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AsthmaAsthma
MBBS.weebly.comMBBS.weebly.com
Beethoven Ludwig van
He was a patient with asthma, and died in 1827.
Teresa Deng
She was also a patient with asthma, and died in 1995.
哮喘造成的负担:13-14岁儿童喘息的发病率
> 20%> 20%
ISAAC, Eur Respir J, 1998
5 to < 10%5 to < 10%10 to < 20%10 to < 20% < 5%< 5%
Asthma incidence of children
G INA
G INA
lobal
itiative for
sthma
lobal
itiative for
sthma
Asthma (GINA Workshop) Asthma (GINA Workshop)
Topics:Topics: DefinitionDefinition EpidemiologyEpidemiology Risk FactorsRisk Factors Pathogenesis & MechanismsPathogenesis & Mechanisms Diagnosis and ClassificationDiagnosis and ClassificationSix Part Asthma Management PlanSix Part Asthma Management Plan
Topics:Topics: DefinitionDefinition EpidemiologyEpidemiology Risk FactorsRisk Factors Pathogenesis & MechanismsPathogenesis & Mechanisms Diagnosis and ClassificationDiagnosis and ClassificationSix Part Asthma Management PlanSix Part Asthma Management Plan
Definition of AsthmaDefinition of Asthma
Asthma is Asthma is a chronic inflammatory disordera chronic inflammatory disorder of the of the airways in which many cells and cellular elements play airways in which many cells and cellular elements play a role a role
Chronic inflammation causes an associated increase in Chronic inflammation causes an associated increase in airway hyperresponsivenessairway hyperresponsiveness that leads to recurrent that leads to recurrent episodes of wheezing, breathlessness, chest tightness, episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early and coughing, particularly at night or in the early morning morning
These episodes are usually associated with These episodes are usually associated with widespread but variable widespread but variable airflow obstructionairflow obstruction that is often that is often reversiblereversible either spontaneously or with treatment either spontaneously or with treatment
Asthma is Asthma is a chronic inflammatory disordera chronic inflammatory disorder of the of the airways in which many cells and cellular elements play airways in which many cells and cellular elements play a role a role
Chronic inflammation causes an associated increase in Chronic inflammation causes an associated increase in airway hyperresponsivenessairway hyperresponsiveness that leads to recurrent that leads to recurrent episodes of wheezing, breathlessness, chest tightness, episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early and coughing, particularly at night or in the early morning morning
These episodes are usually associated with These episodes are usually associated with widespread but variable widespread but variable airflow obstructionairflow obstruction that is often that is often reversiblereversible either spontaneously or with treatment either spontaneously or with treatment
EpidemiologyEpidemiologyEpidemiologyEpidemiology
Asthma is one of the most common chronic Asthma is one of the most common chronic diseases worldwide —1600 millions patients diseases worldwide —1600 millions patients suffered from asthmasuffered from asthma
Prevalence increasing in many countries, Prevalence increasing in many countries, especially in children — 1~4% in adult, 3~5% in especially in children — 1~4% in adult, 3~5% in children in Chinachildren in China
A major cause of school/work absenceA major cause of school/work absence
An overall increase in severity of asthma An overall increase in severity of asthma increases the pool of patients at risk for deathincreases the pool of patients at risk for death
Asthma is one of the most common chronic Asthma is one of the most common chronic diseases worldwide —1600 millions patients diseases worldwide —1600 millions patients suffered from asthmasuffered from asthma
Prevalence increasing in many countries, Prevalence increasing in many countries, especially in children — 1~4% in adult, 3~5% in especially in children — 1~4% in adult, 3~5% in children in Chinachildren in China
A major cause of school/work absenceA major cause of school/work absence
An overall increase in severity of asthma An overall increase in severity of asthma increases the pool of patients at risk for deathincreases the pool of patients at risk for death
Worldwide Worldwide Variation in Variation in Prevalence of Prevalence of Asthma Asthma SymptomsSymptoms
International Study of International Study of Asthma and Allergies Asthma and Allergies in Children (ISAAC)in Children (ISAAC)
Worldwide Worldwide Variation in Variation in Prevalence of Prevalence of Asthma Asthma SymptomsSymptoms
International Study of International Study of Asthma and Allergies Asthma and Allergies in Children (ISAAC)in Children (ISAAC)
Lancet 1998;351:1225
Increasing Prevalence of Asthma in Increasing Prevalence of Asthma in Children/AdolescentsChildren/AdolescentsIncreasing Prevalence of Asthma in Increasing Prevalence of Asthma in Children/AdolescentsChildren/Adolescents
