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7/28/2019 how to approach a patient with asthma at family practice setting
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BRONCHIALASTHMA
Dr Hanan abbasAssistant professor of familyMedicine
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At the conclusion of the presentation,participants should be able to:
ID signs and symptoms consistent with asthma Differentiate the severity of asthma
Summarize an appropriate treatment regimen forasthma of various severity
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Epidemiology:
According to epidemiological studies asthmaaffects 1-18% of population of different
countries High cost of medical services
5 million work days are lost / yr worldwide
Fatalities still occurring: 0.1-1% of all deaths
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Barriers to control:
About 50% of asthmatics are not controlled Common causes are:
Poor patient education
Poor patient compliance Poor prescription (6-44%) Side effects of drugs Expensive medications Poor communication Steroid resistance
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Asthma is Increasing ?!Why the increase?
Increased recognition, diagnosis-shifting
Environmental allergens - indoor, outdoor Energy-efficient buildings, carpet
Exposure to mothers tobacco smoke
Psychosocial and socioeconomic factors
More time indoors
Overcrowding
Access to care
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The Underlying Mechanism
INFLAMMATION
Risk Factors (for development of asthma)
AirwayHyper-responsiveness
AirflowLimitation
Symptoms- (shortnessof breath, cough,
wheeze)
Risk Factors
(for exacerbations)
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Definition
Chronic inflammatory disorder of the airways , In susceptibleindividuals, this inflammation causes recurrent episodes ofwheezing, breathlessness, chest tightness, and coughing,
particularly at night or in the early morning. These episodes are associated with widespread but variable
airflow obstruction that is reversible either spontaneously, orwith treatment.
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Triggers:
Tobacco smoke. Infections such as colds, flu, or pneumonia .
Allergens such as food, pollen, mold, dust mites, and pet dander
Exercise .
Air pollution and toxins . Weather, especially extreme changes in temperature
Drugs (such as aspirin, NSAID, and beta-blockers)
Food additives
Emotional stress and anxiety . Singing, laughing, or crying .
Smoking, perfumes, or sprays .
Acid reflux .
8
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Some allergens which may cause
asthma
House-dust mites which live incarpets, mattresses andupholstered furniture
Spittle, excrements,hair and fur
of domestic
animals
Plant pollen
Pharmacological agents
(enzymes, antibiotics,vaccines, serums)
Food components(stabilizers, genetically
modified products)
Dust of
bookdepo-sitories
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Signs &
Symptoms: Shortness of breath . Tightness of chest.
Excessive coughing or a cough thatkeeps you awake at
night. Feeling very tiredorweak when exercising.
Wheezing or coughing after exercise .
Decreases or changes in lung function as measuredon a
peak flow meter . Signs of a cold, or allergies (sneezing, runny nose,
cough, nasal congestion, sore throat, and headache) .
Trouble sleeping .
4/9/2013 10
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Diagnosing Asthma
Troublesome cough, particularly at night
Awakened by coughing
Coughing or wheezing after physical activity
Breathing problems during particular seasons
Coughing, wheezing, or chest tightness after
allergen exposure
Colds that last more than 10 days
Relief when medication is used
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Diagnostic Testing
Peak expiratory flow (PEF)
Inexpensive
Patients can use at home May be helpful for patients with severe disease to
monitor their change from baseline every day
Not recommended for all patients with mild or
moderate disease to use every day at home Effort and technique dependent
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Peak expiratory flow (PEF) Meters
Allows the
patient toassess thestatus of his orher asthma
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PEF can be measured with the help of individualdevices peak flow meters
P l i h d
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PeakflowChart
Source: What You and Your Family Can Do About Asthma by the Global Initiative For Asthma
Created and funded by NIH/NHLBI
People with moderate or severeasthma should take readings Every morning and evening After an exacerbation Before inhaling certain
medications
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Asthma severity classification
Clinical course,severity Daytime asthmasymptoms
Nighttimeawakenings FEV1, PEF
Intermittent < 1 /week2 and < /month >80% predicted.
Daily variability 2 /month
>80% predicted.
Daily variability
20-30%
Moderate
persistent
Daily > 1 /week> 60 but < 80%
predicted.Variability>30%.
Severe
persistentPersistent,which limitnormal activity
Daily 30%.
