1. 1
Definition:
• Asthma is a chronic inflammatory disorder of the airways causing recurrent episodes of wheezing, breathlessness,
cough, and chest tightness, particularly at night or early in the morning.
• During episodes, there is variable airway obstruction, often reversible spontaneously or with treatment.
• There is also increased bronchial hyperresponsiveness to a variety of stimuli.
Risk Factors:
• Atopy:
1) which is the genetic predisposition for the development of immunoglobulin E (IgE)-mediated response to
common aeroallergens
2) Common in Childhood
• Exposure to occupational chemical sensitizers
Diagnosis:
• History (symptom, risk factor)
• Pulmonary function test
• Blood gas measurement (For severity)
Differential Diagnosis:
• Alternative diagnoses are excluded. Asthma versus chronic obstructive pulmonary disease (COPD):
2. 2
Feature Asthma COPD
Age of onset < 20 year > 40 year
Pattern of symptoms - Variation in symptoms over minutes, hours, or days
- Worse during the night or early morning
- Triggered by exercise, emotions, dust, or exposure to allergens
- Persistence of symptoms despite treatment
- Good and bad days but always daily symptoms
and exertional dyspnea
- Chronic cough and sputum precede onset of
dyspnea, unrelated to triggers
Lung function Record of variable airflow limitation (spirometry or peak flow),
showing reversibility
Record of persistent airflow limitation (post-
bronchodilator FEV1/FVC < 0.7)
Lung function between
symptoms
Normal Abnormal
Past history or family
history
-Previous diagnosis of asthma
- Family history of asthma and other allergic conditions (allergic
rhinitis or eczema)
-Previous diagnosis of COPD, chronic bronchitis,
or emphysema
- Heavy exposure to a risk factor: Tobacco
smoke, biomass fuels
Time course -No worsening of symptoms over time; symptoms vary either
seasonally or from year to year
- May improve spontaneously or have an immediate response to
bronchodilators or to ICS over weeks
-Symptoms slowly worsen over time
(progressive course over years)
- Rapid-acting bronchodilator provides only
limited relief
Chest radiograph Normal Severe hyperinflation
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Type of asthma:
• Acute exacerbation of asthma
• Chronic asthma
• Seasonal asthma
• Exercise-induced bronchospasm
Goals of Therapy
• Reduce Impairment:
(a) Prevent chronic symptoms (e.g., coughing or breathlessness in the night, in the early morning,
or after exertion);
(b) maintain (near) “normal” pulmonary function;
(c) maintain normal activity levels (including exercise, other physical activities, and attendance at
work or school)
• Reduce Risk:
(a) Prevent recurrent exacerbations of asthma and minimize the need for ED visits or
hospitalizations;
4. 4
(b) prevent progressive loss of lung function— for children, prevent reduced lung growth
(c) provide optimal pharmacotherapy with minimal or no adverse effects
Therapy:
Asthma management has four major components, including
(a)measures of asthma assessment and monitoring
(b)education for a partnership in asthma care
(c) control of environmental factors and comorbid conditions that affect asthma
(d)medications.
Early therapeutic interventions in managing acute exacerbations are very important in decreasing the
chance of severe narrowing of the airways.
5. 5
Management of Acute exacerbation of Asthma:
Mohamed S Al-Moamary, Sami Alhaider. The Saudi Initiative for asthma guideline for diagnosis and management of Asthma
in Adults and children. Saudi Thorasic Society. 2016
6. 6
Management of Chronic Asthma
• Assess the severity of the symptom
• Determine the treatment regimen (depend on asthma step)
• Assess the asthma control
Assess the severity of the symptom
Components Age group Intermittent Mild
Persistent
Moderate
Persistent
Severe
Persistent
Frequency of
symptoms
All age ≤ 2 days/wk > 2 days/wk but
not daily
Daily Throughout
the day
Nighttime
awakening
>5 years ≤ 2 times/mo 3 or 4
times/mo
More than
once weekly
but not nightly
Often 7
times/wk
0-4 years 0 1 or 2
times/mo
3 or 4
times/mo
More than
once weekly
SABA; used
for symptom
control
All age ≤ 2 days/wk > 2 days/wk but
not daily
Daily Several
times a day
Interference
with normal
activity
All age None Minor limitation Some
limitations
Extremely
limited
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Components Age group Intermittent Mild Persistent Moderate
Persistent
Severe
Persistent
FEV1/FVC >12 years Normal Normal Reduced 5% Reduced > 5%
5-11 years > 85% > 80% 75%–80% < 75%
0-4 years Not applicable
FEV1 (% of
normal)
>12 years > 80%
(normal)
80%
(normal)
60% to < 80% < 60%
5-11 years
0-4 years Not applicable
Exacerbations
requiring oral
steroids
>12 years 0 or 1/year ≥ 2/year
5-11 years
0-4 years 0 or 1/yr ≥2 in 6 mo or ≥4 wheezing episodes per year
Recommended
step for
initiating
treatment
All age Step 1 Step 2 Step 3 and
consider short
course of oral
steroids
Step 3 *or 4
or 5 and
consider short
course of oral
steroids
* Episodes lasting > 1 day and risk factors for persistent asthma.
