4. Definition of asthma
• Asthma is a heterogeneous disease, usually characterized
by chronic airway inflammation.
• It is defined by the history of respiratory symptoms such
as wheeze, shortness of breath, chest tightness and cough
that vary over time and in intensity, together with variable
expiratory airflow limitation.
5. • Symptoms and airflow limitation may resolve
spontaneously or in response to medication, and may
sometimes be absent for weeks or months at a time.
• On the other hand, patients can experience episodic flare-
ups (exacerbations) of asthma that may be life-threatening
and carry a significant burden to patients and the
community.
6. Epidemiology
• Asthma is one of the most common chronic diseases worldwide
with an estimated > 334 million affected individuals.
• It affects 1–18% of the population in different countries.
• Prevalence is increasing in many countries, especially in
children.
• Asthma is a major cause of school and work absence.
• Health care expenditure on asthma is very high.
7. The global burden of asthma
~334 million asthmatic
250,000 annual deaths
attributed to the disease
Developed economies might expect
to spend 1-2 percent of total health
care expenditures on asthma.
additional 100 million
asthmatic by 2025
Asthma is the most common chronic
disease among children and the
main cause of school absence
Most asthma-related deaths occur in
low- and lower-middle income
countries
Disability-adjusted life years (DALYs)
lost due to asthma worldwide is currently
estimated to be about 22 million per
year
9. • Asthma is a heterogeneous disease, with different
underlying disease processes.
• Recognizable clusters of demographic, clinical and/or
pathophysiological characteristics are often called ‘asthma
phenotypes.
Asthma phenotypes
10. • Allergic asthma
• Non-allergic asthma
• Adult-onset (late-onset) asthma
• Asthma with persistent airflow limitation
• Asthma with obesity
Some of the most common phenotypes of asthma
12. • Commencement of respiratory symptoms in childhood, a
history of allergic rhinitis or eczema, or a family history of
asthma or allergy.
• However, these features are not specific for asthma and are
not seen in all asthma phenotypes.
• Patients with allergic rhinitis or atopic dermatitis should be
asked specifically about respiratory symptoms.
History and family history
13. • Physical examination in people with asthma is often normal.
• The most frequent abnormality is expiratory wheezing
(rhonchi) on auscultation, but this may be absent or only
heard on forced expiration.
• Wheezing may also be absent during severe asthma
exacerbations, due to severely reduced airflow (so called
‘silent chest’).
Physical examination
15. Time (seconds)
Volume
Note: Each FEV1 represents the highest of
three reproducible measurements
FEV1
1 2 3 4 5
Normal
Asthma
(after BD)
Asthma
(before BD)
Flow
Volume
Normal
Asthma
(after BD)
Asthma
(before BD)
6
Typical spirometric tracings
16.
17. • Atopic status can be identified by skin prick testing or by
measuring the level of specific immunoglobulin E (sIgE) in
serum.
• Skin prick testing with common environmental allergens is
simple and rapid to perform and, when performed by an
experienced tester with standardized extracts, is inexpensive
and has a high sensitivity.
Allergy tests
18. • FeNO has not been established as useful for ruling in or
ruling out a diagnosis of asthma.
• FeNO is higher in asthma that is characterized by Type 2
airway inflammation but it is also elevated in non asthma
conditions (e.g. eosinophilic bronchitis, atopy, allergic
rhinitis, eczema), and it is not elevated in some asthma
phenotypes (e.g. neutrophilic asthma).
Measurement of exhaled nitric oxide
19. 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
20. 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
Further history and tests for
alternative diagnoses
Alternative diagnosis confirmed?
Treat for alternative diagnosis
YES
YES
YES
NO
NO
YES
21. 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?
Repeat on another
occasion or arrange
other tests
Confirms asthma diagnosis?
Consider trial of treatment for
most likely diagnosis, or refer
for further investigations
Further history and tests for
alternative diagnoses
Alternative diagnosis confirmed?
Treat for alternative diagnosis
Treat for ASTHMA
YES
YES
YES NO
NO
NO
NO
YES
YES
NO
26. Assessment of asthma
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
27. Assessment of asthma control
A. Symptom control
In the past 4 weeks, has the patient had:
Well-
controlled
Partly
controlled
Uncontrolled
• Daytime asthma symptoms more
than twice a week? Yes No
None of
these
1-2 of
these
3-4 of
these
• Any night waking due to asthma? Yes No
• Reliever needed for symptoms*
more than twice a week? Yes No
• Any activity limitation due to asthma? Yes No
B. Risk factors for poor asthma outcomes
• Assess risk factors at diagnosis and periodically
• Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patient’s
personal best, then periodically for ongoing risk assessment
ASSESS PATIENT’S RISKS FOR:
• Exacerbations
• Fixed airflow limitation
• Medication side-effects
Level of asthma symptom control
28. Assessment of risk factors for poor asthma outcomes
Risk factors for exacerbations include:
• Ever intubated for asthma
• Uncontrolled asthma symptoms
• Having ≥1 exacerbation in last 12 months
• Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
• Incorrect inhaler technique and/or poor adherence
• Smoking
• Elevated FeNO in adults with allergic asthma
• Obesity, pregnancy, blood eosinophilia
Risk factors for fixed airflow limitation include:
• No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia
Risk factors for medication side-effects include:
• Frequent oral steroids, high dose/potent ICS, P450 inhibitors
29. • Diagnosis
• Risk assessment
• Measure lung function to monitor progress
• Adjusting treatment?