00 55 1010 1515 2020 2525 3030 3535
19921992198219821989198919751975199219921982198219941994198919891992199219821982199219921982198219911991197919791989198919661966FinlandFinland
(Haahtela (Haahtela et alet al))
SwedenSweden(Aberg (Aberg et alet al))
JapanJapan(Nakagomi (Nakagomi etet al al))
ScotlandScotland(Rona (Rona et alet al))
UKUK(Omran (Omran et alet al))
USAUSA(NHIS)(NHIS)
New ZealandNew Zealand(Shaw (Shaw et alet al))
AustraliaAustralia(Peat (Peat et alet al))
{{
Prevalence (%)Prevalence (%)
{{
{{{{{{{{{{{{
7070
6060
5050
4040
3030
20208585 8686 8787 8888 8989 9090 9191 9292 9393 9494
Rate/1,000 PersonsRate/1,000 Persons
YearYear
<18
18-44
45-64
65+
Total (All Ages)
<18
18-44
45-64
65+
Total (All Ages)
Age (years)Age (years)
Trends in Prevalence of AsthmaTrends in Prevalence of Asthma By Age, U.S., 1985-1996By Age, U.S., 1985-1996
9595 9696
8080
Risk Factors for AsthmaRisk Factors for AsthmaRisk Factors for AsthmaRisk Factors for Asthma
Host factors: predispose individuals to, or protect them from, developing asthma
Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist
Host factors: predispose individuals to, or protect them from, developing asthma
Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist
Risk Factors that Lead to Risk Factors that Lead to Asthma DevelopmentAsthma Development
Host Factors Genetic predisposition Atopy Airway hyper- responsiveness Gender Race
Host Factors Genetic predisposition Atopy Airway hyper- responsiveness Gender Race
Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Parasitic infections Socioeconomic factors Family size Diet and drugs Obesity
Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Parasitic infections Socioeconomic factors Family size Diet and drugs Obesity
Factors that Exacerbate AsthmaFactors that Exacerbate AsthmaFactors that Exacerbate AsthmaFactors that Exacerbate Asthma
AllergensAllergens Air PollutantsAir Pollutants Respiratory infectionsRespiratory infections Exercise and hyperventilationExercise and hyperventilation Weather changesWeather changes Sulfur dioxideSulfur dioxide Food, additives, drugsFood, additives, drugs
AllergensAllergens Air PollutantsAir Pollutants Respiratory infectionsRespiratory infections Exercise and hyperventilationExercise and hyperventilation Weather changesWeather changes Sulfur dioxideSulfur dioxide Food, additives, drugsFood, additives, drugs
Mechanisms Underlying the Mechanisms Underlying the Definition of AsthmaDefinition of AsthmaMechanisms Underlying the Mechanisms Underlying the Definition of AsthmaDefinition of Asthma
Risk FactorsRisk Factors(for development of asthma)(for development of asthma)
Risk FactorsRisk Factors(for development of asthma)(for development of asthma)
INFLAMMATIONINFLAMMATIONINFLAMMATIONINFLAMMATION
AirwayAirway
HyperresponsivenessHyperresponsiveness
AirwayAirway
HyperresponsivenessHyperresponsiveness Airflow ObstructionAirflow ObstructionAirflow ObstructionAirflow Obstruction
Risk FactorsRisk Factors(for exacerbations)(for exacerbations) Risk FactorsRisk Factors(for exacerbations)(for exacerbations)
SymptomsSymptomsSymptomsSymptoms
Antigen PresentingCell
TH2
MastCell
Mediators
SurvivalActivation
AttractionAdhesion
Priming
Eosinophil
Endothelium
Ag:
Production
M I nman
BronchoconstrictionHyperresponsiveness
Asthma DiagnosisAsthma Diagnosis
History and patterns of symptoms
Physical examination
Measurements of lung function
Measurements of allergic status to identify risk factors
History and patterns of symptoms
Physical examination
Measurements of lung function
Measurements of allergic status to identify risk factors
Clinical Manifestation of AsthmaClinical Manifestation of AsthmaClinical Manifestation of AsthmaClinical Manifestation of Asthma
Recurrent episodes of wheezingRecurrent episodes of wheezing Troublesome cough at nightTroublesome cough at night Cough or wheeze after exerciseCough or wheeze after exercise Cough, wheeze or chest tightness after Cough, wheeze or chest tightness after
exposure to airborne allergens or exposure to airborne allergens or pollutantspollutants
Colds “go to the chest” or take more than Colds “go to the chest” or take more than 10 days to clear10 days to clear
Recurrent episodes of wheezingRecurrent episodes of wheezing Troublesome cough at nightTroublesome cough at night Cough or wheeze after exerciseCough or wheeze after exercise Cough, wheeze or chest tightness after Cough, wheeze or chest tightness after
exposure to airborne allergens or exposure to airborne allergens or pollutantspollutants
Colds “go to the chest” or take more than Colds “go to the chest” or take more than 10 days to clear10 days to clear
Physical ExaminationPhysical ExaminationPhysical ExaminationPhysical Examination
Because of variable symptoms, the physical Because of variable symptoms, the physical examination of the respiratory system may be examination of the respiratory system may be normal. normal.
