Athma

1. CAPA 2012
Deborah Hellyer MD

2.  Review Asthma – what is it
 Control is possible
 What is new? CTS 2012 Guidelines
 Special considerations
 ASA Triad
 Occupational Asthma
 Asthma in Pregnancy
 Emergency treatment

3.  An inflammatory disorder of the airways
characterized by paroxysmal or persistent
symptoms such as dyspnea, chest tightness,
wheezing, sputum production and cough,
associated with variable airflow limitation and a
variable degree of hyperresponsiveness of
airways to endogenous or exogenous stimuli

4. Asthma Prevalence and Mortality
Source: Masoli M et al. Allergy 2004

5.  2.7 million Canadians have asthma
 13% of Ontarians have asthma , 21% of
Ontario children aged 0-14 have asthma
 39% of people with asthma report limitation
in physical activity
 Asthma is the # 1 reason for children being
hospitalized

6. Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma
Created and funded by NIH/NHLBI, 1995
Normal Asthma
Asthma
involves
inflammation of
the airways

7. Inducers
Allergens, chemical sensitizers
Air pollution, viruses, occupational exposures
Inflammation
Airway
Hyperresponsiveness
Airflow Limitation
Symptoms
Cough, Wheeze, Chest tightness
Dyspnea
Triggers
Allergens, exercise, cold air, SO2
particulates

8. Source: Peter J. Barnes, MD
Asthma Inflammation: Cells and Mediators

9. Source: Peter J. Barnes, MD
Asthma Inflammation: Cells and Mediators

10.  Frequent episodes of breathlessness, chest
tightness, wheezing or cough
 Symptoms worse at night or the early morning
 Symptoms develop with a viral respiratory tract
infection, after exercise, or to exposure to
alloallergens or irritants
 Symptoms develop in young children after
playing or laughing
 Symptoms improve with bronchodilators or
corticosteroids

11.  Post infectious Cough
 Post Nasal Drip
 COPD
 Heart Failure
 Angina
 Lung Cancer
 Hyperventilation Syndrome
 Vocal Cord Dysfunction

12.  Predisposing Factors
 Atopy
 Genetics
 Gender
 Causal Factors
 Indoor Allergens
 Occupational Sensitizers
 Outdoor Allergens
 Contributing Factors
 Air Pollution
 Diet
 Low Birth Weight
 Respiratory Infections
 Smoking

13.  Supplement history with objective measures in
lung function in children over six years of age
 Reversible airway obstruction after
bronchodilator or
 Variable airflow limitation over time or
 Airway hyperresponsiveness
 Assessing Allergic Status

14.  Spirometry Testing:
lung volumes in/out,
lung flow of air in/out
 Peak Flow Monitoring:
lung flow of air in/out

15. Pulmonary Function Measurement Children (> 6 years) Adults
Preferred spirometry showing reversible
airway obstruction
Reduced FEV1/FVC
AND
Increase in FEV1 after bronchodilator or
after a course of controller therapy
Less than lower limit of normal based on
age, height and ethnicity
AND
≥ 12%
Less than lower limit of normal based on
age, sex, height, ethnicity (<0.75-0.8)
AND
≥ 12% (minimum ≥ 200 ml)
Alternative PEF variability
Increase after bronchodilator or course of
controller therapy
OR
Diurnal Variation
≥ 20%
OR
Not recommended
60L/min
OR
 8% based on twice daily readings
 > 20% based on multiple daily readings
Alternative Positive Challenge test
Methacholine
OR
Exercise Challenge
PC20 < 4 mg/ml
4 mg/ml – 16 mg/ml borderline
OR
≥ 10-15% decrease in FEV1 post exercise

16. 1
Time (sec)
2 3 4 5
FEV1
Volume
Normal Subject
Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)
Note: Each FEV1 curve represents the highest of three repeat measurements

17. Measuring Airway Responsiveness

21.  Confirm diagnosis
 Self management education including:
environmental trigger avoidance, inhaler
technique, adherence, action plan
 Reliever therapy
 Daily Controller therapy
 Regular assessment of asthma control,
including spirometry and PEF

22. Asthma Management and Prevention Program
Goals of Long-term Management
 Achieve and maintain control of symptoms
 Maintain normal activity levels, including
exercise
 Maintain pulmonary function as close to
normal levels as possible
 Prevent asthma exacerbations
 Avoid adverse effects from asthma
medications
 Prevent asthma mortality

23. Evidence suggests an
association between
environmental tobacco smoke
exposure and exacerbations of
asthma among school-aged,
older children, and adults.
Evidence shows an association
between environmental tobacco
smoke exposure and asthma
development among pre-school
aged children.