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years of age*12Classification of asthma severity
Components of severity Intermittent Persistent -mild Persistent-moderate Persistent -severeImpairment
Symptoms 2 days per week >2 days per week,but not daily
Daily Throughout the day
Nighttime awakenings 2 times per month 3 to 4 times permonth
> Once per week, but notnightly
Often 7 times per week
Short-acting beta agonistuse for symptom control(not for prevention ofexercise-inducedbronchospasm)
2 days per week >2 days per week,but not more than once perday
Daily Several times per day
Interference with normalactivity
None Minor limitation Some limitation Extremely limited
Lung function Normal FEV1 betweenexacerbations; FEV1 >80percent of predicted;FEV1/FVC normal
FEV1 80 percent ofpredicted; FEV1/FVCnormal
FEV1 > 60 percent but < 80percent of predicted;FEV1/FVC reduced 5percent
FEV1 < 60 percent ofpredicted; FEV1/FVCreduced >5 percent
Risk
Exacerbations requiringoral systemiccorticosteroids
0 to 1 per year 2 per year 2 per year 2 per year
Consider severity and interval since last exacerbation; frequency and severity may fluctuate over time forpatients in any severity category; relative annual risk of exacerbations may be related to FEV1
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In recommendations of Global Initiative for Asthma(GINA) asthma is classified on the base ofcontrolassessment andis divided into well-controlled,partially controlled and uncontrolled.
Asthma control is considered as:
daytime symptoms 2 /week;
ability to engage in normal daily activity;
the absence of night-time awakenings as a result ofasthma symptoms;
need in bronchodilators administration 2 /week;
the absence of asthma exacerbations;
normal or near normal lung function parameters.
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Asthma complicationsThe complications ofasthma exacerbations are:
pneumothorax
lung atelectasis
pneumonia
acute or subacute corpulmonale
asthmatic status.
Persistent asthma causes:
fibrosing bronchitis
small bronchideformation andobliteration
emphysema pneumosclerosis,
chronic respiratoryfailure
chronic cor pulmonale.
Asthmain childhoodleads to growth inhibition
and thoracic deformation.
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Goals of Asthma Treatment
Control chronic and nocturnal symptoms
Maintain normal activity, including exercise
Prevent acute episodes of asthma Minimize ER visits and hospitalizations
Minimize need for reliever medications
Maintain near-normal pulmonary function Avoid adverse effects of asthma medications
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years of age)*12Classification of asthma control (
Components of control Well controlled Not well controlled Very poorly controlledImpairmentSymptoms 2 days per week > 2 days per week Throughout the day
Nighttime awakenings 2 times per month 1 to 3 times per week 4 times per weekInterference with normalactivity
None Some limitation Extremely limited
Short-acting beta agonist usefor symptom control (not forprevention of exercise-induced bronchospasm)
2 days per week > 2 days per week Several times per day
FEV1 or peak flow > 80 percent of predicted/personal best 60 to 80 percent ofpredicted/personal best < 60 percent ofpredicted/personal bestRiskExacerbations requiring oralsystemic corticosteroids
0 to 1 time per year 2 times per year 2 times per yearConsider severity and interval since last exacerbation
Progressive loss of lungfunction
Evaluation requires long-term follow-up care
Treatment-related adverse
effects
Medication adverse effects can vary in intensity from none to very troublesome and
worrisome; the level of intensity does not correlate to specific levels of control, but shouldbe considered in the overall assessment of risk
Recommended action forfor1Figuretreatment (see
treatment steps)
Maintain current step; regularfollow-up every one to sixmonths to maintain control;consider step down if wellcontrolled for at least three
months
Step up one step andreevaluate in two to sixweeks; for adverse effects,consider alternativetreatment options
Consider short course of oralsystemic corticosteroids; stepup one to two steps, andreevaluate in two weeks; foradverse effects, consider
alternative treatment options
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Asthma Control
Levels of Asthma ControlUncontrolledPartly Controlled
(any measure present
in any week)
Controlled(All of thefollowing)
Characteristics
Three or more of
partly controlledasthma present
in any week
> Twice /wNone (twice or
less/week)
Day time symptoms
AnyNoneLimitations of
activity
AnyNoneNocturnalsymptoms/
awakening> Twice / weekNone (twice or
less/week)Need for relievers
< 80% of predictedNormalLung function(PEF or
FEV1)
One in any weekOne or per yearNoneExacerbation
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years of age)*12Classification of asthma control (
Components of control Well controlled Not well controlled Very poorly controlledImpairmentSymptoms 2 days per week > 2 days per week Throughout the day
Nighttime awakenings 2 times per month 1 to 3 times per week 4 times per weekInterference with normalactivity
None Some limitation Extremely limited
Short-acting beta agonist usefor symptom control (not forprevention of exercise-induced bronchospasm)
2 days per week > 2 days per week Several times per day
FEV1 or peak flow > 80 percent of predicted/personal best 60 to 80 percent ofpredicted/personal best < 60 percent ofpredicted/personal bestRiskExacerbations requiring oralsystemic corticosteroids
0 to 1 time per year 2 times per year 2 times per yearConsider severity and interval since last exacerbation
Progressive loss of lungfunction
Evaluation requires long-term follow-up care
Treatment-related adverse
effects
Medication adverse effects can vary in intensity from none to very troublesome and
worrisome; the level of intensity does not correlate to specific levels of control, but shouldbe considered in the overall assessment of risk
Recommended action forfor1Figuretreatment (see
treatment steps)
Maintain current step; regularfollow-up every one to sixmonths to maintain control;consider step down if wellcontrolled for at least three
months
Step up one step andreevaluate in two to sixweeks; for adverse effects,consider alternativetreatment options
Consider short course of oralsystemic corticosteroids; stepup one to two steps, andreevaluate in two weeks; foradverse effects, consider
alternative treatment options
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Management Avoiding the contact with allergen.