The role of lung function in asthma
30. Five Components
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations
Asthma Management and
Prevention Program
31. Goals of Long-term Management
• Achieve and maintain control of symptoms
• Maintain normal activity levels, including exercise
• Maintain pulmonary function as close to normal levels as
possible
• Prevent asthma exacerbations
• Avoid adverse effects from asthma medications
• Prevent asthma mortality
32. • Asthma can be effectively controlled in most patients by
intervening to suppress and reverse inflammation as well as
treating bronchoconstriction and related symptoms.
• Early intervention to stop exposure to the risk factors that
sensitized the airway may help improve the control of asthma
and reduce medication needs.
• Although there is no cure for asthma, appropriate
management that includes a partnership between the
physician and the patient/family most often results in the
achievement of control.
33. • Clear communication between health care professionals and
asthma patients is key to enhancing compliance.
• Educate continually, including the family
• Provide information about asthma
• Provide training on self-management skills
• Emphasize a partnership among health care providers, the
patient, and the patient’s family
Component 1: Develop Patient/Doctor Partnership
34. • Measures to prevent the development of asthma, and asthma
exacerbations by avoiding or reducing exposure to risk factors
should be implemented wherever possible.
• Asthma exacerbations may be caused by a variety of risk
factors – allergens, viral infections, pollutants and drugs.
• Reducing exposure to some categories of risk factors improves
the control of asthma and reduces medications needs.
Component 2: Identify and Reduce Exposure to Risk
Factors
35. • Reduce exposure to indoor allergens
• Avoid tobacco smoke
• Avoid vehicle emission
• Identify irritants in the workplace
• Explore role of infections on asthma development, especially in
children and young infants
• Influenza Vaccination
36. • Influenza vaccination should be provided to patients with
asthma when vaccination of the general population is advised
• However, routine influenza vaccination of children and adults
with asthma does not appear to protect them from asthma
exacerbations or improve asthma control.
Influenza Vaccination
37. • The goal of asthma treatment is to achieve and maintain
clinical control, with a pharmacologic intervention strategy.
• A stepwise approach to pharmacological therapy is
recommended.
• The aim is to accomplish the goals of therapy with the least
possible medication.
• Treatment is adjusted in a continuous cycle driven by changes
in asthma control status.
Component 3: Assess, Treat and Monitor Asthma
41. Track 1: The reliever is as-needed low dose ICS-formoterol.
This is the preferred approach recommended by GINA for
adults and adolescents, because using low dose ICS-formoterol
as reliever reduces the risk of severe exacerbations compared
with regimens with SABA as reliever, with similar symptom
control.
Asthma treatment tracks for adults and adolescents
42. With this approach, when a patient at any treatment step
has asthma symptoms, they use low dose ICS-formoterol in
a single inhaler for symptom relief.
In Steps 3–5, patients also take ICS-formoterol as their
daily controller treatment; together, this is called
‘maintenance and reliever therapy’ or ‘MART’.
43. Track 2: The reliever is as-needed SABA. This is an alternative
approach if Track 1 is not possible, or is not preferred by a
patient with no exacerbations on their current therapy. Before
prescribing a regimen with SABA reliever, consider whether the
patient is likely to be adherent with their ICS-containing
controller therapy, as otherwise they will be at higher risk of
exacerbations.
44. In Step 1, the patient takes a SABA and a low dose ICS
together for symptom relief when symptoms occur (in a
combination inhaler, or with the ICS taken right after the
SABA).
In Steps 2–5, a SABA (alone) is used for symptom relief,
and the patient takes ICS-containing controller medication
regularly every day.
45. • During ongoing treatment, treatment can be stepped up or
down along one track, using the same reliever at each step,
or it can be switched between tracks, according to the
individual patient’s needs and preferences.
• Before stepping up, check for common problems such as
incorrect inhaler technique, poor adherence, and
environmental exposures, and confirm that the symptoms
are due to asthma.
