outpatient management of asthma

1. Outpatient Management of Asthma
Presented by
Abdulaziz Bagasi – R1 Family Medicine NGH
Supervised by
Dr.Kholoud Alsiari
5th July 2018
1

2. Objectives
Definition
Pathophysiology
Epidemiology
Diagnosis of asthma
Assessment of Asthma Control
Outpatient management of Asthma
Referral to a specialist center
2

3. • Asthma is a common chronic disease that can be controlled
but not cured.
• Symptoms are due to :
– Bronchoconstriction (airway narrowing)
– Airway wall thickening
– Increased mucus
What is known about asthma?
GINA 2014

4. Asthma is a common chronic disorder of the airways, characterized
by variable reversible and recurring symptoms related to airflow
obstruction, bronchial hyper-responsiveness, and underlying
inflammation.
Definition

5. Pathophysiology
• video
5

6. Epidemiology of Asthma
• Asthma is one of the most common chronic diseases
worldwide with an estimated 300 million affected
individuals.
• Prevalence is increasing in many countries, especially
in children.
• Asthma is among the most common chronic illnesses
in Saudi Arabia affecting more than 2 million Saudis.

7. Prevalence
• Prevalence of
asthma has
increased between
1986 – 1995
Alfrayyah et al. Ann Allergy Asthma
Immunol 2001;86:292–296

8. • The diagnosis of asthma should be based on:
– A history of characteristic symptom patterns
– Evidence of variable airflow limitation, from bronchodilator reversibility
testing or other tests
• The diagnosis of asthma is based on clinical assessment as there is
no gold standard diagnostic test for asthma. This includes a
detailed history and physical examination supplemented by
spirometry with reversibility testing to support the diagnosis.
Diagnosis of asthma
GINA 2014

9. • Increased probability that symptoms are due to asthma if:
More than one type of symptom (wheeze, shortness of breath,
cough, chest tightness).
Symptoms often worse at night or in the early morning.
Symptoms vary over time and in intensity.
Symptoms are triggered by viral infections, exercise, allergen
exposure.
History (symptoms)
GINA 2014

10. History
10

11. • Bilateral expiratory wheezing.
• Other allergic manifestations: e.g., atopic dermatitis/eczema.
• Consider alternative Dx when there is crackles, stridor, or clubbing.
Physical Examination

12. Investigations
• Measurements of lung function:
– Spirometry
– Peak expiratory flow (PEF)

13. • Confirm presence of airflow limitation:
o Spirometry is necessary to confirm airflow obstruction, assess severity
and demonstrates significant reversibility
o Document that FEV1/FVC is reduced (at least once, when FEV1 is low)
o FEV1/ FVC ratio is normally >0.75 – 0.80 in healthy adults, and
>0.90 in children.
o The degree of significant reversibility is defined as an improvement in
FEV1 ≥12% and ≥200 mL from the prebronchodilator value
Diagnosis of asthma (variable airflow limitation)
GINA 2014, Box 1-2

14. © Global Initiative for Asthma
Time (seconds)
Volume
Note: Each FEV1 represents the highest of
three reproducible measurements
Typical spirometric tracings
FEV1
1 2 3 4 5
Normal
Asthma
(after BD)
Asthma
(before BD)
Flow
Volume
Normal
Asthma
(after BD)
Asthma
(before BD)

15. Other Investigations
• Measurements of allergic status to identify risk
factors (if indicated)
• Chest X-ray is not routinely recommended
• Routine blood tests are not routinely
recommended
• IgE measurement is indicated in severe cases

16. Assessment of Asthma
• Assessment of asthma control [next slide]
• Physiological measurement with tools such as spirometry or
peak flow meter
• Documentation of current treatment and any related issues
such as side effects, adherence, and inhaler technique .
• Assessment of comorbidities such as rhinosinusitis, GERD,
obesity, obstructive sleep apnea, and anxiety .
• Close monitoring for patients with severe asthma and history
of asthma exacerbations.
16

