This document summarizes guidelines for diagnosing and managing asthma from the American Thoracic Society, National Asthma Education and Prevention Program, and Global Initiative for Asthma. It outlines defining features of asthma including airway inflammation and obstruction. Diagnosis involves assessing symptoms, lung function testing, and ruling out other causes. Goals of treatment are avoiding symptoms, limiting reliever medication use, and normal lung function through a stepwise treatment approach tailored to asthma severity and level of control.

1. Asthma Control: GuidelineAsthma Control: Guideline
BasedBased
American Thoracic Society (ATS),American Thoracic Society (ATS),
National Asthma Education and PreventionNational Asthma Education and Prevention
Program (NAEPP), and Global Initiative for AsthmaProgram (NAEPP), and Global Initiative for Asthma
(GINA)(GINA)
Michael P. Pietila, MDMichael P. Pietila, MD
Pulmonary, Critical Care and InternalPulmonary, Critical Care and Internal
Medicine Yankton Medical Clinic, P.C.Medicine Yankton Medical Clinic, P.C.
Assistant Professor Sanford School ofAssistant Professor Sanford School of
Medicine at USDMedicine at USD

2. Professional RelationshipsProfessional Relationships
I am a contracted speaker for:I am a contracted speaker for:
– Merck PharmaceuticalsMerck Pharmaceuticals
– Dey Pharma L.P. Bureau of COPD ResearchDey Pharma L.P. Bureau of COPD Research
and Education to Advance Therapeuticand Education to Advance Therapeutic
Excellence (BREATHE)Excellence (BREATHE)
I will not be speaking specifically aboutI will not be speaking specifically about
any of these companies products today.any of these companies products today.

3. Defining and Recognizing AsthmaDefining and Recognizing Asthma
Netter’s Anatomy

4. Asthma EpidemiologyAsthma Epidemiology
Estimated > 23 million AmericansEstimated > 23 million Americans
– Prevalence 5-25% of populationPrevalence 5-25% of population
Increasing prevalence and severityIncreasing prevalence and severity
– USA and worldwideUSA and worldwide
– Socioeconomics > geneticsSocioeconomics > genetics
$14 Billion direct annual costs in USA$14 Billion direct annual costs in USA

5. EpidemiologyEpidemiology
More common in males (equal after ageMore common in males (equal after age
20).20).
Atopy – Skin test reactivity, elevated IgEAtopy – Skin test reactivity, elevated IgE
levels, blood eosinophilia.levels, blood eosinophilia.
Indoor allergens – dust mites, animalIndoor allergens – dust mites, animal
dander.dander.
Environmental pollution, occupationalEnvironmental pollution, occupational
exposure.exposure.
Respiratory infections.Respiratory infections.
TOBACCO SMOKE.TOBACCO SMOKE.

6. Increasing Asthma MortalityIncreasing Asthma Mortality
500,000 hospitalizations per year in U.S.500,000 hospitalizations per year in U.S.
5-6,000 deaths per year5-6,000 deaths per year
1978 - beginning of increasing mortality1978 - beginning of increasing mortality
Role of poverty (vs. race)Role of poverty (vs. race)
– Access to health care, medications, educationAccess to health care, medications, education
– Greater environmental exposureGreater environmental exposure
– Importance of identifying persons with high risk ofImportance of identifying persons with high risk of
deathdeath

7. Definition of AsthmaDefinition of Asthma
• Obstructive lung disease with characteristicsObstructive lung disease with characteristics
of:of:
– Airway obstruction;Airway obstruction; reversiblereversible in most patientsin most patients
– Chronic airwayChronic airway inflammation (eosinophils)inflammation (eosinophils)
– IncreasedIncreased airwayairway responsivenessresponsiveness
Onset of symptoms can occur at any ageOnset of symptoms can occur at any age
NAEP - Guidelines for the Diagnosis and Management of Asthma 1991NAEP - Guidelines for the Diagnosis and Management of Asthma 1991

8. Guidelines for the Diagnosis and Management ofGuidelines for the Diagnosis and Management of
AsthmaAsthma
Key MessagesKey Messages
Asthma is an inflammatory diseaseAsthma is an inflammatory disease
Environmental factors are importantEnvironmental factors are important
Objective measures are neededObjective measures are needed
Health education is crucialHealth education is crucial
Emphasis on recognition and avoidance ofEmphasis on recognition and avoidance of
triggerstriggers
Buist & Vollmer. NEJM 331:1584-5;1996Buist & Vollmer. NEJM 331:1584-5;1996
Asthma Guidelines 2007Asthma Guidelines 2007