47. Presenting symptoms Preferred INITIAL
treatment
(Track 1)
Alternative INITIAL
treatment
(Track 2)
Infrequent asthma
symptoms, e.g. less than
twice a month and no risk
factors for exacerbations
As-needed low dose ICS-
formoterol
Low dose ICS taken
whenever SABA is taken,
in combination or separate
inhalers
Asthma symptoms or need
for reliever twice a month or
more
As-needed low dose ICS-
formoterol
Low dose ICS with as-
needed SABA. Consider
likely adherence
with daily ICS.
Troublesome asthma
symptoms most days; or
waking due to asthma once
a week or more, especially if
any risk factors exist
Low dose ICS-formoterol
maintenance and reliever
therapy
Low dose ICS-LABA with
as-needed SABA. OR
Medium dose ICS with as-
needed SABA. Consider
likely adherence with daily
controller.
Initial asthma treatment - recommended options for
adults and adolescents
48. Initial asthma treatment - recommended options for
adults and adolescents (Cont.)
Presenting symptoms Preferred INITIAL
treatment
(Track 1)
Alternative INITIAL
treatment
(Track 2)
Initial asthma presentation is
with severely uncontrolled
asthma, or with an acute
exacerbation.
Medium dose ICS-
formoterol maintenance
and reliever therapy. A
short course of oral
corticosteroids may also
be needed.
High dose ICS or medium
dose ICS-LABA with as
needed SABA. Consider
likely adherence with daily
controller. A short course
of oral corticosteroids may
also be needed.
49. Reviewing response and adjusting treatment
• Physicians Patients with asthma should be reviewed regularly
to monitor their symptom control, risk factors and occurrence
of exacerbations, as well as to document the response to any
treatment changes.
• For most controller medications, improvement begins within
days of initiating treatment, but the full benefit may only be
evident after 3–4 months. In severe and chronically under-
treated disease, it may take longer.
How often should asthma be reviewed ?
50. • Day-to-day adjustment: For patients whose reliever inhaler
is combination budesonide-formoterol or beclometasone-
formoterol (with or without maintenance ICS-formoterol),
the patient adjusts the number of as-needed doses of ICS-
formoterol from day to day according to their symptoms.
This strategy reduces the risk of developing a severe
exacerbation requiring oral corticosteroids within the next
3–4 weeks.
Stepping up asthma treatment
51. • Short-term step up (for 1–2 weeks): A short-term increase in
maintenance ICS dose for 1–2 weeks may be necessary; for
example, during viral infections or seasonal allergen
exposure. This may be initiated by the patient according to
their written asthma action plan, or by the health care
provider.
52. • Sustained step up (for at least 2–3 months): Individual ICS
responsiveness varies, and some patients whose asthma is
uncontrolled on low dose ICSLABA despite good adherence
and correct technique may benefit from increasing the
maintenance dose to medium. A step up in treatment may be
recommended.
53. • Any step-up should be regarded as a therapeutic trial, and the
response reviewed after 2–3 months. If there is no response,
treatment should be reduced to the previous level, and
alternative treatment options or referral considered.
54. • Once good asthma control has been achieved and
maintained for 3 months and lung function has reached a
plateau, treatment can often be successfully reduced, without
loss of asthma control. The aims of stepping down are:
To find the patient’s minimum effective treatment.
To encourage the patient to continue controller
treatment.
Stepping down treatment when asthma is well controlled
55. • General principles of stepping down asthma treatment
Consider stepping down when asthma symptoms have been
well controlled and lung function has been stable for 3 or
more months, step down only with close supervision.
Choose an appropriate time (no respiratory infection,
patient not travelling, not pregnant).
Approach each step as a therapeutic trial.
Stepping down ICS doses by 25–50% at 3 month intervals is
feasible and safe for most patients.
56. Other Therapies
• Allergen-specific immunotherapy may be a treatment option
where allergy plays a prominent role, including asthma with
allergic rhinoconjunctivitis. There are currently two approaches:
(SCIT) and
(SLIT).
Allergen immunotherapy:
SCIT
SLIT
57. Subcutaneous immunotherapy (SCIT)
• European physicians tend to favor single allergen
immunotherapy whereas Northern American physicians often
prescribe multiple allergens for treatment.
Advice
• Compared to pharmacological and avoidance options,
potential benefits of SCIT must be weighed against the risk of
adverse effects and the inconvenience and cost of the prolonged
course of therapy, including the minimum half-hour wait
required after each injection.
58. Sublingual immunotherapy (SLIT)
• Modest effects were identified in a systematic review of
SLIT for asthma in adults and children, but there was
concern about the design of many of the studies.
• The evidence for important outcomes such as exacerbations
and quality of life remains limited.
59. Advice
• Compared For adult patients with allergic rhinitis and
sensitized to house dust mite, with persisting asthma
symptoms despite low-medium dose ICS-containing therapy,
consider adding SLIT, provided FEV1 is >70% predicted.
• As for any treatment, potential benefits of SLIT for
individual patients should be weighed against the risk of
adverse effects, and the cost to the patient and health system.
