Management of Stable  Bronchial Asthma         Dr Subin Ahmed MD, FCCP             Assistant Professor    Department of Pu...
WORLD ASTHMA DAY         May 1st 2012‘You can control your Asthma’
COMPONENTS OF ASTHMA         MANAGEMENT4 essential components• Routine monitoring of symptoms and lung  function• Patient ...
GOALS OF ASTHMA TREATMENT• 2 domains: Reduction in impairment and Reduction of riski. Reduce impairment:• Impairment refer...
GOALS OF ASTHMA TREATMENTii. Reduce risk1. Prevention of recurrent exacerbations    and need for emergency department or  ...
Classification of asthma control (youth ≥ 12                                     years of age and adults)    Components of...
Classification of asthma severity (≥12 years of age)Components of severity                                                ...
Assessment of impairment• Has your asthma awakened you at night or in the  early morning?• Have you needed your quick-acti...
Assessment of risk• Have you taken oral glucocorticoids for your  asthma in the past year?• Have you been hospitalized for...
NON-PHARMACOLOGICAL           THERAPYTrigger avoidance and Patient education1. Trigger avoidance — Elimination or avoidanc...
PHARMACOLOGICAL   TREATMENT
All Asthma Drugs Should Ideally              Be   Taken Through The Inhaled             Route
WHY INHALATIONAL ROUTE?         ORAL                   INHALED• Slow Onset of Action    • Rapid Onset of Action• Large Dos...
Reliever• Reliever (also known as rescue medication)• Bronchodilator (beta 2 agonist)• Quickly relieves symptoms (within 2...
RELIEVERS• Short acting B2 agonists  Salbutamol  Levosalbutamol• Anti-cholinergics  Ipratropium bromide• Xanthines  Theoph...
Rescue Medication• SALBUTAMOL INHALER 100 mcg:  1 or 2 puffs as necessary• LEVOSALBUTAMOL INHALER 50 mcg :   1 or 2 puffs ...
Controller• Anti-inflammatory• Takes time to act (1-3 hours)• Long-term effect (12-24 hours)• Only for regular use (whethe...
CONTROLLERS• Corticosteroids  Prednisolone, Betamethasone  Beclomethasone, Budesonide  Fluticasone• Long acting B2 agonist...
Aerosol delivery systems        currently available•   Metered dose inhalers•   Dry powder inhalers•   Spacers / Holding c...
WHICH DEVICE TO USE IN WHOM??????
Classification of asthma severity (≥12 years of age)Components of severity                                                ...
Stepping Down Therapy• When controlled on medium to high dose ICS, 50%  dose reduction at 3months interval• When controlle...
Stepping Up Therapy in     response to loss of control• Rapid onset short or long acting beta 2 agonist as  reliever• Need...
Systemic GCS-Indications• Acute exacerbations• Symptoms not controlled with other treatment• Steroid dependant Asthma• ABP...
Chronic Therapy• Reassessed at each visit for asthma care• Return visits should also allow for ongoing  patient/family edu...
SMART TherapySINGLE INHALERMAINTAINANCEANDRELEIVERTHERAPY
LABA+ steroids better than highdose inhaled steroidsFormetrol            Salmetrol                            Slower onset...
The actions of ICS and LABA       complement each other• The two components of asthma are  – Airway inflammation  – Bronch...
Advantages of SMART therapy• Rapid onset of action• Less side effects• Decreased use of inhaled and oral steroids.
