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2. Definition
• Exacerbations of asthma are episodes characterized
by a progressive increase in symptoms of shortness
of breath, cough, wheezing or chest tightness and
progressive decrease in lung function, i.e. they
represent a change from the patient's usual status
that is sufficient to require a change in treatment.

3. • Definition based on combination of symptom, clinical
findings and lung function is more objective in
assessing severity.
• A minority of patients perceive airflow limitation
poorly and can experience a significant decline in
lung function change in symptoms. This especially
affects patients males with a history of near fatal
asthma.

4. Assessment of risk
The prevention of exacerbations is the most
important aim for patients with asthma and
healthcare professionals.
In order to achieve this aim, it is important to
plan the re-assessment of asthma patients and
treatment adjustments because of the immediate
risks (i.e. acute respiratory failure, death) and
future risks (recurrence of exacerbations, decline
in lung function, and side-effects of treatments)

5. • Factors which are associated with exacerbation
1) the level of asthma control,
2) asthma severity based on ERS/ATS definition,
3) lung function,
4) the presence of comorbidities,
5) the psychosocial status (to assess the ability to seek
help in case of clinical worsening),
6) previous history of near fatal attacks and
7) response to treatment.
• Such factors seem important in guiding treatment
decisions and, importantly, decisions regarding
hospitalizations.

6. Triggers of exacerbation
• Indoor allergens
– House dust mites in bedding, coach roach eggs
carpet, stuffed furniture, pollution and pet dander
• Outdoor allergen
– Pollen, molds
• Tobacco smoke
• Chemical irritants in workplace
• Cold air and physical exercise
• Certain medications, such as aspirin, NSAID

7. Classification of asthma severity &
management
• Mild
• Moderate
• Severe
• Very severe

8. DEGREE OF
SEVERITY SYMPTOMS AND SIGNS INITIAL PEF (OR FEV1) CLINICAL COURSE
Mild Dyspnea only
with activity
(assess
tachypnea in
young children)
PEF ≥ 70 percent of
predicted or personal
best
Usually treated at home
Prompt relief with inhaled
short-acting beta2 agonist
Possible short course of
oral systemic
corticosteroids
Moderate Dyspnea
interferes with or
limits usual
activity
O2 saturation
90-95%
PEF 50-69 percent of
predicted or personal
best
Usually requires office or
emergency department
visit
Relief from frequent
inhaled short-acting
beta2 agonist
Oral systemic
corticosteroids; some
symptoms last for one to
two days after treatment
begins

9. Self management of exacerbation
• Severe exacerbations are potentially life threatening
and their treatment requires careful assessment and
monitoring by health care professionals.
• A careful written asthma action plan helps patients to
recognize and respond appropriately to worsening of
symptoms.
• The criteria for initiating an increase in controller
medication will vary from patient to patient.

10. Asthma action plan

11. ICS-Formoterol
• For patients with mild asthma prescribed as-needed
combination low dose ICS-formoterol, increasing the
as-needed doses of ICS-formoterol when asthma
worsens reduces the risk of severe exacerbations
requiring OCS by 2/3rd compared to SABA-only
treatment. However the benefit is achieved when
initiated at the early stage of worsening asthma.

12. ICS
• For patients with maintenance-only ICS containing
treatment should generally be increased if asthma
symptoms are interfering with normal activities, or
PEF has fallen by >20% for more than 2 days.
Possible options
– Temporarily doubling ICS dose (delay of 5-7 days
may contribute to failure)
– Age >16 years quadrupling ICS dose can reduce
use of OCS.

13. OCS
Short course of 40 mg prednisolone for 5 days with
instructions can be tried if:
– Fail to respond to an increase in reliever and
controller medication for 2-3 days
– Deteriorate rapidly or who have a PEF or FEV1< 60%
of their personal best or predicted value.
– Have a history of sudden severe exacerbations.