60. • Influenza causes significant morbidity and mortality in the
general population, and contributes to some acute asthma
exacerbations. In 2020, many countries saw a reduction in
influenza-related illness, likely due to the hand washing, masks
and social/physical distancing introduced because of the COVID-
19 pandemic.
• The risk of influenza infection itself can be reduced by annual
vaccination.
Vaccinations
61. Advice
• Advise patients with moderate to severe asthma to receive an
influenza vaccination every year, or at least when vaccination
of the general population is advised.
• There is insufficient evidence to recommend routine
pneumococcal vaccination in people with asthma.
62. • Bronchial thermoplasty is a potential treatment option at
Step 5 in some countries for adult patients whose asthma
remains uncontrolled despite optimized therapeutic regimens
and referral to an asthma specialty center.
• Bronchial thermoplasty involves treatment of the airways
during three separate bronchoscopies with a localized
radiofrequency pulse.
Bronchial thermoplasty
63. Advice
• For adult patients whose asthma remains uncontrolled
despite optimization of asthma therapy and referral to a
severe asthma specialty center, bronchial thermoplasty is
a potential treatment option at Step 5 in some countries.
64. • Several cross-sectional studies have shown that low serum levels
of Vitamin D are linked to impaired lung function, higher
exacerbation frequency and reduced corticosteroid response.
Vitamin D supplementation may reduce the rate of asthma
exacerbation requiring treatment with systemic corticosteroids
in asthma patients with baseline 25(OH)D of less than 25
nmol/L.
Vitamin D
65. Non-pharmacological Strategies
• Cessation of smoking and ETS exposure
• Physical activity
• Avoidance of occupational exposures
• Avoidance of medications that may make asthma worse
• Healthy diet
• Avoidance of indoor allergens
66. • Weight reduction
• Breathing exercises
• Avoidance of indoor air pollution
• Avoidance of outdoor allergens
• Dealing with emotional stress
• Avoidance of outdoor air pollutants/weather conditions
• Avoidance of foods and food chemicals
67. Severe Asthma
Definition of severe asthma
• When a diagnosis of asthma is confirmed and comorbidities
have been addressed, severe asthma is defined as “asthma
which requires treatment with high dose inhaled corticosteroids
(ICS) plus a second controller (and/or systemic corticosteroids)
to prevent it from becoming ‘uncontrolled’ or which remains
‘uncontrolled’ despite this therapy.”
68. • Asthma which requires treatment with guidelines
suggested medications for GINA steps 4–5 asthma (high
dose ICS and LABA or leukotriene modifier/theophylline)
for the previous year or systemic CS for ≥50% of the
previous year to prevent it from becoming ‘‘uncontrolled’’
or which remains ‘‘uncontrolled‘‘ despite this therapy .
69. • Severe asthma is a heterogeneous disease that affects
only 5%-10% of asthmatic patients, although it
accounts for a significant percentage of the
consumption of health care resources. It includes
several clinical and pathophysiological phenotypes.
70. • The American Thoracic Society (ATS) definition of severe
refractory asthma was very similar, and included criteria
that specified asthma control.
71. Definition of high daily dose of various inhaled corticosteroids in
relation to patient age
74. Such an approach can reveal an incorrect diagnosis and
comorbid conditions that aggravate asthma, such as:
Gastro-oesophageal reflux,
Obstructive sleep apnoea,
Sinonasal disease,
Recurrent respiratory infections
Obesity.
Also, non-adherence with inhaled glucocorticosteroid
treatment.
Incorrect inhalation technique are frequently encountered
factors that perpetuate poorly controlled asthma
• Addressing and treating these factors has been shown to result
in better clinical outcomes
75. Factors Involved in Non-Adherence
Medication Usage
Difficulties associated
with inhalers
Complicated regimens
Fears about, or actual
side effects
Cost
Distance to pharmacies
Non-Medication Factors
Misunderstanding/lack of information
Fears about side-effects
Inappropriate expectations
Underestimation of severity
Attitudes toward ill health
Cultural factors
Poor communication
Editor's Notes
Asthma is a significant burden, not only in terms of healthcare costs, but also in terms of lost productivity and reduced participation in family life
The number of disability-adjusted life years (DALYs) lost due to asthma worldwide is currently estimated to be about 15 million per year3. The DALY score is a measure of the overall burden of disease, expressed as the number of years lost due to ill-health, disability or early death
The increasing number of hospital admissions for asthma, which are most pronounced in young children, reflect an increase in severe asthma, poor disease management and poverty4.
References:
Global surveillance, prevention and control of chronic respiratory diseases: a comprehensive approach, World Health Organisation
Chronic Respiratory Diseases, World Health Organisation
Masoli et al. Allergy, 2004; 59: 469-478
Braman. Chest, 2006; 130:4S–12S