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Initiation, adjustment and maintenance of out-patient asthma treatment in adults & adolescent patient
Mohamed S Al-Moamary, Sami Alhaider. The Saudi Initiative for asthma guideline for diagnosis and management of Asthma in Adults
and children. Saudi Thorasic Society. 2016
11. 11
Assessment (after 3 month)
• During follow-up evaluations, clinicians should carefully investigate factors that may contribute to poor asthma control, including exposure to
inhalant allergens, indoor or outdoor irritants, medications, and tobacco smoke.
• Secondhand smoke exposure has been demonstrated to reduce the benefit of ICS in children and necessitate step-up therapy, and asthma patients
who smoke have reduced response to ICS therapy
Component Well Controlled Not Well Controlled Very Poorly Controlled
Frequency of symptoms ≤2 days/wk >2 days/wk Throughout the day
Nighttime awakening ≤ 2 times/mo 1–3 times/wk ≥ 4 times/wk
SABA; used for symptom control ≤ 2 days/wk > 2 days/wk Several times a day
Interference with normal activity None Some limitations Extremely limited
FEV1/FVC NA NA NA
FEV1 (% of normal) >80% of predicted/
personal best
60%–80% of predicted/
personal best
<60% of predicted/
personal best
Questionnaires ACT (range 5–25) ≥ 20 16–19 ≤15
Exacerbations requiring oral steroid 0 or 1/yr ≥2/yr
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Recommendation action for treatment
• Well controlled: Maintain current step; regular follow-up every 1–6 mo; consider step-down if
well controlled ≥ 3 m
• Not well controlled: step up one step, Reevaluate in 2–6 wk
• Very poorly controlled: considered short course of oral steroids Step-up 1 or 2 steps
Reevaluate in 2 wk
Management of Seasonal Asthma
• Asthma combined with worsening rhinitis symptoms in the springtime
• This syndrome is consistent with a diagnosis of seasonal asthma and allergic rhinitis
• low-dose ICS combined with a long-acting inhaled β2-agonist (LABA).
OR
• Monotherapy with medium-dose ICS would also be an acceptable therapy.
• Antihistamines (preferably non-sedating): Despite precautions listed in manufacturer literature that
older (sedating) antihistamines should be avoided in asthma, these agents are safe in patients with
asthma.
• Intranasal corticosteroid therapy offers excellent relief of nasal symptoms and also improves asthma
control
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Management of Exercised induced asthma
• During sustained exercise, at least 90% of patients with asthma experience an initial improvement in
pulmonary functions quickly followed by a significant decline
• Patients can be diagnosed by measuring the FEV1 or PEF before and after exercise (6- to 8-minute
treadmill or bicycle exercise test).
• A reduction of FEV1 by more than 15% of the baseline value is a positive test.
• Hyperventilation of cold, dry air increases the sensitivity to EIA and induces bronchospasm
• The main stimulus for EIA is respiratory heat loss, water loss, or both, while breathing heated,
humidified air completely blocks EIA in many patients
• With appropriate premedication, most EIA can be prevented, so virtually all patients with stable
asthma should be encouraged to exercise
• SABAs are generally the agents of choice for prophylaxis.
• For typical periods of exercise (e.g., <3 hours), pretreatment with agents such as albuterol 5 to 15
minutes before exercise usually provides excellent protection from EIA.
