Asthma Signs and Symptoms, Severity Classification, GINA and ATS Classification, Step-up Management of Chronic Asthma and Management of Acute Exacerbation of Asthma

1. MANAGEMENT OF ASTHMA
AT PRIMARY CARE LEVEL
DR MUHAMMAD REDZWAN

2. Clinical Symptoms and Medical History
• Recurrent cough / wheeze / difficult breathing /chest
tightness
• More at night and early morning, or after exposure to
risk factors or worsen at night
• Patient colds ‘go to the chest’ or take more than 10
days to clear up
Symptoms and History (< 5 years old)
• Frequent wheezing (> once / month)
• Activity-induced cough or wheeze
• Cough at night during periods without viral infections
• Symptoms persist after 3 years old
• Symptoms occur or worsen after exposure to risk
factors
• Symptoms improved after asthma medication is given
Physical Examination
• Unable to complete sentences
• Tachypneic, sign of respiratory distress
• Wheezing on auscultation
• ‘Silent chest’

3. LUNG FUNCTION TEST / MEASUREMENT
SPIROMETRY
• Increased FEV1 > 12% & > 200mL after bronchodilators (reversibility)
PEAK EXPIRATORY FLOW
• Increased 60L/min (>20%) after bronchodilators or diurnal variation > 20% (variability)

5. CLASSIFICATION OF ASTHMA SEVERITY
SYMPTOMS
Severe Persistent • Daily symptoms
• Frequent exacerbation
• Frequent nocturnal asthma Sx
• Limitation of activity
• FEV1 or PEFR < 60% predicted
• FEV1 or PEFR variability > 30%
Moderate Persistent • Daily symptoms
• Exacerbation may affect sleep and activity
• Nocturnal symptoms > once/week
• Daily used of Inhaled SABA
• FEV1 or PEFR 60-80% predicted
• FEV1 or PEFR variability > 30%

6. SYMPTOMS
Mild Persistent • Symptoms > once/week but not daily
• Exacerbation may affect sleep and activity
• Nocturnal symptoms > twice/months
• FEV1 or PEFR > 80% predicted
• FEV1 or PEFR variability 20 - 30%
Intermittent • Symptoms < once/week
• Brief exacerbation
• Nocturnal symptoms not more than
twice/month
• FEV1 or PEFR > 80% predicted
• FEV1 or PEFR variability <20%

7. GINA ASSESSMENT OF ASTHMA CONTROL
1. Asthma Control
2. Treatment issue
• Inhaler techniques
• Side effects
• Goals for treatment
• Asthma action plan?
3. Co-morbidities
• Rhinosinusitis
• GERD
• OSA
• Depression
• Anxiety

8. ASTHMA CONTROL TEST (ACT)

9. PRIMARY PREVENTION OF ASTHMA
• Avoid exposure to tobacco smoke (ETS) in pregnancy and early life.
• Encourage vaginal delivery.
• Advise breast-feeding for its general health benefits.
• Where possible, avoid use of paracetamol (acetaminophen) and
broadspectrum antibiotics in the first year of life.

10. GOALS OF ASTHMA MANAGEMENT
• Symptom control: to achieve good control of symptoms and
maintain normal activity levels.
• Risk reduction: to minimize future risk of exacerbations, fixed
airflow limitation and medication side-effects.

11. STEPWISE APPROACH TO CONTROL ASTHMA
*For children 6 – 11 years old, preferred Step 3 is medium dose ICS
**for patient prescribed BPD / Formoterol or BUD / formoterol maintenance and reliever therapy

12. REMEMBER TO…
• Provide guided self management education
• Treat modifiable risk factors and co-morbids (smoking, obesity, anxiety)
• Consider stepping up if uncontrolled symptoms, exacerbations or risks, but
check diagnosis, inhaler technique and adherence first
• Consider stepping down if symptoms controlled for 3 months, but ceasing ICS
is not advisable

15. REVIEWING RESPONSE AND ADJUSTING TREATMENT
1. How often should be reviewed?
• 1-3 months after treatment started
• During pregnancy every 4-6 weeks
• After AEBA, within 1 week
2. Stepping up
• Sustained Step Up: 2-3 months
• Short term step up: 1-2 weeks
• Day to day adjustment: for low dose ICS/formoterol maintenance and reliver regiments
3. Stepping down
• Good control maintained 3 months
• Finds each patient minimum effective dose that control symptoms and exacerbation

16. MANAGEMENT OF AEBA
The aims of management are:
1. To prevent death
2. To relieve respiratory distress
3. To restore the patient's lung function to the best possible level as soon as possible.
4. To prevent early relapse

17. ASSESSMENT
Features of moderately severe asthma
• normal speech
• pulse rate < 110/min
• respiratory rate < 25 breaths/min
• PEF > 50% predicted or best value
Features of acute severe asthma
The presence of any of the following indicates a
severe attack of asthma:
• too breathless to complete sentences in one
breath
• respiratory rate ³ 25 breaths/min
• pulse rate ³ 110/min
• PEF £ 50% predicted or best value

18. Life threatening features
The presence of any of the following indicates a very severe attack of asthma:
• 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)

19. INITIAL PEF > 75% (MILD ACUTE ASTHMA)
• Give MDI Salbutamol / Terbutaline / Fenoterol
• Observe for 60 minutes. If the patient stable and PEFR is still >75%, discharge.

20. SEVERE ACUTE ASTHMA (PEFR < 75%)
Immediate Treatment With :
• High concentration oxygen (>40%) in cases with initial PEF <50% at presentation.
• High doses of inhaled beta2 agonist (salbutamol 5mg or terbutaline 5mg or fenoterol 5mg) via nebuliser
driven by oxygen.
• Consider adding anticholinergic (e.g. ipratropium bromide 0.5mg) to nebulised beta2 agonist for
patients with acute severe asthma (neb Combivent)
• Prednisolone tablets 30-60mg or in very ill patients, IV hydrocortisone 200mg stat.

21. LIFE THREATENING ASTHMA
• Prepare to refer and transfer to Tertiary Facility
• While waiting for transfer, give neb Salbutamol / Combivent, high flow oxygen, and stat dose of IV
Hydrocortisone

22. ASSESSMENT POST TREATMENT
Good response to initial treatment
• be free of wheezing and dyspnea
• have a clear chest on auscultation
• have a postbronchodilator PEF which is >75% of predicted or best value.
Incomplete response to initial treatment
• persistent wheezing or dyspnea
• rhonchi on auscultation
• A post-bronchodilator PEF which is 50-75% of predicted or best value.
Poor response to initial treatment
• persistent, marked wheezing or breathlessness
• diffuse rhonchi on chest auscultation and other signs of acute severe asthma
• a postbronchodilator PEF <50% of predicted or best value.

23. BEFORE DISCHARGE
• 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.
• make sure patient has a clinic follow-up appointment

24. MANAGING AEBA

26. REFERENCES
1. Management of Asthma at Primary Care Level, training module for healthcare provider
(2015) Bahagian Pembangunan Kesihatan Keluarga KKM
2. Guideline of Managing Adult Bronchial Asthma (2012) Malaysian Thoracic Society
3. Acute Exacerbation of Bronchial Asthma, Sarawak Handbook of Medical Emergencies 3rd
Edition

27. THANK YOU