Guidelines for management ofasthma GlobalINitiative for Asthma (updated Dec 2008)
Guidelines for management ofasthma The British Thoracic Society/Scottish Intercollegiate Guidelines Network British Guideline on the Management of Asthma (updated May 2008)
About asthma…One of the most chronic diseases, with an estimated 300 million individuals affected worldwidePrevalence is increasing especially among children
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
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 treatmentController medication must be taken daily and reliever medication may occasionally be used to treat acute symptoms
DiagnosisSpirometrypreferred 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
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
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
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
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
4 components of asthma care1. develop doctor/patient relationship2. identify and reduce exposure to risk factors3. Assess, treat and monitor asthma4. Manage asthma exacerbations GINA 2008
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
Component 2: identify and reduceexposure to risk factorsExercise may lead to asthmatic symptoms but patients should not avoid exercise but use beta agonist as prophylaxis insteadAdvice patient with moderate to severe asthma to have influenza vaccine every year
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
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
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
Step 5:Controller: ◦ Controller as in step 4, add one or more: ◦ Oral glucocorticosteriod (lowest dose) ◦ Anti-IgE treatmentReliever: ◦ Rapid acting beta 2 agonist
Component 3: assess, treat andmonitor asthmaMonitoring:Typicallypatients should be seen 1-3 months after the initial visit, and every 3 months thereafterAfter an exacerbation, FU within 2-4 weeks
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
ControllersSRtheophyllineAminophylline ◦ Starting dose 10mg/kg/d with usual 800mg max in 1-2 doses ◦ SE: nausea, vomiting, high serum concentration: seizure, tachycardia, arrhythmia
ControllersAntileukotrienesMontelucast (Singulair)Adult: 10mg dailyChildren: 5mg dailyNo specific SE to date
ControllersImmunomodulatorsAntiIgEOmalizumabSubcutaneous injection every 2-4 weeks
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?
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?
Component 4: manageexacerbationsSigns 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
The response to the initial bronchodilator treatment is not prompt and sustained for at least 3 hoursThere is no improvement within 2-6 hours after oral steroidThere is further deterioration
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
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)
Case 1M/16, F.4 studentHistory of asthma on Becotide 2 puff BD and prn VentolinHow would you assess the control of asthma?
He had more frequent cough and chest tightness recently during the cold weather and require to use Ventolin ~3 days per weekPE: occasional wheeze over bilateral chest, AE fairHow would you manage him?
Case 23/MAsthma on Becotide 400 mcg/d ( 2 puff QID)Persistently poor control with 2 attacks in 3 monthsFurther management?
Case 3M/5Currently on Becotide (beclomethasone dipronpionate) at 200mcg/dWheezing every morning when he wakes upUse Ventolin every morningFurther management?
Case 4F/12On Seretide 100 1 puff BD and prn VentolinShe has not been using Ventolin from last FU 3 months agoFurther management?
Take home message…Good asthma control:Risk factor controlComplianceInhaler techniqueStep up/down treatment as appropriateSuitable treatment for acute exacerbation