management of bronchial asthma

1. BRONCHIAL ASTHMA
DR MUHAMMAD AFIQ ASYRAF
PEGAWAI PERUBATAN SISWAZAH UD 41

2. APPROACH TO MANAGING ASTHMA
A) Education of patient and family
B) Identifying & avoiding the common triggers :
1. Environmental allergens : house dust mites, pollens, animal dander,
insects and mould
2. Cigarette smoke
3. URTI
4. Food allergy
5. Exercise
C) Drugs

3. CONTROL-BASED ASTHMA MANAGEMENT
• Asthma treatment is adjusted in a continuous cycle to
assess, adjust treatment and review response.

6. STEPWISE APPROACH FOR ADJUSTING
TREATMENT
STEP 1:
As-needed SABA with no controller
This is indicated only if symptoms are rare, there is no night waking due to asthma, no
exacerbations in the last year, and normal FEV1.
Other options: regular low dose ICS for patients with exacerbation risks.
STEP 2 :
Regular low dose ICS plus as-needed SABA
Other options:
LTRA are less effective than ICS
***For purely seasonal allergic asthma, start ICS immediately and cease 4 weeks after end
of exposure.

7. STEP 3 :
Low dose ICS/LABA as maintenance treatment plus as needed SABA,
or as ICS/formoterol maintenance and reliever therapy
Other options: Medium dose ICS; for adult patients with rhinitis and allergic to house dust
mite (HDM) with exacerbations despite ICS, consider adding sublingual immunotherapy
(SLIT), provided FEV1 is >70% predicted. Children (6–11 years): Medium dose ICS.
Other options: low dose ICS/LABA
STEP 4:
Low dose ICS/formoterol maintenance and reliever therapy, or medium dose ICS/LABA as
maintenance plus as-needed SABA
Other options: Add-on tiotropium by mist inhaler for patients 12 years with a history of
exacerbations; high dose ICS/LABA, but more side-effects and little extra benefit; extra
controller, e.g. LTRA or slow-release theophylline (adults); for adult patients with rhinitis
and allergic to HDM with exacerbations despite ICS, consider adding SLIT, provided FEV1 is
>70% predicted. Children (6–11 years): Refer for expert assessment and advice.

8. STEP 5:
Refer for expert investigation and add-on treatment
Add-on treatments include
tiotropium by mist inhaler for patients with a history of exacerbations age 12 years,
anti-IgE (omalizumab) for severe allergic asthma >6 years
anti-IL5 (SC mepolizumab or IV reslizumab) for severe eosinophilic asthma (age 12
years.
Other options: Some patients may benefit from low dose OCS but long-term
systemic side-effects commonly occur.

9. Medications / Drugs
Medication Action Side effect
CONTROLLER
ICS (pMDI or DPIs)
- beclomethasone, fluticasone,
budesonide
Reduce sx, increase lung function,
reduce risk of exacerbation
Long term : (high doses)
- osteoporosis, cataract, glaucoma
ICS + LABA
- Beclomethasone + formoterol,
budesonide + formoterol,
fluticasone + formeterol
Addition of LABA will improve the
sx more rapidly , and reduce risk of
exacerbation
Tachycardia, headache, cramps
LEUKOTRIENE MODIFIER
- Montelukast, pranlukast,
zafirlukast
Target one part of the
inflammatory pathway in asthma
Risk of serious behaviour and mood
changes
CHROMONES
- Sodium chromoglycate and
nedocromil sodium
Weak anti-inflammatory effect
Less effective than low dose ICS
Uncommon – may include cough
upon inhalation

10. Add on controller medications
LAMA
- Beclomethasone + formoterol +
glycopyrronium
- Fluticasone + vilanterol +
umeclidinium
Uncontrolled asthma despite of ICS
+ LABA
Dry mouth (uncommon)
Anti-IgE (SC)
- omalizumab
Severe allergic asthma uncontrolled
with high dose ICS-LABA
Local reaction to injection site
Anti–IL5 or Anti –IL5R
- Mepolizumab
- Reslizumab
Severe eosinophilic asthma
uncontrolled with high dose ICS –
LABA
Headache, local reaction at
injection site
Anti – IL4R
- Dupilumab
Severe eosinophilic asthma ot Type
2 asthma uncontrolled with high
dose ICS – LABA
Reaction at injection site - common
SYSTEMIC CORTICOSTEROID
(tablets, suspension, IV, IM)
- prednisone, prednisolone,
methylprednisolone,
hydrocortisone
Short term (5-7 days) is important
in treatment of severe acute
exacerbation.
Tappering is required if treatment
>2weeks
Short term : sleep disturbances,
reflux, increase appetite, mood
changes
Long term : cataract, glaucoma,
HPT, DM, adrenal suppression
osteoporosis

