manageexacerbationsSigns and symptoms of severe attack: ◦ Breathless at rest, ◦ talks in words rather than sentences (infant stops feeding), ◦ agitated, drowsy, or confuse ◦ Tachycardia (pulse>120) or Bradycardia ◦ Tachypnea ◦ PEF < 60% predicted ◦ Patient is exhausted
  47. 47. The response to the initial bronchodilator treatment is not prompt and sustained for at least 3 hoursThere is no improvement within 2-6 hours after oral steroidThere is further deterioration
  48. 48. Treatment of acute attack Inhaled rapid-acting beta agonist  begin with 2-4 puff q20min for the first hour, then mild attack: 2-4 puff q3-4h mod attack: 6-10 puff q1-2h Oral steroid 0.5-1mg prednisolone/kg/day Oxygen (keep SaO2>95%) combination of beta agonist/anticholinergic therapy is associated with lower hospitalization rates and greater improvement in PEF and FEV1 Methylxanthines are not recommended together with high doses of inhaled beta agonists. If patient is already on theophylline daily, check level before adding short acting theophylline
  49. 49. Therapies not recommended fortreating asthma attacks Sedatives Mucolytic drugs (may worsen cough) Chest physio (may increase patient discomfort) Hydration with large volume of fluid for adults and older children (may be necessary for younger children and infants) Antibiotics (do not treat attacks, only use when pneumonia present) Epinephrine/adrenaline (may be indicated for acute treatment of anaphylaxis and angioedema but not indicated for asthma attacks)
  50. 50. Case 1M/16, F.4 studentHistory of asthma on Becotide 2 puff BD and prn VentolinHow would you assess the control of asthma?
  51. 51. He had more frequent cough and chest tightness recently during the cold weather and require to use Ventolin ~3 days per weekPE: occasional wheeze over bilateral chest, AE fairHow would you manage him?
  52. 52. Case 23/MAsthma on Becotide 400 mcg/d ( 2 puff QID)Persistently poor control with 2 attacks in 3 monthsFurther management?
  53. 53. Case 3M/5Currently on Becotide (beclomethasone dipronpionate) at 200mcg/dWheezing every morning when he wakes upUse Ventolin every morningFurther management?
  54. 54. Case 4F/12On Seretide 100 1 puff BD and prn VentolinShe has not been using Ventolin from last FU 3 months agoFurther management?
  55. 55. Take home message…Good asthma control:Risk factor controlComplianceInhaler techniqueStep up/down treatment as appropriateSuitable treatment for acute exacerbation
  56. 56. ReferenceGINA 2008BTS guideline May 2008