17. Assessment of Asthma Control

18. Level of Control :
• Total: 25
• Control: 20-24
• Partial control: 16-19
• Uncontrolled: < 16
Asthma Control Test

19. Outpatient Management of Asthma

20. The long-term goals of asthma management are:
1. Symptom control: to achieve good control of symptoms and maintain
normal activity levels.
2. Risk reduction: to minimize future risk of exacerbations and
medication side-effects.
Goals of Asthma management
GINA 2014

21. Non-pharmacological Management
21

22. Asthma Education
• Partnership between patient and healthcare worker.
• Ability to differentiate between “relievers” and “controllers”
medications and their appropriate indications.
• Recognition of potential side effects of medications and the
appropriate action to minimize them.

23. Asthma Education
• Performance of the proper technique of devices.
• Identification of symptoms and signs that suggest worsening of
asthma control.
• Recognition of the situations that need urgent medical attention.
• Ability to use a written self-management plan.

24. Inhaler technique
• video
24

25. Self-management plan

26. www.tnfos.com
‫اإلجراء‬‫الواجب‬‫إتخاذه‬:
‫إستخدام‬‫البخاخ‬‫الموسع‬‫للشعب‬‫الهوائية‬___‫بخة‬‫كل‬____‫ساعات‬
‫طلب‬‫اإلستشارة‬‫الطبية‬‫بصفة‬‫عاجلة‬.
‫زيادة‬‫جرعة‬‫البخاخ‬‫الواقي‬____)‫إلى‬______‫بخة‬____)‫مرة‬ً‫يوميا‬‫لمدة‬
10‫أيام‬‫ثم‬‫الرجوع‬‫إلى‬‫الجرعة‬‫السابقة‬‫عمل‬‫ما‬‫يلي‬:
3 -‫الحالة‬‫المتأزمة‬‫الحادة‬(‫سارع‬‫بطلب‬‫المساعدة‬
‫الطبية‬)‫إذا‬‫لم‬‫تحدث‬‫استجابة‬‫لما‬‫سبق‬‫أو‬‫حدث‬:
‫زيادة‬‫أعراض‬‫أزمة‬‫الربو‬.
‫عدم‬‫القدرة‬‫على‬‫إتمام‬‫كلمتين‬‫في‬‫نفس‬‫واحد‬.
‫عودة‬‫أعراض‬‫الربو‬‫بعد‬‫أقل‬‫من‬‫نصف‬‫ساعة‬‫من‬‫إستخدام‬‫البخاخ‬‫الموسع‬
‫للشعب‬‫الهوائية‬.
‫القدرة‬‫على‬‫نفخ‬‫الهواء‬‫أقل‬50%‫من‬‫الحد‬‫الطبيعي‬.
‫اإلجراء‬‫الواجب‬‫إتخاذه‬ :
‫زيادة‬‫جرعة‬‫البخاخ‬‫الواقي‬______‫إلى‬______‫بخة‬_____‫مرة‬ً‫يوميا‬‫لمدة‬10‫أيام‬
‫ثم‬‫الرجوع‬‫إلى‬‫الجرعة‬‫السابقة‬
‫إستخدام‬‫البخاخ‬‫الموسع‬‫للشعب‬‫الهوائية‬( )