11. RELIEVER MEDICATION
SABA
- Salbutamol, Terbutaline
Quick relief of asthma sx and
bronchoconstriction
Tremor and tachycardia
LOW DOSE ICS – FORMOTEROL
- Beclomethasone + formoterol
- Budesonide + formoterol
Reduce risk of exacerbation
compared with using SABA as
reliever, with similar sx control
SHORT ACTING ANTICHOLINERGIC
- Ipratropium bromide, oxitropium
bromide
Long term : less effective than
SABA
Short term in severe acute asthma :
When added with SABA – reduce
risk of hospital admission
Dryness of mouth and bitter taste

12. Types of inhaler devices

13. AIMS OF MANAGEMENT
• To prevent death
• To relieve symptoms
• To restore the patient’s lung function to the best
possible level as soon as possible
• To prevent early relapse

14. ASTHMA FLARE-UPS (EXACERBATIONS)
- A flare-up or exacerbation is an acute or sub-acute worsening in
symptoms and lung function from the patient’s usual status
- It may be the initial presentation of asthma
STATUS ASTHMATICUS
- commonly known as acute severe asthma or a severe asthma
exacerbation.
- It refers to an asthma attack that doesn’t improve with traditional
treatments, such as inhaled bronchodilator.
- These attacks can last for several minutes or even hours.

15. Identifying patients at risk of asthma-related death :
• A history of near-fatal asthma - intubation and ventilation
• Hospitalization / emergency care for asthma in last 12 months
• Not currently using ICS, or poor adherence with ICS
• Currently using or recently stopped using OCS
(this indicates the severity of recent events)
• Over-use of SABAs, especially more than 1 canister/month
• Lack of a written asthma action plan
• History of psychiatric disease or psychosocial problems
• Confirmed food allergy in a patient with asthma

16. MANAGING EXACERBATIONS IN PRIMARY OR ACUTE CARE
• Assess exacerbation severity while starting SABA and oxygen.
• Assess dyspnea (e.g. is the patient able to speak sentences, or only
words) RR, PR, Spo2 and lung function (e.g. PEF).
• Consider alternative causes of acute breathlessness (e.g. heart
failure, upper airway dysfunction, inhaled foreign body or pulmonary
embolism).
• Arrange immediate transfer to an acute care facility if there are signs
of severe exacerbation, or to intensive care if the patient is drowsy,
confused, or has a silent chest.
For these patients, immediately give inhaled SABA, inhaled ipratropium
bromide, oxygen and systemic corticosteroids.
• Start treatment with repeated doses of SABA (usually by pMDI and
spacer), early oral corticosteroids, and controlled flow oxygen if
available.

17. • Check response of symptoms and saturation frequently, and measure
lung function after 1 hour. Titrate oxygen to maintain saturation of
93–95% in adults and adolescents (94–98% in children 6–12 years).
• For severe exacerbations, add ipratropium bromide, and consider
giving SABA by nebulizer.
In acute care facilities, intravenous magnesium sulfate may be
considered if the patient is not responding to intensive initial
treatment.

18. • Criteria for admission
• Failure to respond to standard home treatment.
• Failure of those with mild or moderate acute asthma to respond to
nebulised β₂-agonists.
• Relapse within 4 hours of nebulised β₂- agonists.
• Severe acute asthma ( Status Asthmaticus )

19. MANAGEMENT OF ASTHMA EXACERBATIONS
IN ACUTE SETTINGS
GINA

20. GINA

21. References
• Malaysia Thoracic Society: Guidelines on Management of Adult
Asthma
• Pocket Guide for Asthma Management and Prevention, GINA 2015