24.  Use bedding
encasements
 Wash bed linens weekly
 Avoid down fillings
 Limit stuffed animals to
those that can be
washed
 Reduce humidity level
(between 30% and 50%
relative humidity per
EPR-3)
Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For
Asthma Created and funded by NIH/NHLBI, 1995

25. Eliminating mold and the moist conditions that permit
mold growth may help prevent asthma exacerbations.

26. Remove as many water and food sources as
possible to avoid cockroaches.

27. Exercise can cause asthma symptoms …
BUT
Asthma should not usually prevent you from
exercising if you:
 Keep your asthma under control
 Warm-up before and cool-down after exercise
 Take a “reliever” medicine 5–10 minutes before
exercising, if needed

28.  Air pollution comes from many sources, including
vehicles and industry
 Highest pollution levels tend to be during the hot
humid days of summer
 To reduce exposure to air pollution, the following
may help:
 Reduce outdoor activity when pollution levels are high
 Keep windows and doors closed when there
are high pollution levels (air conditioning
may be needed when it gets hot)

29.  Moulds can be indoors in damp basements and
bathrooms, and outdoors in damp weather
 The following can help:
 Clean mouldy areas well
 Keep humidity around 35-45%
 A de-humidifier can help, especially in damp basements
 Get rid of clutter in the basement, to allow air to move freely
 Ensure proper water drainage around your home
 Keep bathroom dry and use fan to remove humidity
 Seek professional help if indoor mould doesn’t go away or if
there is a lot of mould
 Limit outdoor activity when outdoor mould levels are high

30.  Pollens are tiny particles that come off trees,
grass and weeds
 If you are allergic to pollens, the
following may help:
 Keep windows and doors closed in home and car
during pollen seasons (air conditioner is often
needed when it’s hot outside)
 After being outside for a long time during pollen
season, shower and change clothes
 Person with allergies should not mow the lawn

31.  If a pet is making your asthma worse, the best
option by far is to find it a new home
 If it is not possible to find it a new home:
 Keep pet out of bedroom always
 Wash pet twice a week
 Encase pillows and mattress in
allergy-proof covers
 Remove carpeting if possible
 Use a large HEPA* filter air cleaner in bedroom
 Vacuum furniture regularly with vacuum equipped with a
HEPA* filter, or central vacuum system with exhaust outside
the house
*HEPA = High Efficiency Particulate Air

34. Reliever Medications
 Rapid-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Anticholinergics
 Theophylline
 Short-acting oral β2-agonists

35. Controller Medications
 Inhaled glucocorticosteroids
 Leukotriene modifiers
 Long-acting inhaled β2-agonists in combination
with inhaled glucocorticosteroids
 Systemic glucocorticosteroids
 Theophylline
 Cromones
 Anti-IgE

36. Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400
Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400
Budesonide-Neb
Inhalation Suspension
250-500 500-1000 >1000
Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250
Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500
Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400
Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200

37.  Control
 Spirometry or PEF
 Inhaler Technique
 Adherence
 Triggers and new exposures
 Medications
 Environment – home and work
 Comorbidities
 Sputum eosinophils

38. 60% of Canadians with asthma do
not have it under control
Why do so many people
let asthma affect them so much?