Dyspnea, airflow limitation (wheeze), and Dyspnea, airflow limitation (wheeze), and hyperinflation are likely to be present if hyperinflation are likely to be present if patients are examined during symptomatic patients are examined during symptomatic periods.periods.
Silent chest, cyanosis, drowsiness, difficult Silent chest, cyanosis, drowsiness, difficult speaking, tachycardia and use of accessory speaking, tachycardia and use of accessory muscles in severe asthma. muscles in severe asthma.
Measurement of Lung FunctionMeasurement of Lung Function
Spirometry: FEV1, FVC,FEV1/FVC
Bronchial Provocation Test (BPT)
FEV1>70% predicted
Histamine,methacholine, or exercise
FEV1↓≥20% at a dose of ≤16mg/ml
Spirometry: FEV1, FVC,FEV1/FVC
Bronchial Provocation Test (BPT)
FEV1>70% predicted
Histamine,methacholine, or exercise
FEV1↓≥20% at a dose of ≤16mg/ml
Measurement of Lung FunctionMeasurement of Lung Function
Bronchial Dilation Test (BDT)
FEV1<70% predicted
FEV1↑≥12% and 200ml, FVC↑≥15% and 200ml, after inhaling a short-acting bronchodilator
Typical Spirometric (FEV1) TracingsTypical Spirometric (FEV1) Tracings
11Time (sec)Time (sec)
22 33 44 55
FEV1FEV1
VolumeVolume
Normal SubjectNormal Subject
Asthmatic (After Bronchodilator)Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)Asthmatic (Before Bronchodilator)
Note: Each FEVNote: Each FEV11 curve represents the highest of three repeat measurements curve represents the highest of three repeat measurements
Measurement of Lung FunctionMeasurement of Lung Function
Peak Expiratory Flow (PEF) and PEF Variation.
PEF Variation ≥20%
Peak Expiratory Flow (PEF) and PEF Variation.
PEF Variation ≥20%
PE
F (
L/m
in)
300
400
500
600
700
800
Days70 14
Lowest morning PEF (570)
Highest PEF (670)
Morning PEFEvening PEF
Minimum morning PEF ( % recent best): 570/670 = 85%(From Reddel, H.K. et al. 1995)
Arterial blood gas
• Respiratory alkalosis, during a mile asthma exacerbation
• Respiratory acidosis and hypoxemia, during a severe asthma exacerbation
Measurement of Allergic StatusMeasurement of Allergic Status
Skin test
Measurement of specific IgE in serum
Skin test
Measurement of specific IgE in serum
Standards of DiagnosisStandards of Diagnosis
Recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, Recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning particularly at night or in the early morning
Dyspnea, airflow limitation (wheeze), and hyperinflation are likely to be present if Dyspnea, airflow limitation (wheeze), and hyperinflation are likely to be present if patients are examined during symptomatic periodspatients are examined during symptomatic periods
These episodes and symptoms are often reversible either spontaneously or with These episodes and symptoms are often reversible either spontaneously or with treatmenttreatment
Exclude other diseases that manifested with similar symptomsExclude other diseases that manifested with similar symptoms
At least one or more of the following three: At least one or more of the following three:
Bronchial Provocation Test (BPT)Bronchial Provocation Test (BPT)
Bronchial Dilation Test (BDT) Bronchial Dilation Test (BDT)
Peak Expiratory Flow (PEF) VariationPeak Expiratory Flow (PEF) Variation
Recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, Recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning particularly at night or in the early morning
Dyspnea, airflow limitation (wheeze), and hyperinflation are likely to be present if Dyspnea, airflow limitation (wheeze), and hyperinflation are likely to be present if patients are examined during symptomatic periodspatients are examined during symptomatic periods