• For prolonged periods of exercise, LABAs (formoterol, salmeterol) provide several hours of
protection
• SABAs are generally the agents of choice for prophylaxis.
• For typical periods of exercise (e.g., <3 hours), pretreatment with agents such as albuterol 5 to 15
minutes before exercise usually provides excellent protection from EIA.
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• For prolonged periods of exercise, LABAs (formoterol, salmeterol) provide several hours of
protection
• Leukotriene receptor antagonists (e.g., montelukast once-daily chronic therapy) have also been
demonstrated to prevent EIA
• it is important to point out that in persistent asthma, long-term anti-inflammatory therapy is helpful in
reducing the response to most asthma triggers, including exercise
Medication
Short-acting β2-agonist (SABA)
- Formulation:
1- Albuterol MDI 90 mcg/puff>> q 3–4 hr
2- Albuterol Nebulizer >>> 2.5-5 mg three- or four-times daily PRN
- Used for acute bronchospasm; regular use indicates poor control
- Side effect: Tremor Tachycardia Hypokalemia Hypomagnesemia Hyperglycemia Tachyphylaxis
Long-acting β2-agonist (LABA)
- Formulations:
1. Salmeterol DPI 50 mcg/puff >>>>Inhale 1 blister/puff BID
2. Formoterol 20 mcg/2 mL nebs >>>Inhale 1 vial BID
- LABAs have minimal adverse effects (e.g., tachycardia, tremor)
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- (FDA) offered recommendations regarding the use of LABA in patients with asthma, including
always using combination products (ICS/LABA) versus two single-agent products.
Short-acting anticholinergic/muscarinic (SAMA)
- Ipratropium MDI 17 mcg/puff >>2 puffs QID (up to 12 puffs/24 hr),
- Ipratropium Nebulization Solution >> 0.5 mg/2.5 Ml >>>>0.5 mg every 6–8 hr
Long-acting anticholinergic/muscarinic (LAMA)
- Formulation:
1- Tiotropium DPI 18 mcg>>>> Inhale 1 capsule/day
2- Tiotropium Mist 1.25 mcg/puff >>>>2 puffs once daily
- Side effect: Headache Flushed skin Blurred vision Tachycardia Palpitations
Leukotriene Modifiers
- In patients of any age with mild-persistent asthma, and certainly in children or adolescents, an oral
agent such as montelukast with once-daily dosing at bedtime has advantages
Anti-Immunoglobulin E Therapy
- Omalizumab (Xolair) is a humanized monoclonal anti-IgE antibody that binds to free IgE in serum.
16. 16
- Thus, binding of IgE to high-affinity receptors on mast cells is subsequently inhibited, and the
initiation of the allergic inflammatory cascade is blocked.
- Omalizumab is effective in reducing oral and ICS dose requirements in patients with severe asthma
and in reducing exacerbations
- This novel therapy is administered as a 150- to 375-mg subcutaneous injection every 2 or 4 weeks.
- The dose and frequency of administration are based on the serum total IgE level (international
units/mL) and the patient’s body weight.
- Common side effects associated with omalizumab include injection site reactions, upper respiratory
tract infections, sinusitis, and headache. Thrombocytopenia (transient)
- Less common but potentially serious adverse effects include anaphylaxis (0.2% in post marketing
spontaneous reports), which can occur after any dose even if previous doses have been well
tolerated and 24 or more hours after administration
- The development of malignant neoplasms (0.5% of omalizumab-treated patients compared with
0.2% in control patients).
- Because omalizumab is expensive and must be administered as a subcutaneous injection, it should
be reserved for patients with severe asthma who are not adequately controlled with standard
therapies.
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- It might be considered as cost effectiveness for patient with frequent ED visits and hospitalizations.
- After reconstitution of omalizumab, the drug must be administered within 4 hours if stored at room
temperature and within 8 hours when refrigerated.
- As a result of its viscosity, the injection may take 5 to 10 seconds.