Management of Stable Asthma
Management of Stable Asthma
Management of Stable Asthma
Management of Stable Asthma
Management of Stable Asthma
Management of Stable Asthma
Management of Stable Asthma
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Management of Stable Asthma

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Talk given by me at K S Hegde Medical College, Mangalore; on World Asthma Day

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Management of Stable Asthma

  1. 1. Management of Stable Bronchial Asthma Dr Subin Ahmed MD, FCCP Assistant Professor Department of Pulmonary MedicineYenepoya Medical College Hospital, Mangalore
  2. 2. WORLD ASTHMA DAY May 1st 2012‘You can control your Asthma’
  3. 3. COMPONENTS OF ASTHMA MANAGEMENT4 essential components• Routine monitoring of symptoms and lung function• Patient education to create a partnership between clinician and patient• Controlling environmental factors (trigger factors) and comorbid conditions that contribute to asthma severity• Pharmacologic therapy
  4. 4. GOALS OF ASTHMA TREATMENT• 2 domains: Reduction in impairment and Reduction of riski. Reduce impairment:• Impairment refers to the intensity and frequency of asthma symptoms and the degree of limitation1. Freedom from frequent or troublesome symptoms of asthma (cough, chest tightness, wheezing, or shortness of breath), including symptoms that disturb sleep2. Minimal need (≤2 times per week) of inhaled short acting beta agonists (SABAs) to relieve symptoms3. Optimization of lung function4. Maintenance of normal daily activities, including work or school attendance and participation in athletics and exercise5. Satisfaction with asthma care on the part of patients and families
  5. 5. GOALS OF ASTHMA TREATMENTii. Reduce risk1. Prevention of recurrent exacerbations and need for emergency department or hospital care2. Prevention of reduced lung growth in children, and loss of lung function in adults3. Optimization of pharmacotherapy with minimal or no adverse effects
  6. 6. Classification of asthma control (youth ≥ 12 years of age and adults) Components of control Well-controlled Not-well Very poorly controlled controlled Symptoms ≤ 2 days/week > 2 days/week Throughout dayI Nighttime awakenings ≤ 2x/month 1-3x/week ≥ 4x/weekm Interference with normal None Some Limitation Extremelyp activity limiteda SABA use for symptom control ≤2days/week >2days/week Several timesi (not prevention of EIB) per dayr FEV1 or peak flow >80% predicted/ 60-80 % predicted/ < 60 predicted/m personal best personal best personal beste Validated Questionnaires ATAQ 0 1-2 3-4n ACQ ≤0.75 ≥1.5 N/At ACT >20 16-19 ≤15 Exacerbations 0-1/year ≥2/yearR Progressive Loss of lung Evaluation requires long term follow-up care functioni Treatment related side effects Medication side effects can vary intensity from none to verys troublesome. The level of intensity does not correlate tok specific levels of control but should be considered in the overall assessment of risk.
  7. 7. Classification of asthma severity (≥12 years of age)Components of severity Persistent Intermittent Mild Moderate SevereImpairment Symptoms ≤ 2 days/week > 2days/week but Daily Throughout day not daily• Normal Night-time ≤ 2x/month 3-4x/month >1x/week but not Often 7x/week FEV1/FVC: awakenings nightly 8-19 yrs SABA use for ≤2days/week >2days/week but not Daily Several times per day 85 percent symptom control daily, and not more• 20-39 yrs (not prevention than 1x on any day 80 percent of EIB)• 40-59 yrs Interference with None Minor limitation Some limitation Extremely limited75 percent normal activity• 60-80 yrs Lung functions - Normal FEV1 - FEV1 ≥ 80 percent - FEV1>60 but <80 - FEV1/FVC reduced >70 percent between predicted percent predicted 5 percent exacerbation - FEV1/FVC normal - FEV1/FVC - FEV1>80 percent reduced 5 percent predicted - FEV1/FVC normalRisk Exacerbations 0-1/year ≥2/years requiring oral Consider severity and interval since last exacerbation systemic Frequency and severity may fluctuate over time for patients in any severity category corticosteroids Relative annual risk of exacerbations may be related to FEV1Recommended step for Step 1 Step 2 Step3 Step 4 or 5initiating treatment And consider short course of oral systemic corticosteroids In 2-6 weeks, evaluate level of asthma control that is achieved and adjust therapy
  8. 8. Assessment of impairment• Has your asthma awakened you at night or in the early morning?• Have you needed your quick-acting relief medication more than usual?• Have you needed any unscheduled care for your asthma, including calling in, an office visit, or an emergency department visit?• Have you been able to participate in school/work and recreational activities as desired?• If you are measuring your peak flow, has it been lower than your personal best?• Have you had any side effects from your asthma medications?
  9. 9. Assessment of risk• Have you taken oral glucocorticoids for your asthma in the past year?• Have you been hospitalized for your asthma? If yes, how many times have you been hospitalized in the past year?• Have you been admitted to the intensive care unit or been intubated because of your asthma? If yes, did this occur within the past five years?• Do you currently smoke cigarettes?• Have you ever noticed an increase in asthma symptoms after taking aspirin or a non-steroidal anti-inflammatory agent (NSAID)?