( )‫بخة‬‫كل‬____‫ساعات‬‫بإنتظام‬‫لمدة‬_____‫أيام‬‫أو‬‫حتى‬‫تتحسن‬‫الحالة‬
‫إستشارة‬‫الطبيب‬‫في‬‫أقرب‬‫وقت‬‫ممكن‬.
2 -‫الحالة‬‫المتوسطة‬‫اإلستقرار‬(‫أزمة‬‫ربو‬‫على‬‫وشك‬‫الحدوث‬) :
‫إستخدام‬‫البخاخ‬‫الموسع‬‫للشعب‬‫الهوائية‬‫أكثر‬‫من‬3‫مرات‬ً‫يوميا‬.
‫اإلستيقاظ‬‫في‬‫الليل‬‫بسبب‬(‫كحة‬،‫كتمة‬،‫صفير‬‫في‬‫الصدر‬)
‫وجود‬‫أعراض‬‫نزلة‬‫برد‬‫فيروسية‬.
‫القدرة‬‫على‬‫نفخ‬‫الهواء‬‫بين‬60 – 80 %‫من‬‫الحد‬‫الطبيعي‬.
‫اإلجراء‬‫الواجب‬‫إتباعه‬ : ‫اإلستمرار‬‫على‬‫األدوية‬‫المعطاة‬ :
‫إستخدام‬‫البخاخ‬‫الموسع‬‫للشعب‬‫الهوائية‬_____‫بخة‬‫كل‬____‫ساعات‬‫عند‬‫الضرورة‬
‫وقبل‬‫التمارين‬‫ارياضية‬‫ب‬15 – 30‫دقيقة‬.
‫إستخدام‬‫البخاخ‬‫الواقي‬_____‫بخة‬______‫مرة‬ً‫يوميا‬‫و‬‫بشكل‬‫منتظم‬‫لمدة‬( ) .
‫أدوية‬‫أخرى‬:
1-‫الحالة‬‫المستقرة‬:
‫ممارسة‬‫الحياة‬‫بشكل‬‫طبيعي‬(‫لعب‬،‫نوم‬،‫دراسة‬)
‫إختفاء‬‫أعراض‬‫الربو‬‫في‬‫الليل‬.
‫ندرة‬‫إستخدام‬‫البخاخ‬‫في‬‫الموسع‬‫للشعب‬‫الهوائية‬(‫أقل‬‫من‬3‫مرات‬ً‫أسبوعيا‬)
‫سرعة‬‫تدفق‬‫الهواء‬‫أكثر‬‫من‬80%‫من‬‫الحد‬‫الطبيعي‬
‫لكل‬‫مريض‬‫خطة‬‫عالجية‬‫ذاتية‬‫خاصة‬‫به‬‫توضع‬‫تحت‬‫إشراف‬‫الطبيب‬‫المختص‬‫حسب‬‫حالته‬
Self-management plan
‫البد‬‫من‬‫التوجه‬‫لقسم‬‫الطوارئ‬ً‫فورا‬.
(‫توجه‬‫للطوارئ‬‫أو‬‫أطلب‬‫اإلسعاف‬) :‫إذا‬‫تدهورت‬‫أزمة‬‫الربو‬‫على‬‫الرغم‬‫من‬
‫اإلجراءات‬‫السابقة‬،‫أو‬‫حدث‬‫إزرقاق‬‫فياألطراف‬‫أو‬‫تدهور‬‫في‬‫مستوى‬‫الوعى‬،‫أو‬‫ت‬‫دني‬
‫في‬‫سرعة‬‫تدفق‬‫الهواء‬‫ألقل‬‫من‬50 %‫من‬‫المعدل‬‫الطبيعي‬

27. Precipitating Factors
GINA 2014

28. Precipitating Factors
GINA 2014

29. Causes of Non-Adherence
• Drugs:
– Poor technique of inhaler devices.
– Occurrence of Side effects from the
drugs.
– Cost of medications.
• Non-drugs
– Lack of knowledge about asthma.
– Lack of partnership in the
management.
GINA 2014

30. Pharmacological Management

31. Asthma Medications
• Relievers: medications used on an “as-
needed” basis that act quickly to reverse
bronchoconstriction.
• Controllers: medications taken daily on a
long-term basis to keep asthma under clinical
control.