39.  Do not know what good asthma control is
 Do not realize that you can get good control of
asthma
 May not think that their asthma is bad enough to
need treatment (even mild asthma often needs daily
medicines)
 Worried about taking medicines every day, about
side effects, and costs
 It may be hard to avoid triggers (eg. pets, smoke,
dust mites in the bed, carpets, moulds, pollen)
Possible reasons …

40. Medication Usage
 Difficulties associated
with inhalers
 Complicated regimens
 Fears about, or actual
side effects
 Cost
 Distance to pharmacies
Non-Medication Factors
 Misunderstanding/lack of
information
 Fears about side-effects
 Inappropriate expectations
 Underestimation of severity
 Attitudes toward ill health
 Cultural factors
 Poor communication

41. Characteristic Frequency or Value
Daytime Symptoms < 4 days/week
Night time symptoms < 1 night/week
Physical Activity Normal
Exacerbations Mild, infrequent
Absence from work/school None
Need for fast acting beta2 agonist < 4 doses/week
FEV1 or PEF ≥ 90% personal best
PEF diurnal variation < 10-15%
Sputum eosinophils <2-3%

43. Warning Signs What to Do
Green Light
 I feel Good!
 I am not coughing!
 I sleep well!
 I have lots of energy!
 Green Zone
 Take my regular controller
 Carry my blue reliever
 Exercise /play everyday
Yellow Light
 I am coughing/wheezing
 I use my reliever 3 or more
times
 I don’t feel good!
Yellow Zone
 Follow my action plan
 Use my controller
 Get lots of rest
 Go get help!
Red Light
 I am breathing fast
 I have trouble walking/
talking
 I am coughing lots
 Red Zone
 Asthma is dangerous!!!
Take my reliever!
Go Get Help from an adult
or call 911!

44. Step 1 – As-needed reliever medication
 Patients with occasional daytime symptoms of
short duration
 A rapid-acting inhaled β2-agonist is the
recommended reliever treatment (Evidence A)
 When symptoms are more frequent, and/or
worsen periodically, patients require regular
controller treatment (step 2 or higher)
Treating to Achieve Asthma Control

45. Step 2 – Reliever medication plus a single
controller
 A low-dose inhaled glucocorticosteroid is
recommended as the initial controller
treatment for patients of all ages (Evidence A)
 Alternative controller medications include
leukotriene modifiers (Evidence A)
appropriate for patients unable/unwilling to
use inhaled glucocorticosteroids
Treating to Achieve Asthma Control

46. Step 3 – Reliever medication plus one or two
controllers
 For adults and adolescents, combine a low-dose
inhaled glucocorticosteroid with an inhaled long-
acting β2-agonist either in a combination inhaler
device or as separate components (Evidence A)
 Inhaled long-acting β2-agonist must not be used
as monotherapy
 For children, increase to a medium-dose inhaled
glucocorticosteroid (Evidence A)
Treating to Achieve Asthma Control

47. Additional Step 3 Options for Adolescents and Adults
 Increase to medium-dose inhaled
glucocorticosteroid (Evidence A)
 Low-dose inhaled glucocorticosteroid
combined with leukotriene modifiers
(Evidence A)
 Low-dose sustained-release theophylline
(Evidence B)
Treating to Achieve Asthma Control

48. Step 4 – Reliever medication plus two or more controllers
 Medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled β2-agonist
(Evidence A)
 Medium- or high-dose inhaled glucocorticosteroid
combined with leukotriene modifiers (Evidence A)
 Low-dose sustained-release theophylline added
to medium- or high-dose inhaled
glucocorticosteroid combined with a long-acting
inhaled β2-agonist (Evidence B)
Treating to Achieve Asthma Control

49. Treating to Achieve Asthma Control
Step 5 – Reliever medication plus additional controller options
 Addition of oral glucocorticosteroids to other
controller medications may be effective
(Evidence D) but is associated with severe
side effects (Evidence A)
 Addition of anti-IgE treatment to other
controller medications improves control of
allergic asthma when control has not been
achieved on other medications (Evidence A)

50. Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
 Rapid-onset, short-acting or long-
acting inhaled β2-agonist
bronchodilators provide temporary
relief.
 Need for repeated dosing over more
than one/two days signals need for
possible increase in controller therapy

51. Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
 Use of a combination rapid and long-acting
inhaled β2-agonist (e.g., formoterol) and an
inhaled glucocorticosteroid (e.g., budesonide)
in a single inhaler both as a controller and
reliever is effecting in maintaining a high level
of asthma control and reduces exacerbations
(Evidence A)
 Doubling the dose of inhaled glucocortico-
steroids is not effective, and is not
recommended (Evidence A)

52. Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
 When controlled on medium- to high-dose
inhaled glucocorticosteroids: 50% dose
reduction at 3 month intervals (Evidence
B)
 When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily
dosing (Evidence A)

53. Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
 When controlled on combination inhaled
glucocorticosteroids and long-acting
inhaled β2-agonist, reduce dose of inhaled
glucocorticosteroid by 50% while
continuing the long-acting β2-agonist
(Evidence B)
 If control is maintained, reduce to low-
dose inhaled glucocorticosteroids and
stop long-acting β2-agonist (Evidence D)

54. Assess Patient Risk
Features that are associated with increased
risk of adverse events in the future include:
 Poor clinical control
 Frequent exacerbations in past year
 Ever admission to critical care for asthma
 Low FEV1, exposure to cigarette smoke,
high dose medications

55. Assessment of Future Risk
Risk of exacerbations, instability, rapid decline
in lung function, side effects
Features that are associated with increased
risk of adverse events in the future include:
 Poor clinical control
 Frequent exacerbations in past year
 Ever admission to critical care for asthma
 Low FEV1, exposure to cigarette smoke,
high dose medications
Any exacerbation
should prompt review
of maintenance
treatment

56.  Exacerbations of asthma are episodes of
progressive increase in shortness of breath,
cough, wheezing, or chest tightness
 Exacerbations are characterized by
decreases in expiratory airflow that can be
quantified and monitored by measurement of
lung function (FEV1 or PEF)
 Severe exacerbations are potentially life-
threatening and treatment requires close
supervision

57. Primary therapies for exacerbations:
 Repetitive administration of rapid-acting
inhaled β2-agonist
 Early introduction of systemic
glucocorticosteroids
 Oxygen supplementation
Closely monitor response to treatment with serial
measures of lung function

58.  Role of noninvasive measurements of airway
inflammation for the adjustment of anti-
inflammatory therapy
 The initiation of adjunct therapy to ICS for
uncontrolled asthma
 The role of single inhaler ICS/long acting
beta2agonist as a reliever
 Escalation of controller for acute loss of asthma
control as a part of self management

59.  Sputum Eosinophils are not normally present in
healthy, nonatopic
 Increased in asthmatics exposed to aeroallergens
 Decline within 3-7 days of ICS
 Normal sputum eosinophilic counts <2-3% of a
differential sputum count
 Maybe useful in guiding treatment
 Recommendation – monitoring sputum eosinophils
in adults in addition to
 Standard methods of control

60.  Biological mediator produced in the airways
 Produced through a reaction catalyzed by
inducible NO synthetase
 Upregulated in the presence of airway
inflammation
 Correlates with eosinophilic airway inflammation
 Confounding effect of atopic status, smoking and
concomitant ICS treatment
 Recommendation cannot be endorsed –
insufficient evidence

62.  Initiation of adjunct therapy with uncontrolled
asthma despite adherence to low dose ICS in
adults and medium dose ICS in children
 In adults with asthma not achieving control with
low dose ICS, addition of a LABA; alternative
increase ICS to medium or start LTRA
 In children not achieving control on medium
ICS add in LABA or LTRA; also should be
referred to a specialist

63.  Do not recommend use as a reliever in lieu of
FABA in adults with no maintenance therapy
 Use of a SABA as a reliever in individuals with
mild asthma on ICS monotherapy
 In exacerbation prone individuals >12 yrs with
moderate asthma on a fixed ICS/LABA; use of
budesonide/formoterol as a reliever

64.  Recommend daily ICS in lieu of starting
intermittent ICS at the onset of an acute loss of
asthma control
 Safest and minimal effective ICS dose be
prescribed to minimize side effects in all age
groups

