This document provides an overview of asthma diagnosis and management. It discusses defining asthma as a chronic inflammatory airway disease, guidelines for diagnosis and assessing severity, common precipitating factors and comorbidities, and treatment options including inhaled corticosteroids as first-line controller therapy and omalizumab for severe uncontrolled asthma. It also addresses special considerations for asthma diagnosis and treatment during pregnancy.

1. Asthma: Current Concepts in Diagnosis and Management Christie F. Michael, MD Assistant Professor University of Tennessee, Memphis

2. Goals of Talk Scope of asthma Definition/diagnosis NHLBI guidelines 2007 Asthma in pregnancy Omalizumab

3. Asthma in Adults 14.7 million in US >10million office visits/yr ~1.9million ED visits/yr 466,000 hospitalizations/yr

4. Asthma Mortality Asthma deaths: >5000 each year (1998,USA) Asthma death in children 36% severe persistent 31% moderate persistent 33% mild persistent

5. The Good News Mortality on decline despite increasing incidence Most asthmatics can lead normal, active life with proper treatment

6. Asthma Definition Obstructive lung disease with key features including partial reversibility, airway hyper-responsiveness and airway modeling Davies, et al. Airway remodeling in asthma: new insights. JACI 2003; 111:215-25

7. Asthma: Expanding Definition “ A chronic inflammatory disorder of the airways in which many cells and cellular elements play a role…” 1.“Reversibility incomplete in some patients..” 2. Anti-inflammatory tx fails to prevent dz progression.

8. Airway Remodeling Sub-basement fibrosis Mucus hypersecretion Epithelial injury Smooth muscle hypertrophy Angiogenesis

10. Not All That Wheezes Is Asthma… -Foreign body - Upper airway diseases - Enlarged lymph nodes or tumor - Vocal cord dysfunction - Aspiration/GERD - COPD - CHF - PE - Drug reaction/side effect

11. Asthma Does Not Always Wheeze… Chronic or nocturnal cough with awakenings Exercise induced symptoms Chest tightness Viral induced symptoms

12. Asthma Diagnosis Lower airway obstruction Variation in the magnitude of obstruction Recurrence of obstruction on more than one occasion PFT’s/ peak flow variability Exclusion of alternative diagnoses

13. Diagnosis of Asthma PFTs - FEV1 <80% - Fev1/FVC Ratio <65% - >12%(200ml) Reversibility in FEV1 after B2 Agonist

14. Diagnosis of Asthma Methacholine challenge: Peak expiratory flow rate (PEFR): Ht (cm) X 5.25-425

16. Gene by Environment RSV in pediatrics Smoking/ smoke exposure Atopy Many others…

17. Link Between Asthma/Atopy: “One Airway, One Disease” ~80% asthmatics with allergic rhinitis 40% AR pts with asthma Of asymptomatic AR pts- up to 40% with AHR Nasal allergen challenge increases AHR tx AR lowers asthma sx’s and related costs

18. Guidelines for Asthma Diagnosis and Management ASSESSMENT and MONITORING CONTRIBUTING FACTORS PATIENT EDUCATION PHARMACOTHERAPY

19. Asthma Severity Classification Intrinsic intensity of dz process Used as the basis for selection of therapy Incorporates subjective and objective parameters Must apply with clinical judgement

20. Impairment AND Risk Domains of both assessment and control Current symptoms Future risk Objective and subjective measures

21. Impairment Quality of life Missed school or work Surveys (ACT, ACQ..) Lung functions

22. Risk Hospital stays/ICU ED visits Oral steroid bursts Lung function (FEV1, FEV1/FVC) Other biomarkers not proven (FeNO, serum IgE, bld/sputum eos)

26. Assess Control Once long-term control therapy initiated Responsiveness- the ease with which control achieved Continue to assess impairment and risk

30. Guidelines for Asthma Diagnosis and Management ASSESSMENT and MONITORING CONTRIBUTING FACTORS PATIENT EDUCATION PHARMACOTHERAPY

31. Precipitating Factors Viral URIs Inhalant allergens- grasses, trees, molds, pets, dust/dust mite, feather, cockroach Food allergens- soy, wheat, milk, nuts, eggs Irritant triggers- strong odors, smoke, cold air Weather changes

32. Comorbid Conditions Sinusitis Rhinitis Gastroesophageal reflux ABPA Vocal cord dysfunction OSA

33. Recognizing High-risk Asthmatics Beta2-agonist over-use Disregard of symptoms Psychosocial factors Previous respiratory arrest or ICU admit

34. Asthma in Pregnancy 1/3 patients better 1/3 stay the same 1/3 worsen

35. Acute Treatment of Asthma  2 Agonists- PO, IV (albuterol, terbutaline) Anticholinergics- Ipatropium (Atrovent) Steroids- PO, IV (solumedrol, prednisone) Methylxanthines- PO, IV (Aminophylline, Theophylline) Heliox (60/40) Magnesium Sulfate Intubation

37. Treatment of Asthma -Controller Therapy Inhaled Corticosteroids- gold standard Long-Acting B2 Agonists Leukotriene Modifiers Mast Cell Stabilizers Theophylline Omalizumab (Xolair) Immunotherapy

40. Inhaled corticosteroids Preferred treatment for all classes of persistent asthma Maximize benefit/ minimize risks combination therapies to minimize doses (leukotriene modifiers, long acting beta2- agonists…)

41. Medications in Pregnancy NASAL Pseudoephedrine (avoid in 1st trimester) Oxymetazoline nasal spray (3-5 days) Nasal steroids budesonide* beclomethasone Nasal saline irrigation Antihistamines chlorpheniramine cetirizine (after 1st trimester) loratadine (after 1st trimester)

42. Medications in Pregnancy ASTHMA theophylline inhaled beta-agonists cromolyn prednisone (when indicated) inhaled steroids budesonide* beclomethasone

43. Anti- IgE Therapy: Omalizumab XOLAIR multicenter, randomized, DBPCT, phase III Anti-IgE reduces asthma exacerbations, ED visits and hospitalization rates Adjunctive tx in poorly controlled asthmatics and pt in need of IT but unable to tolerate due to severity of asthma

45. Anti-IgE: Qualifying for tx Documented allergy to perennial allergen Serum total IgE 30-700 Asthma

46. Referral Guidelines Difficulty achieving/mx control Step 4 or higher Immunotherapy Omalizumab ICU stay