This document provides an in-depth overview of asthma, detailing its definitions, phenotypes, diagnostic criteria, and management strategies, including medications and assessments. It highlights various risk factors for asthma exacerbations, potential medication side effects, and specific considerations during pregnancy. Additionally, the document emphasizes the importance of a stepwise approach to treatment and proper inhaler technique for effective asthma management.

1. Asthma
고려대학교 안암병원 이은
주
2016.6.7

2. Definition-1
 Heterogeneous dz, characterized by chronic airway
inflammation
 Dx : characteristic Sx
(wheeze, shortness of breath, chest tightness, cough
worse at night or in the early morning
triggered by infection, exercise, allergen, weather…)
+
variable airflow limitation
(bronchodilator reversibility test, hyperresponsiveness test..)

3. Definition-2
 Asthma phenotypes
Allergic asthma: childhood, PHx/FHx(+) of allergic dz,
eosinophilic inflammation in sputum,
well response to ICH
Non-allergic asthma: adult, less well to ICS
Late-onset asthm: women, adult, often require higher doses of ICS
relatively refractory steroid
Asthma with fixed airflow limitation: long-standing, d/t
remodeling
Asthma with obesity: prominent Sx, little eosinophilic
inflammtaion

4. Diagnosis-1
Confirmed variable expiratory airflow limitation
*Documented excessive variability in
lung function AND airflow limitation
(* 아래의 test 중 하나 이상에서 증
명 )
The greater the variations, the more confident the Dx
At least once, when FEV1 is low, confirm that FEV1/FVC is
reduced (normally >0.75-0.8)
BDR(+) Increase in FEV1 >12% & 200ml
(after 200-400mcg albuterol)
Excessive variability in twice-daily
PEF over 2 weeks
Average daily diurnal PEF variabilitity >10%
Significant increase in lung function
after 4 weeks of anti-inflammatory Tx
Increase in FEV1 >12% & 200ml from 4 weeks of Tx
(PEF > 20%)
Exercise challenge test(+) Fall in FEV1 >10% & 200ml from baseline
Bronchial challenge test(+) Fall in FEV1 >20% (metacholine or histamine)
Fall in FEV1 >15% (hyperventilation, hypertonic saline, or
mannitol)
Excessive variation in lung function
between visits(less reliable)
Variation in FEV1 >12% & 200ml between visits

5. Diagnosis – 2
 Reversibility : improvement of FEV1(or PEF) after bronchodilator
or controller (ICS..)
≥ 12% & 200mL
 Variability : Sx / lung function 의 improvement / deterioration
예 > diurnal variability

6. Diagnosis -3
 Peak expiratory flow (PEF)
diurnal PEF variability =
(1-2 주간의 평균 )
≥ 10% 시 Dx 에 도움
( 밤 PEF)- ( 아침 PEF)
{( 밤 PEF)+ ( 아침 PEF)} /2

7. Diagnosis -4
 Airway responsiveness
methacholine, histamine, mannitol, exercise challenge
PC(or PD) 20%
(+): asthma, allergic rhinitis, cystic fibrosis, COPD

8. Diagnosis -5
 Allergic status
: strong association between asthma & allergic dz
skin test, specific IgE in serum (not total)
skin-prick test
: 팽진≥ 3mm
&
발적 ≥ 10mm

9. Differential Diagnosis
 Vocal cord dysfunction
 Hyperventilation, dysfunctional breathing
 COPD
 Bronchiectasis
 Cardiac failure
 Medication related cough
 Parenchymal lung dz, pulmonary embolism..

10. Classification
Characteristic
Controlled
(All of the following)
Partly controlled
(Any present in any week)
Uncontrolled
Daytime symptoms None (2 or less / week)
More than
twice / week
3 or more
features of partly
controlled asthma
present in any
week
Limitations of activities None Any
Nocturnal symptoms /
awakening
None Any
Need for reliever / rescue
treatment
None (2 or less / week)
More than
twice / week
Lung function
(PEF or FEV1)
Normal
< 80% predicted or personal
best (if known)

11. Assessment-1(Sx control)

12. Asthma Control Test(ACT)

13. Assessment-2(Future risk)
Risk factors for poor asthma outcomes
Potentially modifiable independent risk factors for flare-ups (exacerbations)
uncontrolled asthma Sx
High SABA use ( increased mortality if > 1x 200-dose canister/month)
Inadequate ICS: not prescribed ICS : poor adherence : incorrect inhaler technique
Low FEV1 (<60%)
Major psychological or socioeconomic problems
Exposures: smoking, allergen
Comorbidities : obesity, rhinosinusitis, confirmed food allergy
Sputum / blood eosinophilia
Pregnancy
Other major independent risk factors for flare-ups (exacerbations)
Ever intubated or in intensive care unit for asthma
≥ 1 severe exacerbation in last 12 months
Risk factors for developing fixed airflow limitation
Lack of ICS Tx
Exposures: smoke; noxious chemicals; occupational exposures
Low initial FEV1 ; chronic mucus hypersecretion; sputum or blood eosinophilia
Risk factors for medication side-effects
Systemic : frequent OCS; long-term, high dose/potent ICS; also taking P450 inhibitors
Local: high-dose / potent ICS; poor inhaler technique

14. Medication - Controller MedicationsController Medications
 Inhaled / systemic glucocorticosteroids (ICS)
 Leukotriene modifiers
 Long-acting inhaled / oral β2-agonists (LABA)
 Theophylline ( sustained-release)
 Anti-IgE

15. Medication - Reliever MedicationsReliever Medications
 Rapid-acting inhaled β2-agonists
 Inhaled anticholinergics
 Systemic glucocorticosteroids
 Theophylline (short-acting)
 Short-acting oral β2-agonists

