Practice guidelines for Bronchial Asthma, for medical students and GPs.

1. BRONCHIAL ASTHMA :
Practice Guidelines
DR Prasad Honap

2. Bronchial Asthma
• Common cause of visit to a Doctor
• Common cause of missed school or
office
• Common cause of Non-surgical
admission
• Common cause of Emergency Room
Visit

3. Bronchial Asthma
• Common cause of Morbidity
• Common cause of Disability
• Occasional Mortality

4. Bronchial Asthma
• Failure of Asthma management is not
due to inadequate therapeutic options
but due to failure of effective medical
care delivery.

5. Bronchial Asthma
• Most of the patients will come to
primary care physician ( Family
Physician ).
• Family Physician can treat most of the
patients effectively.
• He can prevent costly admissions.
• He can reduce morbidity.

6. Bronchial Asthma : Guidelines
• Guidelines apply to most of the patients.
• Some patients may need specialist
treatment but they are in minority.
• Guidelines are low intensity-high yield
strategies.

7. Asthma : Diagnosis
 Recurrent or chronic lower respiratory
wheezing most prominent on expiration
 Recurrent or chronic coughing
 Repeated diagnoses of bronchitis
 Repeated diagnoses of pneumonia not
clinically consistent with pyogenic
infection
Consider Asthma in following situations

8. Asthma : Clinical patterns
• Intermittent
• Chronic
• Seasonal Allergic

9. Asthma : Clinical Features
• Dyspnea
• Cough
• Wheezing

10. Acute Asthma :Aims of
Management
• i. To prevent death
ii. To relieve respiratory distress
iii. To restore the patient’s lung function
to the best possible level as soon as
possible.
iv. To prevent early relapse

11. Acute Asthma : Assessment
of severity
i. History taking
ii.Physical examination
iii.PEF measurement

12. G ra d e
H is t o ry B ro n c h o d ila t o r
re q u ire m e n t
V a r ia b ilit y
in P E F
B e s t P E F
( p e rc e n t a g e o f
p re d ic t e d )
S e v e r e W a k e s a t n ig h t fr e q u e n tly
w ith w h e e ze , c o u g h ; c h e s t
tig h tn e s s o n w a k i n g in
m o r n i n g ; h o s p ita l a d m is s io n
in th e la s t y e a r ; p r e v io u s life
th r e a te n i n g a tta c k s
N e e d e d m o r e th a n
fo u r ti m e s a d a y
> 3 0 % < 6 0 %
M o d e r a te S y m p to m s o n m o s t d a y s
N o c tu r n a l s y m p to m s
> tw ic e a m o n th
N e e d e d o n m o s t
d a y s
2 0 % - 3 0 % 6 0 % - 8 0 %
M ild M ild o c c a s io n a l s y m p to m s ;
e .g . o n ly w ith e x e r c is e o r
in fe c tio n s
N e e d e d
o c c a s io n a lly
1 0 % - 2 0 % 8 0 % - 1 0 0 %
Acute Asthma : Assessment of
severity

13. Acute Asthma : Moderate
 Normal speech
 Pulse rate < 110/min
 Respiratory rate < 25 breaths/min
 PEF > 50% predicted or best value

14. Acute Asthma : Severe
 Too breathless to complete sentences in one
breath
 Respiratory rate  25 breaths/min
 Pulse rate  110/min
 PEF  50% predicted or best value

15. Acute Asthma : Life
threatening
• Central cyanosis
• Feeble respiratory effort
• Silent chest on auscultation
• Bradycardia or hypotension
• Exhaustion
• Confusion or unconsciousness
• PEF < 33% predicted or best value
(or a single reading of <150 l/min of
patients who are not able to blow)

16. Mild Asthma : Management
• Nebulization or inhaled bronchodilator
like salbutamol or terbutaline
• Observe for 60 min.
• Measure PEF if possible. If > 75% ,
send home

17. Mild Asthma : Management
 Review adequacy of usual treatment and
step up if necessary according to
guidelines for treatment of chronic
persistent asthma
 Ensure patient has enough supply of
medications
 Check inhaler technique and correct if
faulty
 Advise patient to return immediately if
asthma worsens.
Checklist before patient goes home