These episodes and symptoms are often reversible either spontaneously or with These episodes and symptoms are often reversible either spontaneously or with treatmenttreatment
Exclude other diseases that manifested with similar symptomsExclude other diseases that manifested with similar symptoms
At least one or more of the following three: At least one or more of the following three:
Bronchial Provocation Test (BPT)Bronchial Provocation Test (BPT)
Bronchial Dilation Test (BDT) Bronchial Dilation Test (BDT)
Peak Expiratory Flow (PEF) VariationPeak Expiratory Flow (PEF) Variation
Differential DiagnosisDifferential Diagnosis
Congestive Heart Failure
Pseudoasthma caused by vocal cord dysfunction
Chronic bronchitis & COPD
Lung cancer
Congestive Heart Failure
Pseudoasthma caused by vocal cord dysfunction
Chronic bronchitis & COPD
Lung cancer
Definition of COPDDefinition of COPD
Chronic obstructive pulmonary disease(COPD) is a disease state characterized by airflow limitation that is not fullyreversible. The airflow limitation is usuallyboth progressive and associated with anabnormal inflammatory response of thelungs to noxious particles or gases.
Chronic obstructive pulmonary disease(COPD) is a disease state characterized by airflow limitation that is not fullyreversible. The airflow limitation is usuallyboth progressive and associated with anabnormal inflammatory response of thelungs to noxious particles or gases.
GOLD 2004
Pointers that differentiate asthma from COPD
Pointers that differentiate asthma from COPD
COPD Asthma
History
Smoker or ex-smoker Nearly all Possibly
Symptoms under age 45 Uncommon Often
Chronic productive cough Common Uncommon
Breathlessness Persistent and progressive Variable
Winter bronchitis Common Uncommon
Investigations
Serial PEF Obstructive picture May be normal Day to day and diurnal variation
Reversibility testing Minimal variationUsually<15% or 200mlchange
Usually>15% or 200ml change
Classification of SeverityClassification of Severity
Asthma severity is classified by the presence of clinical features before treatment is started and/or by the amount of daily medication required for optimal treatment
Asthma severity is classified by the presence of clinical features before treatment is started and/or by the amount of daily medication required for optimal treatment
Classification of Severity of Classification of Severity of chronic stable asthmachronic stable asthma
CLASSIFY SEVERITYClinical Features Before Treatment
SymptomsSymptoms NocturnalNocturnalSymptomsSymptoms
FEVFEV1 1 or PEFor PEF
STEP 4STEP 4
Severe Severe PersistentPersistent
STEP 3STEP 3
Moderate Moderate PersistentPersistent
STEP 2STEP 2
Mild Mild PersistentPersistent
STEP 1STEP 1
IntermittentIntermittent
ContinuousContinuous
Limited physical Limited physical activityactivity
DailyDailyAttacks affect activityAttacks affect activity
> 1 time a week > 1 time a week but < 1 time a day but < 1 time a day
< 1 time a week< 1 time a week
Asymptomatic Asymptomatic and normal PEF and normal PEF between attacksbetween attacks
FrequentFrequent
> 1 time a week> 1 time a week
> 2 times a month> 2 times a month
2 times a 2 times a monthmonth2 times a 2 times a monthmonth
60% predicted60% predicted
Variability > 30%Variability > 30%
60 - 80% predicted 60 - 80% predicted
Variability > 30%Variability > 30%
80% predicted80% predicted
Variability 20 - 30%Variability 20 - 30%
80% predicted80% predicted
Variability < 20%Variability < 20%
The presence of one feature of severity is sufficient to place patient in that category.The presence of one feature of severity is sufficient to place patient in that category.
