Approaching patient with asthma l

APPROACHING PATIENT
WITH ASTHMA
DONE BY:
DR FAHAHD ALBEDAIWI

OBJECTIVES:
• Definition.
• Epidemiology.
• Approaching Adult patient with asthma.
• Management modalities.
• When to refer.
• Reccommendations.

CASE
• Please divided your selves into 3 groups
• Take 10-15 min discussion in: How to approach an asthmatic patient in your OPD?
• 19 year-old male k/c of asthma since childhood came to your clinic for follow up
and refill medications. Last visit was 3 months ago.

DEFINITION OF ASTHMA
Asthma is a heterogeneous disease, usually characterized by chronic airway
inflammation. [GINA 2017]

CONT.
• In Saudi Arabia, Asthma affecting more than 2 million Saudis.
• The prevalence of asthma in KSA was 4.05 %.
-The Saudi initiative for asthma - 2012 update: Guidelines for the diagnosis and management of asthma in adults and children
http://www.thoracicmedicine.org/article.asp?issn=1817-1737;year=2012;volume=7;issue=4;spage=175;epage=204;aulast=Al-Moamary
-Moradi-Lakeh et al. BMC Pulmonary Medicine (2015) 15:77 DOI 10.1186/s12890-015-0080-5
https://pdfs.semanticscholar.org/f08d/ca90e551f2fffa28d6eeff20c3ff46b1ef8e.pdf

HISTORY
• Wheeze (high-pitched whistling sound, usually upon exhalation)
• Cough (often worse at night)
• Shortness of breath or difficulty breathing
• Episodic symptoms
• Characteristic triggers
• Work-related exposures
• Personal or family history of atopy
• History of asthmatic symptoms as a child

PHYSICAL EXAMINATION:
• high-pitched, musical wheezes are a characteristic feature of asthma
• evidence of allergic rhinitise such as mucosal swelling, nasal polyps, and postnasal dripping.
• allergic manifestations, such as atopic dermatitis and/or eczema, also support the diagnosis of
allergic asthma.
• Tachypnea
• Tachycardia
• Prolonged expiratory phase of respiration a seated position with use of extended arms to
support the upper chest ("tripod position")
• Use of the accessory muscles of breathing (Eg, sternocleidomastoid) during inspiration
• A pulsus paradoxus (greater than 12 mmHg fall in systolic blood pressure during inspiration
• Wheezing may be absent during severe asthma exacerbations (‘silent chest’)
• The presence of a localized wheeze, crackles, stridor, clubbing, or heart murmurs should
suggest alternative diagnoses

• Increased probability that symptoms are due to asthma if:
• More than one type of symptom (wheeze, shortness of breath, cough, chest tightness)
• Symptoms often worse at night or in the early morning
• Symptoms vary over time and in intensity
• Symptoms are triggered by viral infections, exercise, allergen exposure, changes in
weather, laughter, irritants such as car exhaust fumes, smoke, or strong smells

• Decreased probability that symptoms are due to asthma if:
• Isolated cough with no other respiratory symptoms
• Chronic production of sputum
• Shortness of breath associated with dizziness, light-headedness or peripheral tingling
• Chest pain
• Exercise-induced dyspnea with noisy inspiration (stridor)

EVALUATION:
• Pulmonary function testing
• 1-Spirometry
• 2-Peak expiratory flow
• 3-Bronchodilator response
• 4-Bronchoprovocation testing
• Blood tests(Peripheral eosinophilia and elevated immunoglobulin E (IgE) level are
supportive of the diagnosis ) not routinely
• Imaging(IF The diagnosis is in doubt, when symptoms are not typical, or suggest
other diagnoses)

MONITORING PULMONARY
FUNCTION
• Peak expiratory flow rate (PEFR)
• spirometry

‫ةنوىص‬ ‫زىت‬4‫شسث‬3‫صشض‬
• Confirm presence of airflow limitation
• FEV1/FVC is reduced (at least once, when FEV1 is low)
• FEV1/ FVC ratio is normally >0.75 – 0.80 in healthy adults
• Significant increase in FEV1 or PEF after 4 weeks of controller treatment
• If initial testing is negative:
• Repeat when patient is symptomatic, or after withholding bronchodilators
• Refer for additional tests (especially elderly)
• 5‫ق‬4‫ثغابيبثثثثثثبء‬

• Measure lung function to monitor progress
• At diagnosis and 3-6 months after starting treatment (to identify personal best)
• Periodically thereafter, at least every 1-2 years for most adults;
more often for high risk patients and for children, depending on age and asthma
severity
• Consider long-term PEF monitoring for patients with severe asthma or impaired
perception of airflow limitation

HOW CAN YOU DETERMINE ASTHMA SEVERITY?
• Reported symptoms over the previous two to four weeks.
• Current level of lung function (PEFR or FEV1 and FEV1/FVC values).
• Number of exacerbations requiring oral glucocorticoids in the previous year.