9. Asthma Guidelines 2007Asthma Guidelines 2007
Components of severity:Components of severity:
– Symptoms and objective testing.Symptoms and objective testing.
– FEV1 and FEV1/FVC measurement.FEV1 and FEV1/FVC measurement.
– Need for short-acting beta-agonist (SABA).Need for short-acting beta-agonist (SABA).
– Nighttime awakenings.Nighttime awakenings.
– Interference with normal activity.Interference with normal activity.

10. Diagnosing AsthmaDiagnosing Asthma
Symptoms and Medical HistorySymptoms and Medical History
– Wheezing, cough, difficult breathing and chestWheezing, cough, difficult breathing and chest
tightnesstightness
Symptoms worse at night/on awakeningSymptoms worse at night/on awakening
Seasonal patternSeasonal pattern
Eczema, hay fever, family historyEczema, hay fever, family history
Triggers – animal fur, chemicals, temperatureTriggers – animal fur, chemicals, temperature
change, dust mites, drugs, exercise, pollen, URI,change, dust mites, drugs, exercise, pollen, URI,
smokesmoke
Symptoms respond to anti-asthma therapySymptoms respond to anti-asthma therapy
Colds “go to the chest” or last > 10 days.Colds “go to the chest” or last > 10 days.
Pocket Guide for Asthma Management and
Prevention 2011

11. Asthma PhenotypesAsthma Phenotypes
Intermittent/PersistentIntermittent/Persistent
– Mild/Moderate/SevereMild/Moderate/Severe
Adult onset wheezingAdult onset wheezing
– Primary asthma and secondary causesPrimary asthma and secondary causes
– Tends to me more severeTends to me more severe
Occupational asthmaOccupational asthma
Neutrophilic inflammationNeutrophilic inflammation

12. Diagnostic TestsDiagnostic Tests
No single test can secure a diagnosis ofNo single test can secure a diagnosis of
asthmaasthma
Spirometry is the most helpful, preferredSpirometry is the most helpful, preferred
method for establishing diagnosis.method for establishing diagnosis.
– Increase in FEV1 of > 12% and 200 ml afterIncrease in FEV1 of > 12% and 200 ml after
inhaled bronchodilator.inhaled bronchodilator.
– Many asthma patients are negative andMany asthma patients are negative and
repeat testing is advised.repeat testing is advised.

13. Diagnostic TestingDiagnostic Testing
Peak expiratory flow (PEF) – aid inPeak expiratory flow (PEF) – aid in
diagnosis and management.diagnosis and management.
– Compare to patient's previous best effortCompare to patient's previous best effort
– 60 L/min improvement after BD or diurnal60 L/min improvement after BD or diurnal
variation in PEF of more than 20%variation in PEF of more than 20%
Bronchoprovaction testing.Bronchoprovaction testing.
– Methacholine, histamine or inhaled mannitolMethacholine, histamine or inhaled mannitol
Skin testing or specific IgE testing forSkin testing or specific IgE testing for
allergens.allergens.

14. Diagnostic ChallengesDiagnostic Challenges
Cough variant asthmaCough variant asthma
– Chronic cough, often at nightChronic cough, often at night
Exercise induced bronchospasmExercise induced bronchospasm
– Exercise challengeExercise challenge
Asthma in the elderlyAsthma in the elderly
– COPD vs asthmaCOPD vs asthma
Occupational asthmaOccupational asthma
– Must correlate symptoms with occupationMust correlate symptoms with occupation

15. Goals of TherapyGoals of Therapy
Avoid troublesome symptoms night andAvoid troublesome symptoms night and
dayday
Use little or no reliever medsUse little or no reliever meds
Have productive and physically active lifeHave productive and physically active life
Have (near) normal lung functionHave (near) normal lung function
Avoid serious attacksAvoid serious attacks

16. Initiating TherapyInitiating Therapy
Determine level of severity.Determine level of severity.
Consider interval since last exacerbation.Consider interval since last exacerbation.
– Fluctuations in severity and frequency may occur.Fluctuations in severity and frequency may occur.
Risk assessment:Risk assessment:
– Exacerbations requiring oral corticosteroids:Exacerbations requiring oral corticosteroids:
0-1 per year in intermittent (low risk) patient.0-1 per year in intermittent (low risk) patient.
> or equal to 2 per year in persistent (higher risk) patient.> or equal to 2 per year in persistent (higher risk) patient.
Keep in mind the patients baseline FEV1.Keep in mind the patients baseline FEV1.
Initiate treatment in a stepwise fashion.Initiate treatment in a stepwise fashion.
– Reevaluate level of control in 2-6 weeks.Reevaluate level of control in 2-6 weeks.