16. Control-based asthma Mx
Sx
Exacerbations
Side-effects
Pt satisfaction
Lung function
Dx
Sx control & risk factors
(including lung function)
Inhaler technique &
adherence
Pt preference
Asthma medications
Non-pharmacological strategies
Tx modifiable risk factors

17. Stepwise approach-1
Step 1 Step 2 Step 3 Step 4 Step 5
Preferred
controller
choice
Low dose ICS Lose dose
ICS/LABA
Med/high
ICS/LABA
Refer for
add-on Tx
e.g.
tiotropium,
omalizumab,
mepolizumab
Other
controller
options
Consider low
dose ICS
LTRA
Low dose
theophylline
Med/high
dose ICS
Low dose
ICS+LTRA
(or + theoph)
Add
tiotropium
High dose
ICS+LTRA
(or + theoph)
Add low dose
OCS
Reliever As-needed SABA As-needed SABA or low dose ICS/formoterol

18. Stepwise approach-2
 3 개월 이상 Sx, PFT 가 안정적이면 stepdown 고려
- ICS dose 를 25-50% 정도를 3 개월 이상 간격으로 줄임
 만약 6-12 개월간 증상이 없고 , risk factor 가 없다면
controller 를 중단 고려 .
하지만 ICS 의 complete cessation 은 exacerbation 이
증가한다는 보고가 많아 권하지 않음 .

19. Manage asthma exacerbations
 Repetitive administration of rapid-acting inhaled
bronchodilators
 Early introduction of systemic glucocorticosteroid
 Oxygen supplement

20. Manage asthma exacerbations-1

21. Manage asthma exacerbations-2

22. Manage asthma exacerbations-4
 Oxygen : target 93-95%
 SABA : 4-10 puffs q 20min for 1 hr
 4-10 puffs q 3-4 hrs ~ 6-10 puffs q 1-2hrs (primary care)
nebulizer 일때는 초기엔 continuous  이후엔 prn 으로
(adm 시 )
 Epinephrine: only anaphylaxis, angioedema
 Systemic steroid : prednisolone 1mg/kg(max 50mg) for 5-7 days
1 시간 이내로 투여  효과 보는데 4 시간은 걸려
oral = IV
 Ipratropium bromide (atrovent): addictive bronchodilation
 항생제는 routine 으로 주지 말 것 !!

23. Manage asthma exacerbations
 Magnesium : MgSO4 2g/IV (20 분간 ) single dose
FEV1 25-30% at presentation
pt who fail to response to initial Tx
 재원 기간 줄임
 Leukotriene modifiers : little data to suggest a role in acute
asthma
 Sedative : avoided during exacerbation

24. Drug side effects
 β2-agonists : muscle tremor, palpitation, K 저하
 Anticholinergics: dry mouth, urinary retension, glaucoma
 Theophylline : N/V, headache, diuresis, palpitation, arrhythmia,
seizures, death…
 Steroid: hoarseness, oral candidiasis,
truncal obesity, bruising, osteoporosis, DM, HTN,
gastric ulcer, proximal myopathy, depression, cataracts

25. Special consideration - Pregnancy
 Severity : 1/3 은 호전 , 1/3 은 악화 , 1/3 은 unchanged
 AE 가 중기에 흔함 .
 분만 도중 AE 가 흔하지는 않지만 , hyperventilation 에 의해
bronchoconstriction 발생 가능
 SABA 로 조절 가능
BA 를 많이 사용시 baby 에서 HypoG 가능
(24 시간 monitoring 요망 )
 Tx: theophylline, ICS, BA, leukotriene modifier(montelukast)
 Exacerbation : to avoid fetal hypoxia
rapid-acting BA, O2, systemic steroid

26. Medications

Ventolin / Atrovent (MDI)
Foster (MDI)Seretide (Diskus, MDI) Symbicort (Turbuhaler)
Oral steroid/ theophylline
Oral long acting β2-agonist
Leukotriene modifiers
기 타

27. 27
Ref) 세레타이드 에보할러 , 벤토린 에보할러 제품 설명서

28. Spacer

29. 29
※ 사용법은 보조흡입기의 종류에 따라 다를 수 있으며 , 정확한 사항은 보조흡입기 사용법을 참고해주십시오 .

30.  환자 자신의 들여 마시는 힘에 의해 약물이 비산되어 흡입
 흡입기를 입에 물고 숨을 내쉬지 않도록 교육
 빠르고 세게 흡입
터부헬러 (Turbuhaler)디스커스 (DisKus)
DPI : Dry Powder Inhaler

31. 31
숨을 끝까지 내쉰다 . 한번에 강하고 깊게 들이 마신다 .
5~10 초간 숨을 참은 후 코로 숨을 천천히 내쉰다
손잡이를 돌려 한번에 닫는다 .

32. 물로 입안을 깨끗이 헹군다 .
Ref) 세레타이드 디스커스 제품 설명서

33. Cases

34. Case 1
 M/ 38
 CC: dyspnea, wheezing (onset: 3 일전 )
 PI : 약 10 일 전부터 cough, rhinorrhea 있어 오다가
내원 3 일 전부터 dyspnea, wheezing 발생하여 내원
 Never smoker
 PHx : DM/HTN/TBc/Hepatitis(-/-/-/-)
Allergic rhinitis(+)
 PEx; whole lung wheezing(+)

36. Case 2
 M/ 51
 CC: cough (onset: 3 달 전부터 )
 PI : 특이 병력 없는 never smoker 남자로
3 개월 전부터 dry cough 지속되어 내원
 PHx : DM/HTN/TBc/Hepatitis(-/-/-/-)
 PEx: SBS without c/w

37. CXR 및 PNS

38. Esophageal 24hr pH monitoring

39. PFT 및 Provocation test