Classification of SeverityClassification of Severity
Classification of severity of asthma exacerbation
breathlessness RR HR PEF/FEV1 PaO2 PaCO2 SaO2
Mild With activity ↑ <100 >80% normal <45 >95
Moderate With talking ↑ 100~120 60-80% 60~80 <45 91~95
Severe At rest >30 >120 <60% <60 >45 <91
Impending respiratory failure
Consciousness Relative bradycardia
<60 >45 <91
Six-Part Asthma Management Six-Part Asthma Management ProgramProgram
1. Educate patients to develop a partnership in asthma management
2. Assess and monitor asthma severity with symptom reports and measures of lung function as much as possible
3. Avoid exposure to risk factors
4. Establish medication plans for chronic management in children and adults
5. Establish individual plans for managing exacerbations
6. Provide regular follow-up care
1. Educate patients to develop a partnership in asthma management
2. Assess and monitor asthma severity with symptom reports and measures of lung function as much as possible
3. Avoid exposure to risk factors
4. Establish medication plans for chronic management in children and adults
5. Establish individual plans for managing exacerbations
6. Provide regular follow-up care
Six-part Asthma Management ProgramSix-part Asthma Management Program
Goals of Long-term ManagementGoals of Long-term Management
Achieve and maintain control of symptoms Prevent asthma episodes or attacks Maintain pulmonary function as close to normal
levels as possible Maintain normal activity levels, including
exercise Avoid adverse effects from asthma medications Prevent development of irreversible airflow
limitation Prevent asthma mortality
Achieve and maintain control of symptoms Prevent asthma episodes or attacks Maintain pulmonary function as close to normal
levels as possible Maintain normal activity levels, including
exercise Avoid adverse effects from asthma medications Prevent development of irreversible airflow
limitation Prevent asthma mortality
Six-part Asthma Management ProgramSix-part Asthma Management Program
Control of AsthmaControl of Asthma
Minimal (ideally no) chronic symptoms Minimal (infrequent) exacerbations No emergency visits Minimal (ideally no) need for “as needed” use of
β2-agonist
No limitations on activities, including exercise PEF circadian variation of less than 20% (Near) normal PEF Minimal (or no) adverse effects from medicine
Minimal (ideally no) chronic symptoms Minimal (infrequent) exacerbations No emergency visits Minimal (ideally no) need for “as needed” use of
β2-agonist
No limitations on activities, including exercise PEF circadian variation of less than 20% (Near) normal PEF Minimal (or no) adverse effects from medicine
Six-Part Asthma Management Six-Part Asthma Management ProgramProgram
The most effective management is to prevent airway inflammation by eliminating the causal factors
Asthma can be effectively controlled in most patients, although it can not be cured
The major factors contributing to asthma morbidity and mortality are under-diagnosis and inappropriate treatment
Any asthma more severe than intermittent asthma is more effectively controlled by treatment to suppress and reverse airway inflammation than by treatment only of acute bronchoconstriction and symptoms
The most effective management is to prevent airway inflammation by eliminating the causal factors
Asthma can be effectively controlled in most patients, although it can not be cured
The major factors contributing to asthma morbidity and mortality are under-diagnosis and inappropriate treatment
Any asthma more severe than intermittent asthma is more effectively controlled by treatment to suppress and reverse airway inflammation than by treatment only of acute bronchoconstriction and symptoms
.
Six-part Asthma Management Program
Part 1: Educate Patients to Develop a Partnership
Six-part Asthma Management Program
Part 1: Educate Patients to Develop a Partnership
Educate continually
Include 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
Educate continually
Include 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
Six-part Asthma Management ProgramPart 2: Assess and Monitor Asthma Severity with Symptom Reports and Measures of Lung Function
Six-part Asthma Management ProgramPart 2: Assess and Monitor Asthma Severity with Symptom Reports and Measures of Lung Function
Symptom reports Use of reliever medication Nighttime symptoms Activity limitations
Spirometry for initial assessment. Peak Expiratory Flow for follow-up: Assess severity Assess response to therapy
PEF monitoring at home Important for those with poor perception of symptoms Daily measurement recorded in a diary Assesses the severity and predicts worsening Guides the use of a zone system for asthma self-management
Arterial blood gas for severe exacerbations
Symptom reports Use of reliever medication Nighttime symptoms Activity limitations
Spirometry for initial assessment. Peak Expiratory Flow for follow-up: Assess severity Assess response to therapy
PEF monitoring at home Important for those with poor perception of symptoms Daily measurement recorded in a diary Assesses the severity and predicts worsening Guides the use of a zone system for asthma self-management