19. Asthma CareAsthma Care
Patient/doctor relationshipPatient/doctor relationship
– Avoid triggers, understand and take meds, recognizeAvoid triggers, understand and take meds, recognize
symptoms and seek advice in timely fashionsymptoms and seek advice in timely fashion
Identify and reduce exposure to riskIdentify and reduce exposure to risk
– Smoke, drugs, dust, fur, pollens, moldSmoke, drugs, dust, fur, pollens, mold
Assess, treat and monitorAssess, treat and monitor
– Stepwise approach, Ongoing monitoring q 3 monthlyStepwise approach, Ongoing monitoring q 3 monthly
when stable, within 2 weeks after exacerbation.when stable, within 2 weeks after exacerbation.
Manage exacerbationsManage exacerbations

20. Stepwise ApproachStepwise Approach
If disease is poorly controlledIf disease is poorly controlled
– First evaluate for adherence to treatments andFirst evaluate for adherence to treatments and
avoidance of triggersavoidance of triggers
– Consider a step up treatmentsConsider a step up treatments
If disease is well controlledIf disease is well controlled
– Step down treatmentsStep down treatments
Medications must be adjusted based onMedications must be adjusted based on
response to treatment and control of underlyingresponse to treatment and control of underlying
disease, not on a fixed timetable.disease, not on a fixed timetable.
– If a medicine is not effective after 3 months, it shouldIf a medicine is not effective after 3 months, it should
be stoppedbe stopped

21. Inhaler TechniqueInhaler Technique

24. Moderate to Severe PersistentModerate to Severe Persistent
AsthmaAsthma
Daytime symptoms daily and nighttimeDaytime symptoms daily and nighttime
symptoms at least weekly.symptoms at least weekly.
Using their rescue inhaler at least onceUsing their rescue inhaler at least once
daily.daily.
FEV1 < 80% of predicted.FEV1 < 80% of predicted.
FEV1/FVC ratio reduced by 5% fromFEV1/FVC ratio reduced by 5% from
baseline.baseline.

25. Moderate to Severe PersistentModerate to Severe Persistent
AsthmaAsthma
Moderate to High dose InhaledModerate to High dose Inhaled
Corticosteroids (ICS) are the cornerstoneCorticosteroids (ICS) are the cornerstone
of treatment.of treatment.
– Higher potency preparations require fewerHigher potency preparations require fewer
puffs and encourage compliancepuffs and encourage compliance
– Under dosing of ICS will result in poorerUnder dosing of ICS will result in poorer
controlcontrol

26. Managing DiseaseManaging Disease
Add in a Long Acting Beta Agonist (LABA)Add in a Long Acting Beta Agonist (LABA)
– Most pts in the severe category require at least 2 controllerMost pts in the severe category require at least 2 controller
agentsagents
– Should NEVER be used as monotherapyShould NEVER be used as monotherapy
Leukotriene antagonists are also an option:Leukotriene antagonists are also an option:
– Limited evidence in literatureLimited evidence in literature
– Montelukast, Zafirlukast, ZiluetonMontelukast, Zafirlukast, Zilueton
TheophyllineTheophylline
– Limited role, controller agent only, not as efficacious as LABA’sLimited role, controller agent only, not as efficacious as LABA’s
If symptoms are severe add oral corticosteroids.If symptoms are severe add oral corticosteroids.
– 5-7 days if normal FEV1, 14-21 days if reduced FEV15-7 days if normal FEV1, 14-21 days if reduced FEV1
Consider treatment with IgE antibody.Consider treatment with IgE antibody.