  10. 10. NON-PHARMACOLOGICAL THERAPYTrigger avoidance and Patient education1. Trigger avoidance — Elimination or avoidance of known triggers. History taking - exposure to environmental allergens and irritants in the home, school, and/or workplace1. Patient education — ongoing process, create a partnership between the patient and provider in achieving and maintaining asthma control. educational materials, personalized asthma action plan that gives detailed instructions about how to self-administer medications at baseline and during exacerbations
  11. 11. PHARMACOLOGICAL TREATMENT
  12. 12. All Asthma Drugs Should Ideally Be Taken Through The Inhaled Route
  13. 13. WHY INHALATIONAL ROUTE? ORAL INHALED• Slow Onset of Action • Rapid Onset of Action• Large Dosage Required • Less Amount of Drug Used• Greater Side Effects • Better Tolerated• Not Useful in Acute Symptoms • Treatment of Choice in Acute Symptoms
  14. 14. Reliever• Reliever (also known as rescue medication)• Bronchodilator (beta 2 agonist)• Quickly relieves symptoms (within 2-3 minutes)• Action lasts 4-6 hrs• Not for regular use
  15. 15. RELIEVERS• Short acting B2 agonists Salbutamol Levosalbutamol• Anti-cholinergics Ipratropium bromide• Xanthines Theophylline, Aminophylline• Adrenaline
  16. 16. Rescue Medication• SALBUTAMOL INHALER 100 mcg: 1 or 2 puffs as necessary• LEVOSALBUTAMOL INHALER 50 mcg : 1 or 2 puffs as necessary
  17. 17. Controller• Anti-inflammatory• Takes time to act (1-3 hours)• Long-term effect (12-24 hours)• Only for regular use (whether well or not well)• Prevent future attacks• Long term control of asthma• Prevent airway remodelling
  18. 18. CONTROLLERS• Corticosteroids Prednisolone, Betamethasone Beclomethasone, Budesonide Fluticasone• Long acting B2 agonists Bambuterol, Salmeterol Formoterol• COMBINATIONS Salmeterol/Fluticasone Formoterol/Budesonide Salbutamol/Beclomethasone
  19. 19. Aerosol delivery systems currently available• Metered dose inhalers• Dry powder inhalers• Spacers / Holding chambers• Nebulizer
  20. 20. WHICH DEVICE TO USE IN WHOM??????
  21. 21. Classification of asthma severity (≥12 years of age)Components of severity Persistent Intermittent Mild Moderate SevereImpairment Symptoms ≤ 2 days/week > 2days/week but Daily Throughout day not dailyNormal Night-time ≤ 2x/month 3-4x/month >1x/week but not Often 7x/weekFEV1/FVC: awakenings nightly• 8-19 yrs SABA use for ≤2days/week >2days/week but not Daily Several times per day 85 percent symptom control daily, and not more• 20-39 yrs (not prevention than 1x on any day 80 percent of EIB)• 40-59 yrs Interference with None Minor limitation Some limitation Extremely limited75 percent normal activity• 60-80 yrs Lung functions - Normal FEV1 - FEV1 ≥ 80 percent - FEV1>60 but <80 - FEV1/FVC reduced >70 percent between predicted percent predicted 5 percent exacerbation - FEV1/FVC normal - FEV1/FVC - FEV1>80 percent reduced 5 percent predicted - FEV1/FVC normalRisk Exacerbations 0-1/year ≥2/years requiring oral Consider severity and interval since last exacerbation systemic Frequency and severity may fluctuate over time for patients in any severity category corticosteroids Relative annual risk of exacerbations may be related to FEV1Recommended step for Step 1 Step 2 Step3 Step 4 or 5initiating treatment And consider short course of oral systemic corticosteroids In 2-6 weeks, evaluate level of asthma control that is achieved and adjust therapy
  22. 22. Stepping Down Therapy• When controlled on medium to high dose ICS, 50% dose reduction at 3months interval• When controlled on low dose ICS, switch to once daily dosing.• When controlled on ICS + LABA, reduce ICS by 50%• If control is still maintained, reduce to low dose ICS alone and stop LABA.
  23. 23. Stepping Up Therapy in response to loss of control• Rapid onset short or long acting beta 2 agonist as reliever• Need for repeated dosing over more than one/ two days signals need for increase in controller therapy – Increase the dose of ICS or consider short course of oral corticosteroids• Use of combination of rapid and long acting inhaled beta 2 agonists and ICS in a single inhaler both as controller and reliever (SMART) is effective in maintaining a high level of asthma control and reduces exacerbation.
  24. 24. Systemic GCS-Indications• Acute exacerbations• Symptoms not controlled with other treatment• Steroid dependant Asthma• ABPA with Asthma
  25. 25. Chronic Therapy• Reassessed at each visit for asthma care• Return visits should also allow for ongoing patient/family education• Therapy should be stepped up if asthma is not well-controlled• Stepped down if symptoms have been well- controlled over a period of months• Patients should be reevaluated every 2 to 6 weeks when therapy has been adjusted
  26. 26. SMART TherapySINGLE INHALERMAINTAINANCEANDRELEIVERTHERAPY
  27. 27. LABA+ steroids better than highdose inhaled steroidsFormetrol Salmetrol Slower onsetRapid onsetShort duration of side Long duration of sideeffect effectResponse increase with No such effectdoseNo cumulative side effect Cumulative side effect +
  28. 28. The actions of ICS and LABA complement each other• The two components of asthma are – Airway inflammation – Broncho-constriction• ICS – Reduce and control inflammation• LABA – Cause primarily broncho-dilation• Thus, complementing each others action.
  29. 29. Advantages of SMART therapy• Rapid onset of action• Less side effects• Decreased use of inhaled and oral steroids.

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