Arterial blood gas for severe exacerbations
Six-part Asthma Management Program
Part 3: Avoid Exposure to Risk Factors
Six-part Asthma Management Program
Part 3: Avoid Exposure to Risk Factors
Reduce exposure to indoor allergensReduce exposure to indoor allergens Avoid tobacco smokeAvoid tobacco smoke Avoid vehicle emissionAvoid vehicle emission Identify irritants in the workplaceIdentify irritants in the workplace Explore role of infections on asthma Explore role of infections on asthma
development, especially in children and development, especially in children and young infantsyoung infants
Reduce exposure to indoor allergensReduce exposure to indoor allergens Avoid tobacco smokeAvoid tobacco smoke Avoid vehicle emissionAvoid vehicle emission Identify irritants in the workplaceIdentify irritants in the workplace Explore role of infections on asthma Explore role of infections on asthma
development, especially in children and development, especially in children and young infantsyoung infants
Six-part Asthma Management Program
Part 4: Establish Medication Plans for Long-Term Asthma Management
Six-part Asthma Management Program
Part 4: Establish Medication Plans for Long-Term Asthma Management
A stepwise approach to pharmacological A stepwise approach to pharmacological therapy is recommended therapy is recommended
The aim is to accomplish the goals of The aim is to accomplish the goals of therapy with the least possible medicationtherapy with the least possible medication
Although in many countries traditional Although in many countries traditional methods of healing are used, their efficacy methods of healing are used, their efficacy has not yet been established and their use has not yet been established and their use can therefore not be recommendedcan therefore not be recommended
A stepwise approach to pharmacological A stepwise approach to pharmacological therapy is recommended therapy is recommended
The aim is to accomplish the goals of The aim is to accomplish the goals of therapy with the least possible medicationtherapy with the least possible medication
Although in many countries traditional Although in many countries traditional methods of healing are used, their efficacy methods of healing are used, their efficacy has not yet been established and their use has not yet been established and their use can therefore not be recommendedcan therefore not be recommended
Part 4: Long-term Asthma Management
Stepwise Approach to Asthma TherapyPart 4: Long-term Asthma Management
Stepwise Approach to Asthma Therapy
The choice of treatment should be guided by: Severity of the patient’s asthma Patient’s current treatment Pharmacological properties and availability of
the various forms of asthma treatment Economic considerations
Cultural preferences and differing health caresystems need to be considered..
The choice of treatment should be guided by: Severity of the patient’s asthma Patient’s current treatment Pharmacological properties and availability of
the various forms of asthma treatment Economic considerations
Cultural preferences and differing health caresystems need to be considered..
Part 4: Long-term Asthma Management
Pharmacologic TherapyPart 4: Long-term Asthma Management
Pharmacologic Therapy
Controller Medications: Inhaled glucocorticosteroids Systemic glucocorticosteroids Cromones Methylxanthines Long-acting inhaled β2-agonists Long-acting oral β2-agonists Leukotriene modifiers
Controller Medications: Inhaled glucocorticosteroids Systemic glucocorticosteroids Cromones Methylxanthines Long-acting inhaled β2-agonists Long-acting oral β2-agonists Leukotriene modifiers
Part 4: Long-term Asthma Management
Pharmacologic TherapyPart 4: Long-term Asthma Management
Pharmacologic Therapy
Reliever Medications:
Rapid-acting inhaled β2-agonists
Systemic glucocorticosteroids
Anticholinergics
Methylxanthines
Short-acting oral β2-agonists
Reliever Medications:
Rapid-acting inhaled β2-agonists
Systemic glucocorticosteroids
Anticholinergics
Methylxanthines
Short-acting oral β2-agonists
© GSK 2002
© GSK 2002
© GSK 2002
Part 4: Long-term Asthma Management
Stepwise Approach to Asthma Therapy - Adults
Part 4: Long-term Asthma Management
Stepwise Approach to Asthma Therapy - Adults
Reliever: Rapid-acting inhaled β2-agonist prn
Controller: Daily inhaledcorticosteroid
Controller: Daily inhaled
corticosteroid Daily long-
acting inhaled β2-agonist
Controller: Daily inhaled
corticosteroid Daily long –
acting inhaled β2-agonist
plus (if needed)
When asthma is controlled, reduce therapy
Monitor
STEP 1:STEP 1:IntermittentIntermittent
STEP 2:STEP 2:Mild PersistentMild Persistent
STEP 3:STEP 3: Moderate Moderate PersistentPersistent
STEP 3:STEP 3: Moderate Moderate PersistentPersistent
STEP 4:STEP 4:Severe Severe
PersistentPersistentSTEP DownSTEP DownSTEP DownSTEP Down
Outcome: Asthma Control Outcome: Best Possible Results
Alternative controller and reliever medications may be considered (see text). Alternative controller and reliever medications may be considered (see text).
