8.Asthma

Asthma MBBS.weebly.com

Beethoven Ludwig van He was a patient with asthma, and died in 1827.

Teresa Deng She was also a patient with asthma, and died in 1995.

Asthma incidence of children

G IN A lobal itiative for sthma

Asthma (GINA Workshop)
Topics:
Definition
Epidemiology
Risk Factors
Pathogenesis & Mechanisms
Diagnosis and Classification
Six Part Asthma Management Plan

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

Epidemiology
Asthma is one of the most common chronic diseases worldwide —1600 millions patients suffered from asthma
Prevalence increasing in many countries, especially in children — 1~4% in adult, 3~5% in children in China
A major cause of school/work absence
An overall increase in severity of asthma increases the pool of patients at risk for death

Worldwide Variation in Prevalence of Asthma Symptoms International Study of Asthma and Allergies in Children (ISAAC) Lancet 1998;351:1225

Increasing Prevalence of Asthma in Children/Adolescents 0 5 10 15 20 25 30 35 1992 1982 1989 1975 1992 1982 1994 1989 1992 1982 1992 1982 1991 1979 1989 1966 Finland (Haahtela et al ) Sweden (Aberg et al ) Japan (Nakagomi et al ) Scotland (Rona et al ) UK (Omran et al ) USA (NHIS) New Zealand (Shaw et al ) Australia (Peat et al ) { Prevalence (%) { { { { { { {

70 60 50 40 30 20 85 86 87 88 89 90 91 92 93 94 Rate/1,000 Persons Year <18 18-44 45-64 65+ Total (All Ages) Age (years) Trends in Prevalence of Asthma By Age, U.S., 1985-1996 95 96 80

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

Risk Factors that Lead to Asthma Development
Host Factors
Genetic predisposition
Atopy
Airway hyper-
responsiveness
Gender
Race
Environmental Factors
Indoor allergens
Outdoor allergens
Occupational sensitizers
Tobacco smoke
Air Pollution
Respiratory Infections
Parasitic infections
Socioeconomic factors
Family size
Diet and drugs
Obesity

Factors that Exacerbate Asthma
Allergens
Air Pollutants
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs

Mechanisms Underlying the Definition of Asthma
Risk Factors
(for development of asthma)
INFLAMMATION Airway Hyperresponsiveness Airflow Obstruction Risk Factors (for exacerbations) Symptoms

Asthma Diagnosis
History and patterns of symptoms
Physical examination
Measurements of lung function
Measurements of allergic status to identify risk factors

Clinical Manifestation of 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

Physical Examination
Because of variable symptoms, the physical examination of the respiratory system may be normal.
Dyspnea, airflow limitation (wheeze), and hyperinflation are likely to be present if patients are examined during symptomatic periods.
Silent chest, cyanosis, drowsiness, difficult speaking, tachycardia and use of accessory muscles in severe asthma.

Measurement of Lung Function
Spirometry: FEV1, FVC,FEV1/FVC
Bronchial Provocation Test (BPT)
FEV1>70% predicted
Histamine,methacholine, or exercise
FEV1↓≥20% at a dose of ≤16mg/ml

Bronchial Dilation Test (BDT)
FEV1<70% predicted
FEV1↑≥12% and 200ml, FVC↑≥15% and 200ml, after inhaling a short-acting bronchodilator

Typical Spirometric (FEV 1 ) Tracings 1 Time (sec) 2 3 4 5 FEV 1 Volume Normal Subject Asthmatic (After Bronchodilator) Asthmatic (Before Bronchodilator) Note: Each FEV 1 curve represents the highest of three repeat measurements

Peak Expiratory Flow (PEF) and PEF Variation.
PEF Variation ≥20%

Arterial blood gas
Respiratory alkalosis, during a mile asthma exacerbation
Respiratory acidosis and hypoxemia, during a severe asthma exacerbation

Measurement of Allergic Status
Skin test
Measurement of specific IgE in serum

Standards of Diagnosis
Recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning
Dyspnea, airflow limitation (wheeze), and hyperinflation are likely to be present if patients are examined during symptomatic periods
These episodes and symptoms are often reversible either spontaneously or with treatment
Exclude other diseases that manifested with similar symptoms
At least one or more of the following three:
Bronchial Provocation Test (BPT)
Bronchial Dilation Test (BDT)
Peak Expiratory Flow (PEF) Variation

Differential Diagnosis
Congestive Heart Failure
Pseudoasthma caused by vocal cord dysfunction
Chronic bronchitis & COPD
Lung cancer

Definition of COPD
Chronic obstructive pulmonary disease
(COPD) is a disease state characterized by airflow limitation that is not fully
reversible . The airflow limitation is usually
both progressive and associated with an
abnormal inflammatory response of the
lungs to noxious particles or gases.
GOLD 2004

Pointers that differentiate asthma from COPD COPD Asthma History Smoker or ex-smoker Nearly all Possibly Symptoms under age 45 Uncommon Often Chronic productive cough Common Uncommon Breathlessness Persistent and progressive Variable Winter bronchitis Common Uncommon Investigations Serial PEF Obstructive picture May be normal Day to day and diurnal variation Reversibility testing Minimal variation Usually<15% or 200ml change Usually>15% or 200ml change