14. Follow up after outpatient
management
• Ideally before ceasing oral corticosteroids if prescribed.
• Maintenance controller treatment can generally be
resumed at previous levels 2-4 weeks after
exacerbation, unless the history suggests that the
exacerbation occurred on a background of long-term
poorly controlled asthma.
• In this situation use this opportunity to train inhaler
technique, check adherence and provide additional
asthma education.
• After checking technique and adherence a step up in

16. First Line Therapy at PHC
1. Prednisolone 30-40 mg per day for five days for
adults initiated within one hour of presentation
AND
2. Salbutamol four- six puffs by metered dose
inhaler and by spacer every 20 minutes for one
hour
3. Oxygen supplementation if saturation is below
90%.

17. Second Line treatment at
General Hospital and above
• Increase frequency of dosing via metered dose inhaler
and spacer or give salbutamol by continuous
nebulization at 5-10 mg per hour.
• Add nebulized ipratropium, if available
• Continue steroid therapy
• IV magnesium sulfate (2g infused over 20 minutes)
• IV theophylline or Aminophylline

18. Review
• Patient’s response after discharge (within a week)
• Patient’s understanding of the cause of their
asthma
• Modifiable risk factors for asthma
• Understanding of correct uses of medications
• Adult and adolescent patients with more than 1-2
exacerbations per year despite more than Step 3
therapy should be referred to a specialist.

19. Part II Asthma education

20. Goals of asthma education
• An explanation of the nature of asthma and its
inflammatory basis
• A description of the different classes of drugs
and their purpose in treatment (i.e. as-needed
“relievers” and regular “controllers”)
• Advice on prevention strategies (allergen,
irritant, and tobacco smoke avoidance)

21. • How to recognize worsening asthma and how and
when to implement their action plan
• In some patients, particularly those requiring
stabilization or patients who have had a recent
exacerbation or deterioration, the use of a PEF
meter and chart.
• The correct choice and use of inhalers and the
opportunity to practice under supervision

22. INHALER USE FOR ASTHMA
MANAGEMENT
• An inhaler is a medical device used for delivering
medication into the body via the lungs. It is mainly
used in the treatment of asthma and chronic obstructive
pulmonary disease. The two most common forms are:
– Metered-dose inhaler
– Dry powder inhalers (Accuhalers and turbuhalers)
• Some of the types of inhalers include: Autohalers
(Breath Activated aerosol devices), Nebulizers mists
and nasal inhalers

23. • Most patients (up to 80%) cannot use their inhaler
correctly. This contributes to poor symptom
control and exacerbations. To ensure effective
inhaler use.
• Choose the most appropriate device for the
patient before prescribing, check in haler
technique at every opportunity, correct using
physical demonstrations, paying attention to
incorrect steps and confirm that you have
checklists.

24. Metered-dose inhaler (MDIs)
• The medicine is in a small canister, inside a plastic
case. When the inhaler is pressed, a measured dose
of medicine comes through the mouthpiece.
• MDIs require good technique and coordination by
pressing down on the inhaler and breathing in at the
same time.
• Because using the inhaler correctly can be
difficult, spacer devices are recommended for use
with MDIs. The spacer is attached to the MDI to
make it easier to use the inhaler and get more
medicine into the lungs

25. A. How to use Metered Dose Inhaler
• Remove the cap and check the mouthpiece is clean
and free of objects.
• Shake the inhaler four or five times
• Holding the inhaler upright with your thumb on the
base, breathe out as far as comfortable
• Place the mouthpiece in your mouth; closing your lips
around it to form a good seal - do not bite
• Start to breathe in slowly; press down firmly on the
top of the canister to release a dose; while continuing
to breathe in slowly and deeply

26. • Removing the inhaler from your mouth; hold your
breath for about 10 seconds, or as long as is
comfortable.
• Breathe out gently away from your inhaler
mouthpiece
• For a second dose, wait approximately 30 seconds
before repeating steps 2-7
• Replace the cap