18. • Start Oxygen
• Bronchodilator by nebulization driven by
Oxygen
• IV Hydrocortisone 100 - 200 mg
• Antibiotics if indicated.
Moderate Asthma ( PEF < 76%) : Management in
clinic

19. Severe Life threatening
Asthma
• IV Aminophylline / Terbutaline
• Nebulization
• Oxygen
• Hydrocortisone
• Shift to Hospital and accompany the
patient

20. Acute Asthma
I n d ic a tio n s fo r im m e d ia te r e fe r r a l to h o s p ita l
 A n y life th r e a te n in g fe a tu r e s
 A n y fe a tu r e s o f a s e v e r e a tta c k th a t p e r s is t a fte r in itia l
tr e a tm e n t
 P E F 1 5 -3 0 m in u te s a fte r n e b u lis a tio n w h ic h is < 5 0 % o f
p r e d ic te d o r b e s t v a lu e .

21. Chronic Asthma : Approach
i. Education of patient and family
ii. Avoidance of precipitating factors
iii. Use of the lowest effective dose of
convenient medications minimising
short and long term side effects.
iv. Assessment of severity and
response to treatment.

22. Patient & Family Education
i. Nature of asthma
ii. Preventive measures/avoidance of
triggers
iii. Drugs used and their side-effects
iv. Proper use of inhaled drugs
v. Proper use of peak flow meter
vi. Knowledge of the difference between
relieving
and preventive medications

23. Patient & Family Education
Recognition of features of worsening asthma
(increase in bronchodilator requirement,
development of nocturnal symptoms,
reducing peak flow rates).
Self management plan for selected, motivated
patients or parents.
The danger of non prescribed self medication
including certain traditional medicines.

24. Avoidance of triggers
i. B e ta b lo c ke rs - c o ntra ind ic a te d in a ll a s th m a tic s
ii. A s p irin a nd no ns te ro id a l a nti-in fla m m a to ry d r u gs
iii. A lle rge ns , e .g. ho us e d us t m i te s , d o m e s tic p e ts , p o lle n.
iv . O c c up a tio n
v . S m o kin g - a c tiv e o r p a s s iv e .
v i. D a y to d a y trig ge rs - s uc h a s e xe rc is e a nd c o ld a ir.
v ii. A tm o s p he ric p o llutio n.
v iii. F o o d - if k no w n to trig ge r a s th m a , s ho uld b e a v o id e d .

25. Chronic Asthma : Clinical Exam.
• Confirm Diagnosis
Rule out
Pnumothorax
LRTI
COPD / Cor Pulmonale
PE

26. Chronic Asthma : Investigations
• Routine Hematology
• Biochemistry
• X-Ray Chest PA
• Pulmonary Function Tests

27. S T E P 1
M IL D E P IS O D IC A S T H M A
 In fr e q u e n t s y m p t o m s
 N o n o c t u r n al s y m p to m s
 P E T 8 0 -1 0 0 % p r e dic t e d
T r e a t m e n t:
 i n h al e d b e t a 2 a g o nis t " a s
n e e d e d " fo r s y m p t o m r e lie f. If
n e e d e d m o r e t h a n o n c e a d a y ,
a d v a n c e to S t e p 2
Management Of Chronic Asthma In Adults

28. S T E P 2
M O D E R A T E A S T H M A
 F re q u e n t s y m p to m s
 N o ctu r n al s y m p to m s pr es e nt
 P E F 6 0 -8 0 % p r e di cte d
T r e a tm e n t
 i n h al e d s te ro i ds , e .g .
b e clo m e th a so n e o r b u d e so ni d e
2 0 0 -8 0 0 m cg /d a y
 i n h al e d s o di u m c ro m o g l yc a te
p l u s
 i n h al e d b eta 2 a g o nis t " a s
n e e d e d "
Management Of Chronic Asthma In Adults