32. 32

33. Relievers
• Use on an ‘as-needed’ basis at the lowest dose and
frequency required
• Increased use, especially daily use, is a warning of
deterioration of asthma control
Rapid-acting inhaled
β2-agonists
(e.g. salbutamol)
• But less effective than rapid-acting inhaled β2-agonists
• An alternative for patients that experience side effects with
rapid-acting inhaled β2-agonists
Short-acting
Anticholinergics (e.g.
ipratropium bromide)

34. Short-acting B2-agonists
• Salbutamol and Albuterol .
• The medications of choice for symptoms relief.
• Pre-treatment for exercise-induced asthma.
• Increased daily use is a warning of deterioration of asthma
control
• Side effects: tremor and tachycardia.

35. Short-Acting Anticholinergics
• Ipratropium bromide
• Less effective than SABA.
• Used in combination with SABA in acute asthma.
• An alternative bronchodilator for patients with adverse
effects from SABA.
• Side effects: can cause a dryness of the mouth and a
bitter taste.

36. Controller Medications
• Inhaled corticosteroid
• Systemic steroid: IV, Oral
• Long Acting B2 Agonists(LABA)
• Long acting Anti-cholinergic
• Leukotrienes Modifiers
• Anti-IgE

37. Inhaled Corticosteroid
• Fluticazone
• Reduce frequency and severity of asthma
exacerbations.
• To reach control add-on therapy with another class of
controller is preferred
• Local adverse effects : Oropharyngeal candidiasis and
dysphonia

38. Inhaled corticosteroid

39. Combination Devices
• Sympicort turbohaler:
– Combination of Budesonide/Formeterol : 160/4.5
• Seretide:
– Combination of Fluticasone/Salmeterol
• Evohaler: 50/25 125/25 250/25
• Diskus: 100/50 250/50 500/50

40. LABA
• Formoterol and Salmeterol.
• Never used alone.
• Combination with ICS lead to significant
improvement .

41. Long Acting Anti-cholenergic
• Tiotropium
• Bronchodilation more than 24 h.
• It improves lung function in patients with severe
uncontrolled asthma.
• Not inferior to LABA in management of asthma
not controlled on ICS or combination.

42. Systemic corticosteroids
• IV or oral
• Long-term steroid therapy for uncontrolled asthma despite
maximum therapy.
• It is limited by the risk of significant adverse effects.
• Side effects:
– Osteoporosis, hypertension, diabetes, adrenal insufficiency,
obesity, cataracts, glaucoma, and muscle weakness.

43. Leukotriene Modifiers (LTRA)
• Montelukast (Singulair)
• LTRA reduces airway inflammation, improve asthma symptoms
and lung function
• It has less effect on exacerbations when compared to ICS.
• Alternative treatment to ICS for patients with mild asthma and
clinical rhinitis.

44. Theophylline
• Weak bronchodilator with modest anti-inflammatory properties .
• It may provide benefit as add-on therapy in patients who do not
control on ICS alone.
• Data shown that low dose theophylline may have important role
in improving steroid resistance in patient with severe asthma
requiring high dose ICS

45. Theophylline
• Side effects:
gastrointestinal symptoms
cardiac arrhythmias
seizures, death

46. ANTI-IGE
• Omalizumab (Xolair) indication:
– Uncontrolled severe allergic asthma on high dose ICS and
other controllers.
– Positive skin test or specific IgE
– Needs specialist consultation.
• Side effects:
– Pain and bruising at injection site
– anaphylaxis

47. Principles of management
The principles of asthma management in adults
will follow 3 stages:
1. Initiation
2. Adjustment
3. Maintenance

48. Asthma Treatment in Adults

49. 1) Initiation based on SINA approach
The consensus among SINA panel is to simplify the
approach to initiate asthma therapy by using ACT
score :
– ACT Score ≥ 20  Step 1
– ACT Score 16–19  Step 2
– ACT Score < 16  Step 3

50. Adults Patients with Asthma

51. Initiation When ACT ≥20
• Step 1: for patients with mild and infrequent
symptoms
• Step 2: for Patients with risk factors for flare-up or
fixed obstruction
• Step 2: for patients with seasonal asthma who are
symptomatic during the season, otherwise should
be treated at step 1 for the rest of the year

52. Initiation When ACT 16-19
• Step 2: for patients partially controlled asthma .
This includes those with history of asthma flare-
up in the past year.