© Global Initiative for Asthma
Patient with
respiratory symptoms
Are the symptoms typical of asthma?
Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?
Treat for ASTHMA
YES
YES
YES
© Global Initiative for AsthmaGINA 2017, Box 1-1 (1/4)

Patient with
for asthma
asthma diagnosis?
Further history and tests for
alternative diagnoses
Alternative diagnosis confirmed?
Treat for alternative diagnosisTreat for ASTHMA
YES
YES
YES
NO
NO
YES

Patient with
for asthma
asthma diagnosis?
Repeat on another
occasion or arrange
other tests
Confirms asthma diagnosis?
Consider trial of treatment for
most likely diagnosis, or refer
for further investigations
YES
YES
YES NO
NO
NO
NO
YES
YES
NO

Patient with
for asthma
asthma diagnosis?
Empiric treatment with
ICS and prn SABA
Review response
Diagnostic testing
within 1-3 months
Repeat on another
occasion or arrange
other tests
Confirms asthma diagnosis?
Consider trial of treatment for
most likely diagnosis, or refer
for further investigations
Clinical urgency, and
other diagnoses unlikely
YES
YES
YES NO
NO
NO
NO
YES
YES
NO

ASTHMA MANAGEMENT
• monitoring of symptoms and lung function
• Patient education
• Controlling environmental factors (trigger factors) and comorbid conditions that
contribute to asthma severity
• Pharmacologic therapy

GOALS OF ASTHMA MANAGEMENT
• The long-term goals of asthma management are :
1. Symptom control: to achieve good control of symptoms and maintain normal activity
levels
2. Risk reduction: to minimize future risk of exacerbations, fixed airflow limitation and
medication side-effects

ASTHMA MEDICATIONS
• Controllers:
are medications taken daily on a long-term basis to keep asthma under
clinical control chiefly through their anti-inflammatory effects .
• Relievers:
are medications used on an as-needed basis that act quickly to reverse
bronchoconstriction and relieve symptoms.

CONTROLLERS
• Inhaled glucocorticosteroids (ICS)
• Long-acting inhaled B2-agonists (LABA)
• Leukotriene receptor antagonist (LTRA)
• Long-acting anticholinergics
• Theophylline
• Anti-IgE
• Systemic glucocorticosteroids

COMBINATION DEVICES
• Sympicort turbohaler:
• Combination of budesonide/formoterol: 160/4.5
• Seretide:
• Combination of fluticasone/salmeterol
• Evohaler: 50/25 125/25 250/25
• Diskus: 100/50 250/50 500/50

RELIEVER MEDICATIONS
• Short-acting inhaled B2-agonists
• Anticholinergics
• Theophylline

SINA GUIDLINES
• SINA expert panel recommends asthma treatment to be based on following phases:
• Initiation of treatment
• Adjustment of treatment
• Maintenance of treatment.

INITIATION OF TREATMENT BASED ON SINA
• ACT Score ≥ 20  Step 1
• ACT Score 16–19  Step 2
• ACT Score 16  Step 3

ADJUSTMENT OF TREATMENT
• Treatment of asthma should be adjusted continuously based on asthma
control.
• If current treatment has failed to achieve control, then treatment should be
stepped up until control is achieved.
• Whenever control is maintained for at least 3 months, then treatment can be
stepped down.
• This stepwise approach is essential to maintain optimum control with lowest
step to maximize safety and minimize cost.

INITIATION OF TREATMENT BASED ON GINA
• Step 1  SABA on as needed bases
• Step 2  For patients who are not currently taking long-term controller medications.
• Step 3  If the initial symptoms are more frequent.
GINA guidlines

STEPWISE MANAGEMENT -
PHARMACOTHERAPY
*Not for children <12 years
**For children 6-11 years, the
preferred Step 3 treatment is
medium dose ICS
#For patients prescribed
BDP/formoterol or BUD/
formoterol maintenance and
reliever therapy
 Tiotropium by mist inhaler is
an add-on treatment for
patients ≥12 years with a
history of exacerbations
GINA 2017, Box 3-5 (2/8) (upper part)
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Other
controller
options
RELIEVER
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Considerlow
dose ICS
Leukotriene receptor antagonists (LTRA)
Low dose theophylline*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
As-needed short-acting beta2-agonist (SABA) As-needed SABA or
low dose ICS/formoterol#
Low dose
ICS/LABA**
Med/high
ICS/LABA
PREFERRED
CONTROLLER
CHOICE
Add tiotropium*
High dose ICS
+ LTRA
(or + theoph*)
Add low
dose OCS
Refer for
add-on
treatment
e.g.
tiotropium,*
anti-IgE,
anti-IL5*
UPDATED
2017