29. S T E P 3
S E V E R E C H R O N IC A S T H M A
 P e r si st e nt s y m p to m s
 F r e q u e n t no c t u r n al s y m p to m s
 P E F 6 0 % p r e dic te d o r le s s
T r e a t m e n t :
 In h a l e d b e c lo m e t h a so n e o r
b u d e s o ni d e 8 0 0 - 2 0 0 0 m c g /d a y
p l u s
 In h a l e d b e t a 2 a g o nis t a s n e e d e d
p l u s , i f n e c e s s ar y
 O r al b e t a2 a g o nis t pr e fe r a bl y
lo n g ac ti ng , o r
 In h a l e d l o ng a c ti ng b e t a 2
a g o nis t , o r
 In h a l e d i p r a tr o pi u m b r o m i de 4 0
m c g 3 -4 tim e s a d a y , o r
 O r al t h e o p h y lline ( s us t ai n e d
r e le a se ) , o r
 N e b u lise d b e t a2 a g o nis t , 2 -4
ti m e s a d a y
Management Of Chronic Asthma In Adults

30.  E d u c a tio n is im p o rta n t fo r p a t ie n ts a n d re la tiv e s
 T r ig g e rs a v o id a n c e w h e n e v e r p o s s ib le
 I n it ia l t re a tm e n t d e p e n d s o n s e ve rity o f a s th m a a t firs t a s s e ss m e n t
 R e v ie w tre atm e n t e ve ry 3 -6 m o n t h s . W h e n s y m p to m s a re c o n tro lle d ,
c o n s id e r g ra d u a l s te p d o w n o f tre a tm e n t, If u n c o n t ro lle d , c o n s id e r s te p u p .
 M o n ito r p e a k flo w w h e n e v e r p o s s ib le fo r m o d e ra te , se ve re a n d v e ry se ve re
a s th m a .
U s e w ritte n a s th m a p la n w h e n e v e r fe a s ib le fo r m o d e ra te , se ve re a n d v e ry se ve re
a s th m a .

31. R e sc u e C o u rse O f S te ro id T a b le ts
" R e s c ue " c o urs e s o f o ra l s te ro id s m a y b e ne e d e d to c o n tro l e xa c e rb a tio ns o f a s th m a a t
a n y s te p . Ind ic a tio ns m a y i nc lud e :
a . s y m p to m s a nd p e a k e xp ira to ry flo w (P E F ) ge t p ro gre s s iv e ly w o rs e d a y b y d a y.
b . P E F fa lls b e lo w 6 0% o f p a tie nt’s b e s t.
c . s le e p is d is turb e d b y a s th m a .
d . m o rni n g s y m p to m s p e rs is t u n til m id d a y.
e . the re is a d im i nis hi n g re s p o ns e to i n ha le d b ro nc ho d ila to rs .
f. e m e r ge nc y tre a tm e n t w ith ne b ulis e d o r inje c te d b ro nc ho d ila to rs is re q uire d .
M e tho d :
G iv e 3 0 -6 0 m g o f p re d nis o lo ne i m m e d ia te l y. T he d o s e s ho uld b e ta p e re d d o w n a nd
s to p p e d w ithin 7 -1 4 d a ys .

32. Assessment of response :
Clinical
• Relief of symptoms
• Quality of sleep
• Improvement in effort tolerance
• Normalization of daily routine
• Reduced need for bronchodilators.

33. Assessment of response :
PEF %
• Measure Best / Normal PEF when
asymptomatic.
• Estimate PEF during treatment.

34. PEF (max) - PEF (min) x 100 = _____________%
PEF (max)
PEF Variability

35. PEF Veriability
• < 20% = Mild
• 20 - 30% = Moderate
• > 30% = Severe
• < 10% = Good Control

36. PEF % During attack
• < 50% = Severe Attack
• < 33% = Life threatening Attack
• When best PEF is not known a single
reading of < 200 l/min indicates
severe attack.

37. 1 . D o u b t fu l di a g no sis
2 . V e r y s e v er a s t h m a
3 . N e e d fo r lo ng te r m t re a t m e n t
4 . W o r se ni n g a st h m a i n p reg n a n c y
5 . A s t h m a d i s t ur bi n g li fe st yl e de s pit e t re a t m e n t .
Asthma : When to refer ?