Elimination of trigger factors (rational jobplacement, changing the residence, psychological andphysical adaptation, careful drug using) is the second
condition for successful asthma treatment. Optimally selected medical care is the base of
asthma management.
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Treatment:
Bases of treatments: one way is to relaxes themuscles during expiration.
26
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Drug therapy
Antiinflammatory drugs(basic)
Bronchodilators
2 drug categories are used:
Are divided into:
hormone-containing(corticosteroids)
nonhormone-containing(cromones, leukotriene
receptor antagonists)
3 groups:
anticholinergic drugs
b2-agonists
methylxanthines
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Corticosteroids
The working
mechanism lays in:
cell membrane
stabilization
inhibition ofinflammatory
mediators
restoring the sensivity
ofb2-receptors.
Inhaled corticosteroids
(beclamethazone, inhacort,budesonide, flixotid,fluticazone, asmacort,asthmanex) are the mosteffective and safe and
considered to be the firstline drugs for asthmatreatment. Systemic areused during short courses,
mainly in case of severepersistent asthma orasthmatic status.
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Cromones
(cromolyn sodium
intal,and nedocromiltiled)
stabilize cell membranes,
used mainly in pediatricpractice (in childhood)
in case ofintermittent ormild persistent asthma.
Leukotrienereceptor
antagonists(montelukast, zafirlukast)
have the moderateintiinflammatory activity
used in case ofaspirin-
induced asthma and
asthma of physical
exertion.
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Inhaled b2-agonistsare the basic drug group amongbronchodilators.
Short-acting (duration of action 5-6 h) b2-agonists - salbutamolused for quick relief ofasthma symptoms.
Long-acting (> 12 h) b2-agonists - salmoterol,formoterol- for prevention of asthma symptomsoccurring.
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Anticholinergic drugs (ipratropium bromide,
atrovent, troventol) are used predominantly innighttime asthma and in elderly patientsbecause of the least cardiotoxic effect.
Methylxanthines in comparison with otherbronchodilators have the less bronchodilatingpotential. There are long-acting (>12 h) - (theopec,
theolong, theodur, euphilong) as well as short-acting (aminophylline, theophylline) drugs in thisgroup.
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Combined inhaled drugs (corticosteroids with b2-agonists) seretid, simbicort with use ofdelivery
devices (nebulizers, turbuhalers, spacers) enhance theeffectiveness of asthma therapy.
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Prognosis In case of early detection and adequate
treatment the prognosis for the disease
is favourable. It becomes serious in severe persistent
and poorly controlled (insensitive for
corticosteroids) asthma.
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Reducing Exposure to House Dust Mites
Use bedding encasements
Wash bed linens weekly
Limit stuffed animals tothose that can be washed
Reduce humidity level(between 30% and 50%relative humidity
Source: What You and Your Family Can Do About Asthma by the Global Initiative For AsthmaCreated and funded by NIH/NHLBI, 1995
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Reducing Exposure to Tobacco Smoke
Evidence suggests an associationbetween environmental tobaccosmoke exposure and exacerbationsof asthma among school-aged,older children, and adults.
Evidence shows an association
between environmental tobaccosmoke exposure and asthmadevelopment among pre-schoolaged children.
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Tool Kit for Achieving
Management Goals Relievers
Preventers
Peak Flow meter
Patient education
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What Are Relievers?
- Rescue medications- Quick relief of symptoms
- Used during acute attacks
- Action lasts 4-6 hrs
- Not for regular use
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RELIEVERS
Short acting b2 agonistsSalbutamol
Levosalbutamol
Anti-cholinergicsIpratropium bromide
Xanthines
Theophylline Adrenaline injections
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Relievers(Bronchodilators)
Relaxes muscles in the airways to help relieve asthma
symptoms
Should be taken as needed for symptomsNeed to wait 1-2 minutes between puffs for best
deposition of medication in the lungs
Overuse is a big warning sign indicating the childs
asthma may not be well controlled
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What are Preventers?