- No more than 150 mg is injected at each site
- Black box of anaphylaxis side effects
- September 2014: New FDA Drug Safety Communication. Slightly increased risk of cardiovascular
and cerebrovascular serious adverse events, including MI, unstable angina, TIA, PE/DVT, pulmonary
HTN; no increased risk of stroke or CV death
IL-5 antagonist:
- Reduces rate of asthma exacerbations by > 50%; reduces corticosteroid dose by 50%
- Mepolizumab: 100 mg SC every 4 week in the upper arm, thigh, or abdomen
- Reslizumab 3 mg/kg IV infusion over 20–50 min every 4 week
Inhaled Corticosteroid: Controller
- Administration of the total daily ICS dose is preferred twice daily or, in many patients with mild-
persistent to moderate- persistent asthma, once daily. (to enhance the adherence)
- Side effect: A possible association between prolonged, very high dosages of ICS and cataracts and
glaucoma has been reported.
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List ICS inhalers available in the Saudi market for adults and adolescents
Drug (doses in mcg) Low - dose Medium dose High-dose
Beclomethasone dipropionate
(CFC)
200 - 500 >500 - 1000 >1000
Beclomethasone dipropionate
(HFA)
100 - 200 >200 - 400 >400
Budesonide (DPI) 200 - 400 >400 - 800 >800
Ciclesonide (HFA) 80 - 160 >160 - 320 >320
Fluticasone propionate (DPI and
HFA)
100 - 250 >250 - 500 >500
Mometasone furoate 110 - 220 >220 - 440 >440
List of ICS inhalers available in the Saudi market for children
Drug (doses in mcg) <5 years Children >5 years
Low-dose Low-dose Medium dose High-dose
Beclomethasone dipropionate
(CFC)
100 100–200 >200–400 >400
Beclomethasone dipropionate
(HFA)
100 50–100 >100–200 >200
Budesonide 200 100–200 >200–400 >400
Budesonide (Nebules) 500 250–500 >500–1000 >1000
Ciclesonide 160 80 >80–160 >160
Fluticasone propionate (DPI) Not applicable 100–200 >200–400 >400
Fluticasone propionate (HFA) 100 100–200 >200–500 >500
Mometasone furoate Not studied 110-220 >220–440 >440
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Patient education: Key Educational Messages
Basic Facts About Asthma
Ø The contrast between airways of a person who has and a person who does not have asthma; the role of inflammation
Ø What happens to the airways in an asthma attack
Roles of Medications—Understanding the Difference Between the Following:
Ø Long-term control medications: prevent symptoms, often by reducing inflammation. Must be taken daily. Do not
expect them to give quick relief.
Ø Quick-relief medications: Short-acting β2-agonists relax muscles around the airway and provide prompt relief of
symptoms. Do not expect them to provide long-term asthma control. Using quick-relief medication on a daily basis
indicates the need for starting or increasing long-term control medications.
Patient Skills
Ø Taking medications correctly. Inhaler technique (demonstrate to patient and have the patient return the
demonstration). Use of devices, such as prescribed valved holding chamber, spacer, nebulizer.
Ø Identifying and avoiding environmental exposures that worsen the patient’s asthma (e.g., allergens, irritants, tobacco
smoke).
Ø Self-monitoring to:
- Assess level of asthma control
- Monitor symptoms and, if prescribed, peak flow
- Recognize early signs and symptoms of worsening asthma.
Ø Using written asthma action plan to know when and how to:
- Take daily actions to control asthma
- Adjust medication in response to signs of worsening asthma
- Seek medical care as appropriate.
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Steps to Correct Use of Metered-Dose Inhalers
1- Shake the inhaler well and remove the dust cap.
2- Exhale slowly through pursed lips. If using the “closed-mouth” technique, hold the inhaler
upright and place the mouthpiece between your lips.
3- Be careful not to block the opening with your tongue or teeth.
4- If using the “open-mouth” technique, open your mouth wide and hold the inhaler upright 1–2
inches from your mouth, making sure the inhaler is properly aimed.
5- Press down on the inhaler once as you start a slow, deep inhalation.
6- Continue to inhale slowly and deeply through your mouth. Try to inhale for at least 5
seconds.
7- Hold your breath for 10 seconds (use your fingers to count to 10 slowly). If 10 seconds
makes you feel uncomfortable, try to hold your breath for at least 4 seconds.
8- Exhale slowly.
9- Wait at least 30–60 seconds before inhaling the next puff of medicine.