KEY CHANGES IN GINA 2017
• Current guidelines have opposite safety recommendations
• Asthma: never use LABA without ICS
• Clarification about ‘periodical’ assessment of lung function
• Most adults: lung function should be recorded at least every 1-2 yrs
• More frequently in higher risk patients

CONT.
• Step 5 treatment for severe asthma
• Anti-IL5: reslizumab (IV) added to mepolizumab (SC) for ≥18 years
• Step-down from low-dose ICS (Box 3-7)
• Add-on LTRA may help
• Insufficient evidence for step-down to as-needed ICS with SABA
• Side-effects of oral corticosteroids
• When prescribing short-term OCS, remember to advise patients about common side-effects (sleep disturbance,
increased appetite, reflux, mood changes); references added
• Vitamin D
• To date, no good quality evidence that Vitamin D supplementation leads to improved asthma control or fewer
exacerbations
• Chronic sinonasal disease
• Treatment with nasal corticosteroids improves sinonasal symptoms but not asthma outcomes

WHEN TO REFER
• The patient has experienced a life-threatening asthma exacerbation
• The patient has required hospitalization or more than two bursts of oral
corticosteroids in a year
• The adult and pediatric patient older than five years requires step 4 care or higher
or a child under five requires step 3 care or higher
• Asthma is not controlled after three to six months of active therapy and
appropriate monitoring

CONT.
• The patient appears unresponsive to therapy
• The diagnosis of asthma is uncertain
• Other conditions are present which complicate management (nasal polyposis,
chronic sinusitis, severe rhinitis, allergic bronchopulmonary aspergillosis, COPD,
vocal cord dysfunction, etc)
• Additional diagnostic tests are needed (skin testing for allergies, bronchoscopy,
complete pulmonary function tests)

CONT.
• Patient may be a candidate for allergen immunotherapy(Subcutaneous
immunotherapy for allergic disease: Indications and efficacy)
• Patient is a potential candidate for therapy with biologics
(omalizumab, mepolizumab, reslizumab) or bronchial thermoplasty.Patients with
potential occupational triggers

THE FOLLOWING ARE RECOMMENDED BY SINA:
• Reduction in therapy is recommended to be gradual and closely monitored
• If the patient is on ICS as monotherapy, the dose of ICS may be reduced by 25% every
3–6 months to the lowest dose possible that is required to maintain control (Evidence
B)
• and then changed to a single daily dose (Evidence A) is recommended to be clearly
explained to the patient that asthma control may deteriorate if treatment is abruptly
discontinued .
• If patient is on combination of ICS/LABA at step 3 or 4, abrupt discontinuation of
LABA may lead to deterioration of control .

CONT.
• If the patient is on a combination of ICS, LABA, LTRA, and other controllers, taper ICS to the
lowest possible dose(Evidence B).
• If control is achieved, LTRA may be discontinued (Evidence D)
• For significant side effects, consider a change in therapy, reduction in the dose or frequency
of ICS (if possible), advise vigorous mouth washing after inhalation, use of spacer
(concomitant with MDI devices), and/or use of appropriate local antifungal therapy such as
mycostatin mouth wash, for severe oral thrush [166]
• Patients should be informed that asthma control may deteriorate if treatment is completely
discontinued.

TAKE HOME MASSAGE
• Establish a patient-doctor partnership
• Manage asthma in a continuous cycle:
• Assess
• Adjust treatment (pharmacological and
non-pharmacological)
• Review the response
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function

CONT.
1. Asthma control - two domains
• Assess symptom control over the last 4 weeks
• Assess risk factors for poor outcomes, including low lung function
2. Treatment issues
• Check inhaler technique and adherence
• Ask about side-effects
• Does the patient have a written asthma action plan?
• What are the patient’s attitudes and goals for their asthma?
3. Comorbidities
• Think of rhinosinusitis, GERD, obesity, obstructive sleep apnea, depression, anxiety
• These may contribute to symptoms and poor quality of life

REFERENCES
• Global Initiative for Asthma (GINA)
• Saudi Initiative for Asthma (SINA).
• AAFP.
• Uptodate.

Approaching patient with asthma l

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