Classification of Severity
Asthma severity is classified by the presence of clinical features before treatment is started and/or by the amount of daily medication required for optimal treatment

Classification of Severity of chronic stable asthma CLASSIFY SEVERITY Clinical Features Before Treatment Symptoms Nocturnal Symptoms FEV 1 or PEF STEP 4 Severe Persistent STEP 3 Moderate Persistent STEP 2 Mild Persistent STEP 1 Intermittent Continuous Limited physical activity Daily Attacks affect activity > 1 time a week but < 1 time a day < 1 time a week Asymptomatic and normal PEF between attacks Frequent > 1 time a week > 2 times a month  2 times a month  60% predicted Variability > 30% 60 - 80% predicted Variability > 30%  80% predicted Variability 20 - 30%  80% predicted Variability < 20% The presence of one feature of severity is sufficient to place patient in that category.

Classification of Severity

Classification of severity of asthma exacerbation breathlessness RR HR PEF/FEV1 PaO2 PaCO2 SaO2 Mild With activity ↑ <100 >80% normal <45 >95 Moderate With talking ↑ 100~120 60-80% 60~80 <45 91~95 Severe At rest >30 >120 <60% <60 >45 <91 Impending respiratory failure Consciousness Relative bradycardia <60 >45 <91

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
β 2 -agonist
No limitations on activities, including exercise
PEF circadian variation of less than 20%
(Near) normal PEF
Minimal (or no) adverse effects from medicine

. 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 under-diagnosis and inappropriate treatment
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
Educate continually
Include the family
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 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

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
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 β 2 -agonists
Long-acting oral β 2 -agonists
Leukotriene modifiers

Part 4: Long-term Asthma Management Pharmacologic Therapy
Reliever Medications:
Rapid-acting inhaled β 2 -agonists
Systemic glucocorticosteroids
Anticholinergics
Methylxanthines
Short-acting oral β 2 -agonists

Part 4: Long-term Asthma Management Stepwise Approach to Asthma Therapy - Adults Reliever: Rapid-acting inhaled β 2 -agonist prn
Controller:
Daily inhaled
corticosteroid
Controller:
Daily inhaled corticosteroid
Daily long-acting inhaled β 2 -agonist
Controller:
Daily inhaled corticosteroid
Daily long –acting inhaled β 2 -agonist
plus (if needed)
When asthma is controlled, reduce therapy
Monitor
STEP 1: Intermittent STEP 2: Mild Persistent STEP 3: Moderate Persistent STEP 4: Severe Persistent STEP Down Outcome: Asthma Control Outcome: Best Possible Results Alternative controller and reliever medications may be considered (see text). Controller: None -Theophylline- SR -Leukotriene -Long-acting inhaled β 2 - agonist -Oral corticosteroid

Stepwise Approach to Asthma Therapy: Adults Step 1: Intermittent Asthma None required 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
Daily Controller Medications Reliever Medications

Inhaled glucocorticosteroid
(< 500 μg BDP or equivalent)
Other options ( order by cost ):
sustained-release theophylline, or
Cromone, or
leukotriene modifier
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 2: Mild Persistent Asthma Daily Controller Medications Reliever Medications

Inhaled glucocorticosteroid, (200 – 500 μg BDP or equivalent) plus long-acting inhaled β 2 agonist
Other options (order by cost) :
Inhaled glucocorticosteroid (500 – 1000 μg BDP equivalent) plus sustained-release theophylline, or
Inhaled glucocorticosteroid (500 – 1000 μg BDP equivalent) plus long-acting inhaled β 2 - agonist, or
inhaled glucocorticosteroid at higher doses
(> 1000 μg BDP equivalent), or
Inhaled glucocorticosteroid (500 – 1000 μg BDP equivalent) plus leukotriene modifier
Rapid-acting inhaled
 2 -agonist for symptoms
(but < 3 - 4 times/day)
Other options:
inhaled anticholinergic o r
short-acting oral
 2 -agonist or
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, (> 1000 μg
BDP or equivalent) plus long-acting
inhaled β 2 agonist
plus one or more of the following, if
needed (order by cost) :
sustained-release theophylline, or
leukotriene modifier or
oral glucocorticosteroid
Rapid-acting inhaled
 2 -agonist for symptoms
(but < 3-4 times/day)
Other options:
inhaled anticholinergic o r
short-acting oral
 2 -agonist or
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 Reliever Medications

Six-part Asthma Management Program Part 5: Establish Plans for Managing Exacerbations
Primary therapies for exacerbations:
Repetitive administration of rapid-acting inhaled β 2 -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 life-threatening 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 Respiratory Failure Admit to ICU Good Response Observe for at least 1 hour If Stable, Discharge to Home Initial Assessment History, Physical Examination, PEF or FEV 1 Initial Therapy Bronchodilators; O 2 if needed Incomplete/Poor Response Add Systemic Glucocorticosteroids Good Response Discharge Poor Response Admit to Hospital

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: 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

Thank you !!

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8.Asthma

by ghalan on Jan 26, 2010

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