65.  Children and adults on maintenance ICS
monotherapy do not routinely double their dose
of ICS as part of the written action plan at the
onset of an episode of acute loss of asthma
control
 Trial increasing ICS maintenance dose by 4-5
fold for 7-14 days (history of severe
exacerbations in past requiring systemic
steroids

66.  Prednisone dose and duration in adults should
be individualized based on previous response
 Dose of 30-50 mg/day for at least 5 days

67. Special considerations are required to
manage asthma in relation to:
 Pregnancy
 Surgery
 Rhinitis, sinusitis, and nasal polyps
 Occupational asthma
 Respiratory infections
 Gastroesophageal reflux
 Aspirin-induced asthma
 Anaphylaxis and Asthma

68.  Aspirin Exacerbated Respiratory Disease
 Asthma, Nasal Polyposis, ASA sensitivity
 5%-20% asthmatics; symptoms occur 30 mins
to 3 hours after ingestion
 Perturbations of the arachidonic acid
metabolism and a resulting imbalance between
proinflammatory and antiinflammatory
mediators, leading to chronic airway
inflammation
 Leukotriene modifying agents

69.  Think occupation in a newly diagnosed adult
asthmatic or difficult to control asthma
 If diagnosed early and removed from exposure
asthma resolves
 If remains in exposure loss of lung function

73. Previous severe exacerbation (eg, intubation or ICU admission)
Two or more hospitalizations for asthma in the past year
Three or more emergency department visits for asthma in the past
year
Hospitalization or emergency department visit for asthma in the past
month
Use of more than two canisters of short-acting beta agonist per
month
Difficulty perceiving asthma symptoms or severity of exacerbations
Low socioeconomic status, inner city residence, illicit drug use, major
psychosocial problems
Comorbidities, such as cardiovascular, chronic lung, or psychiatric
disease

75.  Clinical Findings
 Pulsus Paradoxus
 Accessory muscle usage
 Diaphoresis
 Breathlessness when supine
 Peak Flow
 < 200
 Gas Exchange
 Hypoxemia
 Hypercapnea

78.  Inhaled Beta agonists
 Inhaled anticholinergics
 Glucocorticosteroids
 Magnesium Sulfate
 Nonconventional therapies
 Helium Oxygen
 Leukotriene receptor antagonists
 Ineffective therapies
 Methylxantines –theophylline
 Inhaled glucocorticosteroids
 Empiric antibiotics

79.  Worse 35%, improve 28%, unchanged 33%
 FVC, FEV1, PEF do not change
 RV, FRC decrease; TLC decrease 3rd trimester
 MV, TV increase circulating progesterone
 PaO2 100-106 mmHg; PaCO2 28-30mmHg –
compensated respiratory alkalosis
 Exacerbations 20-36% middle trimester
 Small but statistically significant perinatal
mortality, preterm delivery, LBW
 Need to control asthma

80.  Asthma control is achievable
 Patient education and self management is the
key
 Aim for the lowest medications, keep it simple
 Monitor, monitor and monitor
 Resources – CTS guidelines, GINA guidelines

83. Characteristic
Controlled
(All of the following)
Partly controlled
(Any present in any week)
Uncontrolled
Daytime symptoms
Twice or less
per week
More than
twice per week
3 or more
features of
partly
controlled
asthma
present in
any week
Limitations of
activities
None Any
Nocturnal symptoms
/ awakening
None Any
Need for rescue /
“reliever” treatment
Twice or less
per week
More than
twice per week
Lung function
(PEF or FEV1)
Normal
< 80% predicted or
personal best (if
known) on any day
Assessment of Future Risk (risk of exacerbations, instability, rapid
decline in lung function, side effects)

84. controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROL
maintain and find lowest
controlling step
consider stepping up to
gain control
step up until controlled
treat as exacerbation
TREATMENT OF ACTION
TREATMENT STEPS
REDUCE INCREASE
STEP
1
STEP
2
STEP
3
STEP
4
STEP
5
REDUCE
INCREASE

86. Shaded green - preferred controller options
TO STEP 3 TREATMENT,
SELECT ONE OR MORE:
TO STEP 4 TREATMENT,
ADD EITHER