53. Initiation When ACT <16
• Step 3: for most patients with an ACT score of
<16.
– For patients with early signs of flare-up at presentation, a short
course of oral steroids may be required.
• Step 4: for patients who have severely
uncontrolled asthma at presentation, initiation of
treatment at step 4 with a combination of high
dose ICS and/LABA required.

54. 2) Adjustment of treatment
• Clinical Assessment
• Obtain ACT score
• Based on ACT, Adjust treatment:
– ACT = 20-25: Controlled  Maintain treatment
– ACT = 16-19: Partial control Step up
– ACT < 16: Uncontrolled Step up
• Introduce self-management plan

55. Asthma Treatment in Adults

56. Principles of Asthma Treatment
• Daily long-term controller medication is the corner stone of treatment.
• ICS are considered as the most effective controller.
• Relievers must be available to all patients at any step .
• Increasing use of reliever treatment is an early sign of worsening asthma
control.

57. Principles of Asthma Treatment
• Treat patients who may have seasonal asthma as having
uncontrolled asthma during the season, then at step 1 for the
rest of the year
• Patients who had two or more exacerbations requiring oral
corticosteroids or hospital admissions in the past year, should
be treated as patients with uncontrolled asthma

58. Step 1 - Recommendations
• Mild and infrequent symptoms
• Initial ACT 20 – 25
• Consider rapid onset B2-agonist to be taken “as
needed” to treat symptoms

59. Step 2 - Recommendations
• Daily ICS at a low dose (< 500 μg of
beclomethasone equivalent/day or
equivalent).
• Alternative treatment is LTRA (montelukast).

60. Step 3 – Recommendations
• Daily LABA combined with low – medium
dose ICS for patients whose asthma is
uncontrolled, such as:
– Twice a day combination of ICS and LABA
– Once a day combination e.g., Fluticasone
furoate/vilanterol
• Rapid onset B2-agonist as a reliever
treatment.

61. Step 3 - GOAL study
• GOAL study has shown that an escalating dose of combination
of Fluticasone/ Salmeterol (Seretide) achieves
– Well controlled asthma in 85% of patients
– Totally controlled asthma in 30% of patients

62. Step 3 – Alternative therapy
• Adding LTRA to ICS, especially those with concomitant
rhinitis or
• Increasing ICS dose from medium to high dose range
as a monotherapy or
• Adding sustained release theophylline or
• Adding long acting anti-cholinergic
• Consultation with a specialist is recommended .

63. Step 4 – Recommendations
• Maximizing treatment is recommended by combining
high-dose ICS with LABA or
• Adding LTRA, tiotropium, or theophylline to high-dose
ICS and LABA or
• Omalizumab may be considered:
– Allergic asthma still uncontrolled.
• Consultation is recommended.

64. Step 5 - Recommendations
• Omalizumab to be considered for patients who
have allergic asthma and persistent symptoms
despite the maximum therapy mentioned above
• Lowest possible dose of long-term oral
corticosteroids for patient who:
– Does not have allergic asthma
– Omalizumab is not available or not adequately
controlling the disease.
• Consultation is mandatory.

65. Referral to a specialist center
Status asthmatics
There is uncertainty regarding the diagnosis
There is difficulty achieving or maintaining control of asthma
 Immunotherapy or omalizumab is considered
 Difficulty to achieve asthma control at step 3 or higher
The patient has acute asthma exacerbation requiring
hospitalization.

66. MCQs
66

67. 67

68. 68

69. 69

70. 70

71. 71

72. Any Questions?