Controller:None
-Theophylline-SR -Leukotriene -Long-acting inhaled β2- agonist -Oral corticosteroid
Stepwise Approach to Asthma Therapy: AdultsStepwise Approach to Asthma Therapy: Adults
Step 1: Intermittent Asthma Step 1: Intermittent Asthma
None requiredNone required Rapid-acting inhaled 2-agonistfor symptoms (but < once a week) Rapid-acting inhaled 2-agonist,cromone, or leukotriene modifier before exercise or exposure toallergen
Continuously review medication technique, compliance and environmental controlContinuously review medication technique, compliance and environmental control Review treatment every three months.Review treatment every three months. Step upStep up if control is not achieved; if control is not achieved; step downstep down if control is sustained for at least 3 months if control is sustained for at least 3 months Preferred treatments are in bold printPreferred treatments are in bold print
Daily Controller Medications
Reliever Medications
Inhaled glucocorticosteroid (< 500 μg BDP or equivalent)
Other options (order by cost): sustained-release theophylline, or Cromone, or leukotriene modifier
Rapid-acting inhaled 2-agonistfor symptoms (but < 3-4 times/day)
Other options: inhaled anticholinergic, or short-acting oral 2-agonist, or short-acting theophylline
Continuously review medication technique, compliance and environmental control.Continuously review medication technique, compliance and environmental control. Review treatment every three monthsReview treatment every three months Step upStep up if control is not achieved; if control is not achieved; Step downStep down if control is sustained for at least 3 months if control is sustained for at least 3 months Preferred treatments are in bold printPreferred treatments are in bold print
Stepwise Approach to Asthma Therapy: AdultsStepwise Approach to Asthma Therapy: Adults
Step 2: Mild Persistent AsthmaStep 2: Mild Persistent Asthma
Daily Controller Medications
Reliever Medications
Inhaled glucocorticosteroid, (200 – 500 μg BDP or
equivalent) plus long-acting inhaled β2agonistOther options (order by cost): Inhaled glucocorticosteroid (500 – 1000 μg BDP
equivalent) plus sustained-release theophylline, or Inhaled glucocorticosteroid (500 – 1000 μg BDP
equivalent) plus long-acting inhaled β2- agonist, or inhaled glucocorticosteroid at higher doses (> 1000 μg BDP equivalent), or Inhaled glucocorticosteroid (500 – 1000 μg BDP
equivalent) plus leukotriene modifier
Rapid-acting inhaled 2-agonist for symptoms (but < 3 - 4 times/day)
Other options: inhaled anticholinergic or short-acting oral 2-agonist or short-acting theophylline
Continuously review medication technique, compliance and environmental control.Continuously review medication technique, compliance and environmental control. Review treatment every three months.Review treatment every three months. Step upStep up if control is not achieved; if control is not achieved; Step downStep down if control is sustained for at least 3 months. if control is sustained for at least 3 months. Preferred treatments are in bold print.Preferred treatments are in bold print.
Stepwise Approach to Asthma Therapy: AdultsStepwise Approach to Asthma Therapy: Adults
Step 3: Moderate Persistent AsthmaStep 3: Moderate Persistent Asthma
Daily Controller Medications
Reliever Medications
Inhaled glucocorticosteroid, (> 1000 μg
BDP or equivalent) plus long-actinginhaled β2agonist
plus one or more of the following, ifneeded (order by cost): sustained-release theophylline, or leukotriene modifier or oral glucocorticosteroid
Rapid-acting inhaled 2-agonist for symptoms (but < 3-4 times/day)
Other options: inhaled anticholinergic or short-acting oral 2-agonist or short-acting theophylline
Continuously review medication technique, compliance and environmental control.Continuously review medication technique, compliance and environmental control. Review treatment every three months.Review treatment every three months. Step upStep up if control is not achieved; if control is not achieved; Step downStep down if control is sustained for at least 3 months. if control is sustained for at least 3 months. Preferred treatments are in bold print.Preferred treatments are in bold print.