- Prevent future attacks
- Long term control of asthma
- Prevent airway remodeling
PREVENTERS
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PREVENTERS
Corticosteroids Anti-leukotrienes
Prednisolone, Betamethasone Montelukast, ZafirlukastBeclomethasone, Budesonide
Fluticasone Xanthines
Theophylline SR
Long acting b2 agonists Mast cell stabilisers
Bambuterol, Salmeterol Sodium cromoglycate
Formoterol
COMBINATIONS
Salmeterol/Fluticasone
Formoterol/Budesonide
Salbutamol/Beclomethasone
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Inhaled Corticosteroids
Potential adverse effects
Cough, dysphonia, thrush
Therapeutic issues
Different inhaled corticosteroids are not
interchangeable
Azmacort and Aerobid reportedly have particularly
bad taste, Pulmicort , Turbuhaler has no taste
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Steroid Phobia: Unfounded!
Inhaled steroids in doses most often prescribedare very safe
Inhaled meds delivered directly to lungs where
they are needed
Little systemic absorption if proper techniqueused
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ICS + LABA
Which LABA ?
Formoterol: Immediate relief (as fast assalbutamol)-----12 hours effect
Can be combined with budesonide
All Asthma Drugs Should Ideally Be Taken
Through The Inhaled Route.Dose: 1- 4 puffs ( OD/BD )
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Combination Medication
Advair(Flovent + Serevent)Combo corticosteroidand long acting beta-agonist
3 strengths: 100/50, 250/50, 500/50
Strengths based on Flovent doses, Serevent doseremains the same in all three strengths.
Usual dosing, 1inhalation every 12 hours
Has remaining-dose counter
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Why inhalation therapy?
Oral
Slow onset of action
Large dosage used
Greater side effects
Not useful in acute
symptoms
Inhaled routeRapid onset of action
Less amount of drugused
Better tolerated
Treatment of choice
in acute symptoms
MDI
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MDI
Metered dose inhalers (MDI)
The health-care provider should evaluate inhaler technique at each visit.
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How MDI Technology Works
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spacers
Spacers can help patients whohave difficulty with inhaleruse and can reduce
potential for adverse effects
from medication.
No co-ordination required
Reduced oro-pharyngeal
deposition Increased drug deposition in
the lungs
N St id l A ti i fl t
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Non-Steroidal Anti-inflammatory
Intal(Cromolyn) (also available as Intal HFA)
Tilade (Nedocromil) For symptom prevention or as preventive treatment
prior to allergen exposure or exercisePotential adverse effects
None (Tilade tastes bad)
Therapeutic issues
Must be taken up to 4 times a day, maximum benefitafter 4-6 weeks
k t i difi
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Leukotriene Modifiers
Singulair(Montelukast) Accolate(Zafirlukast)
Zyflo
Oral: Prevention of symptoms in mild persistent asthma,
and/or to enable a reduction in dosage of inhaled steroids inmoderate to severe persistent asthma
Potential adverse effects
None significant elevation of liver enzymes
Therapeutic issues
Drug interactions, monitor hepatic enzymes (esp. Zyflo)
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Methylzanthines
TheophylineFor prevention of symptoms (bronchodilation, and
possible epithelial effects)
Potential adverse effects Insomnia, upset stomach, hyperactivity, bed wetting
Therapeutic issues
Must monitor serum concentrations, not helpful in acuteexacerbations, absorption and metabolism affected bymany factors
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Systemic Corticosteroids
PrednisonePrevents progression of moderate to severe exacerbations,
reduces inflammation
Potential adverse effects
Short-term- increased appetite, fluid retention, moodchanges, facial flushing, stomachache. Long term-growth suppression, hypertension, glucose intolerance,muscle weakness, cataracts
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CASE SCENARIO
Khalid 14 years old come to the clinic c/o shortnessof breath for one day duration.
He is a known asthmatic patient for more than 8years, he visited A/E frequently.
His school performance is below average, withfrequent absence from school due to his illness.
how you will proceed during thisconsultation ?
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Asthma has been defined as
A. reversible airway obstruction.
B. chronic airway inflammation.C. nonreversible airway obstruction.
D. a and b.
E. b and c.
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Risk factors for the development of asthmainclude all of the following except
A. Personal or family history of atopy.
B. Prenatal smoking by the mother.
C. Being the youngest sibling in a family.
D. Chronic allergic rhinitis.
E. Exposure to increased concentrations ofknown allergens.
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