27. Oral GlucocorticoidsOral Glucocorticoids
Most potent and effective controller agent.Most potent and effective controller agent.
– Reserve for severe disease and those withReserve for severe disease and those with
reduced FEV1, use lowest dose possiblereduced FEV1, use lowest dose possible
– Should see an improvement in FEV1 of 15%Should see an improvement in FEV1 of 15%
after 2-3 weeksafter 2-3 weeks
– If requiring oral GC’s every 2-3 monthsIf requiring oral GC’s every 2-3 months
consider daily low dose (5-10 mg)consider daily low dose (5-10 mg)

28. Follow-upFollow-up
4 to 8 week intervals.4 to 8 week intervals.
– Use a questionnaire to evaluate controlUse a questionnaire to evaluate control
Asthma Control Test (ACT)Asthma Control Test (ACT)
– Consider spirometry if worsening symptomsConsider spirometry if worsening symptoms
or a step down in careor a step down in care

30. http://www.asthma.com/resources/asthma-control-test.html

31. Xolair: What is That?Xolair: What is That?
Xolair (Omalizumab): Is an recombinantXolair (Omalizumab): Is an recombinant
monoclonal anti-IgE antibody designed tomonoclonal anti-IgE antibody designed to
treat moderate to severe allergytreat moderate to severe allergy
associated asthma.associated asthma.
– Must demonstrate sensitization to an allergen.Must demonstrate sensitization to an allergen.
– Inadequate control with inhaled steroids.Inadequate control with inhaled steroids.

32. Asthma Guidelines 2007Asthma Guidelines 2007
Xolair therapy:Xolair therapy:
– Reduce the need for systemic and inhaledReduce the need for systemic and inhaled
glucocorticoids.glucocorticoids.
– Reduce the number of exacerbations, especiallyReduce the number of exacerbations, especially
severe exacerbations.severe exacerbations.
– No effect on FEV1 values.No effect on FEV1 values.
– Given via SubQ route q 2 to 4 weeks.Given via SubQ route q 2 to 4 weeks.
– 850 patients radomized850 patients radomized
25% reduction in rate of exacerbation25% reduction in rate of exacerbation
Overall response rate 30-50%Overall response rate 30-50%
12 week trial should be offered12 week trial should be offered
Hanania, et al;Ann Intern Med
2011;154:573

33. Co-Morbid IllnessCo-Morbid Illness
Allergic rhinitis – treat with nasal GC’s ifAllergic rhinitis – treat with nasal GC’s if
surgical disease refer to ENTsurgical disease refer to ENT
GERD – treat with PPI if patient isGERD – treat with PPI if patient is
symptomatic from GERDsymptomatic from GERD
Vocal cord dysfunction (VCD)- referral toVocal cord dysfunction (VCD)- referral to
qualified speech therapistqualified speech therapist
OSA – study in sleep lab and treat asOSA – study in sleep lab and treat as
indicatedindicated

34. Special ConsiderationsSpecial Considerations
PregnancyPregnancy
– Variable, safeVariable, safe
ObesityObesity
– Weight loss helpsWeight loss helps
SurgerySurgery
– PFT’s, if < 80% FEV1PFT’s, if < 80% FEV1
steroids helpsteroids help
Chronic sinus/rhinitisChronic sinus/rhinitis
– Treating these willTreating these will
improve asthmaimprove asthma
OccupationalOccupational
URI’sURI’s
GERGER
– More common inMore common in
asthma but treatmentasthma but treatment
doesn’t reducedoesn’t reduce
morbiditymorbidity
ASA inducedASA induced
– 28%28%
AnaphylaxisAnaphylaxis

35. SummarySummary
Accurate and complete history andAccurate and complete history and
physical is crucial.physical is crucial.
Objective testing – spirometry,Objective testing – spirometry,
methacholine challenge, peak flows,methacholine challenge, peak flows,
serum studies.serum studies.
Classify the patient.Classify the patient.
Step care.Step care.
Reevaluation/follow-up.Reevaluation/follow-up.

36. SummarySummary
Written action planWritten action plan
Proper inhaler techniqueProper inhaler technique
Trigger avoidanceTrigger avoidance
Inhaled GC’s are cornerstone of therapyInhaled GC’s are cornerstone of therapy
LABA’s should be added nextLABA’s should be added next
LTA’s or theophylline followLTA’s or theophylline follow
Consider IgE antibody in proper subsetConsider IgE antibody in proper subset
Treat comorbid illnessesTreat comorbid illnesses