Stepwise Approach to Asthma Therapy: AdultsStepwise Approach to Asthma Therapy: Adults
Step 4: Severe Persistent AsthmaStep 4: Severe Persistent Asthma
Daily Controller Medications
Reliever Medications
Six-part Asthma Management Program
Part 5: Establish Plans for Managing Exacerbations
Six-part Asthma Management Program
Part 5: Establish Plans for Managing Exacerbations
Primary therapies for exacerbations:• Repetitive administration of rapid-acting
inhaled β2-agonist• Early introduction of systemic
glucocorticosteroids• Oxygen supplementationClosely monitor response to treatmentwith serial measures of lung function
Primary therapies for exacerbations:• Repetitive administration of rapid-acting
inhaled β2-agonist• Early introduction of systemic
glucocorticosteroids• Oxygen supplementationClosely monitor response to treatmentwith serial measures of lung function
Six-part Asthma Management Program
Part 5: Managing Severe Asthma Exacerbations
Six-part Asthma Management Program
Part 5: Managing Severe Asthma Exacerbations
Severe exacerbations are life-threatening medical emergencies
Care must be expeditious and treatment is often most safely undertaken in a hospital or hospital-based emergency department
Severe exacerbations are life-threatening medical emergencies
Care must be expeditious and treatment is often most safely undertaken in a hospital or hospital-based emergency department
Emergency Department Management
Acute AsthmaEmergency Department Management
Acute Asthma
Good Response
Observe for at least 1 hour
If Stable, Discharge to
Home
Initial AssessmentHistory, Physical Examination, PEF or FEV1
Initial TherapyBronchodilators; O2 if needed
Incomplete/Poor Response
Add Systemic Glucocorticosteroids
Good Response
Discharge
Poor Response
Admit to Hospital
Respiratory Failure
Admit to ICU
Six-part Asthma Management Program
Part 6: Provide Regular Follow-up Care
Six-part Asthma Management Program
Part 6: Provide Regular Follow-up Care
Continual monitoring is essential to assure thattherapeutic goals are met. Frequent follow-up visitsare necessary to review: Home PEF and symptom records Techniques in use of medications Risk factors and their controlOnce asthma control is established, follow-upvisits should be scheduled (at 1 to 6 month intervalsas appropriate)
Continual monitoring is essential to assure thattherapeutic goals are met. Frequent follow-up visitsare necessary to review: Home PEF and symptom records Techniques in use of medications Risk factors and their controlOnce asthma control is established, follow-upvisits should be scheduled (at 1 to 6 month intervalsas appropriate)
Six-part Asthma Management Program: SummarySix-part Asthma Management Program: Summary
Asthma can be effectively controlled, although it Asthma can be effectively controlled, although it cannot be curedcannot be cured
Effective asthma management programs include Effective asthma management programs include education, objective measures of lung function, education, objective measures of lung function, environmental control, and pharmacologic therapyenvironmental control, and pharmacologic therapy
A stepwise approach to pharmacologic therapy is A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the recommended. The aim is to accomplish the goals of therapy with the least possible medicationgoals of therapy with the least possible medication
Asthma can be effectively controlled, although it Asthma can be effectively controlled, although it cannot be curedcannot be cured
Effective asthma management programs include Effective asthma management programs include education, objective measures of lung function, education, objective measures of lung function, environmental control, and pharmacologic therapyenvironmental control, and pharmacologic therapy
A stepwise approach to pharmacologic therapy is A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the recommended. The aim is to accomplish the goals of therapy with the least possible medicationgoals of therapy with the least possible medication
Six-part Asthma Management Program: Summary (continued)
Six-part Asthma Management Program: Summary (continued)
Anything more than mild, occasional asthma is Anything more than mild, occasional asthma is more effectively controlled by suppressing more effectively controlled by suppressing inflammation than by only treating acute inflammation than by only treating acute bronchospasmbronchospasm
The availability of varying forms of treatment, The availability of varying forms of treatment, cultural preferences, and differing health care cultural preferences, and differing health care systems need to be considered systems need to be considered
Anything more than mild, occasional asthma is Anything more than mild, occasional asthma is more effectively controlled by suppressing more effectively controlled by suppressing inflammation than by only treating acute inflammation than by only treating acute bronchospasmbronchospasm
The availability of varying forms of treatment, The availability of varying forms of treatment, cultural preferences, and differing health care cultural preferences, and differing health care systems need to be considered systems need to be considered
Thank you !!Thank you !!