27. Dry Powder Inhaler (DPI)
• Dry powder inhalers are handheld devices that deliver
medication to the lungs and airways as you inhale
through it.
• Examples of dry powder inhalers include: Turbuhaler;
Accuhaler; Handihaler; Ellipta inhaler and Breezhaler.
The common forms available in Ethiopia are Turbuhaler
(eg.Symbicort) and Accuhaler (eg.Seritide)

28. B. How to use Accuhaler® (Dry powder inhaler-
DPI)
• Check dose counter.
• Open cover. (Use thumb grip)
• Hold the casing of the Accuhaler® in one hand while
sliding the thumb grip away until a click is heard
• Holding your Accuhaler® with the mouthpiece towards
you slide the lever away from you until a click is heard.
This makes the dose available for inhalation and moves
the dose counter on.

29. • Holding the inhaler horizontally, breathe out
as far as comfortable
• Place the mouthpiece in your mouth; closing
your lips around it to form a good seal - do
not bite
• Breathe in as strongly and deeply as possible
• Removing the inhaler from your mouth;
hold your breath for about 10 seconds, or as
long as is comfortable
• Breathe out gently away from your inhaler
mouthpiece
• To close the Accuhaler®, slide the thumb
grip back towards you as far as it will go
until it clicks.

30. Turbuhaler (DPI)
• Since the turbuhaler is a breath-activated
device, to use the turbuhaler properly, you
must be able to breathe in deeply. Adults
and children 7 years of age and older
should be able to use the turbuhaler.

31. C. How to use Turbuhaler (DPIs )
1. Open: unscrew and remove the cap. Hold the
turbuhaler upright.
2. Load the dose: twist the base anticlockwise and then
back in the other direction until you hear a click. Your
turbuhaler is now loaded with one dose of medicine
3. Breathe out: breathe out, away from the turbuhaler. Do
not blow directly into the turbuhaler.
4. Inhale your dose: place the mouth piece in your mouth
and form a seal with your lips. Breathe in deeply. Remove
the turbuhaler and hold your breath for up to 10 seconds.

32. 5. Close: replace the cap and twist until it is on
properly.
6. Cleaning and storing your turbuhaler: wipe
the mouthpiece with a clean dry tissue. Do not
wash the mouthpiece or allow it to get wet when
cleaning. Keep the cap on when not in use. The
device may clog if exhaled or dribbled into or if
stored in an area of high humidity with the cap
off or unsealed.

33. Common problems when using a turbuhaler
• To get the most benefit, it is important to use the
correct technique. Here are a few common
problems:
• Not holding your turbuhaler upright (vertical)
while loading the dose.
• Covering the air inlets with your lips.
• Breathing in through your nose instead of your
mouth.
• Shaking the inhaler to see how much is left.
• Storing your turbuhaler in a damp place with the
cap off.

34. • How to use Spacers
• If patient unable to use an inhaler correctly, add a spacer
to increase drug delivery to the lungs, especially if using
inhaled corticosteroids. This may also reduce the risk of
oral candida.
• Clean the spacer before first use and every second week:
remove the canister and wash spacer with soapy water.
Allow it to drip dry. Avoid rinsing with water after each
use.
• Spacers are not commonly available in Ethiopia so a
plastic water bottle. See figure below.
• To modify a 500ml plastic bottle for use as an effective
spacer

35. How to use a bottle spacer
Use a modified 500ml plastic bottle in a similar way to
a conventional spacer

37. Case study 3 (30 min)
• The above patient returns back after 2 weeks with Shortness of
breath, fever and cough productive of yellowish sputum appears to
be in distress with difficulty of speaking, his RR was 30, pulse was
100/mt and BP-130/80mmhg and T-37.5, He has no wheezing and
difficult to hear the breath sounds, heart beatare normal and no
murmur, no gallop, no pedal edema. He appears weak and
occasionally confused.
• What is the diagnosis?
• What are the abnormal findings in this patient?
• What do these abnormal findings imply?
• Classify the severity of asthma?
• What are the steps of management?

38. • We would like to thank
Dr Hanan Yusuf, Dr Tewodros Haile,
Dr Amsalu Bekele and Dr Rahel Argaw for
preparing this powerpoint