Dr Hanan abbas Assistant professor of family Medicine

BRONCHIAL ASTHMA

 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 for

asthma of various severity

Epidemiology:
According to epidemiological studies asthma

affects 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

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

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

The Underlying Mechanism

Risk Factors (for development of asthma)

INFLAMMATION

Airway Hyper-responsiveness

Airflow Limitation Symptoms- (shortness Risk Factors of breath, cough, (for exacerbations) wheeze)

Definition

Chronic inflammatory disorder of the airways , In susceptible

individuals, this inflammation causes recurrent episodes of wheezing, 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, or with treatment.

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 .
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Some allergens which may cause asthma

House-dust mites which live in carpets, mattresses and upholstered furniture Spittle, excrements, hair and fur of domestic animals

Plant pollen

Dust of book depositories

Pharmacological agents (enzymes, antibiotics, vaccines, serums)

Food components (stabilizers, genetically modified products)

Signs & Symptoms:

Shortness of breath . Tightness of chest . Excessive coughing or a cough that keeps you awake at

night . Feeling very tired or weak when exercising. Wheezing or coughing after exercise . Decreases or changes in lung function as measured on 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

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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

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

Peak expiratory flow (PEF) Meters

Allows the patient to assess the status of his or her asthma

PEF can be measured with the help of individual devices peak flow meters

Peak flow Chart

People with moderate or severe asthma should take readings Every morning and evening After an exacerbation Before inhaling certain medications

Source: What You and Your Family Can Do About Asthma by the Global Initiative For Asthma Created and funded by NIH/NHLBI

Asthma severity classification

Clinical course, severity Intermittent
Mild persistent

Daytime asthma symptoms

< 1 /week

Nighttime awakenings 2 and < /month

FEV1, PEF >80% predicted. Daily variability < 20% >80% predicted. Daily variability 20-30% > 60 but < 80% predicted. Variability>30%.

1 /week but not daily

> 2 /month

Moderate persistent

Daily

> 1 /week

Severe persistent

Persistent, which limit normal activity

Daily

<60% predicted. Variability > 30%.

Classification of asthma severity 12 years of age*

Components of severity Impairment Symptoms

Intermittent 2 days per week

Persistent -mild >2 days per week, but not daily 3 to 4 times per month

Persistent-moderate Daily

Persistent

-severe

Throughout the day

Nighttime awakenings

2 times per month

> Once per week, but not nightly

Often 7 times per week

Short-acting beta agonist 2 days per week use for symptom control (not for prevention of exercise-induced bronchospasm)

>2 days per week, Daily but not more than once per day

Several times per day

Interference with normal activity Lung function

None

Minor limitation

Some limitation

Extremely limited

Normal FEV1 between exacerbations; FEV1 >80 percent of predicted; FEV1/FVC normal

FEV1 80 percent of predicted; FEV1/FVC normal

FEV1 > 60 percent but < 80 FEV1 < 60 percent of percent of predicted; predicted; FEV1/FVC FEV1/FVC reduced 5 reduced >5 percent percent

Risk Exacerbations requiring oral systemic corticosteroids 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 for patients in any severity category; relative annual risk of exacerbations may be related to FEV1

In recommendations of Global Initiative for Asthma (GINA) asthma is classified on the base of control assessment and is 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 of asthma symptoms; need in bronchodilators administration 2 /week; the absence of asthma exacerbations; normal or near normal lung function parameters.

Asthma complications

The complications of asthma exacerbations are: pneumothorax lung atelectasis pneumonia acute or subacute cor pulmonale asthmatic status.

Persistent asthma causes: fibrosing bronchitis small bronchi deformation and obliteration emphysema pneumosclerosis, chronic respiratory failure chronic cor pulmonale.

Asthma in childhood leads to growth inhibition and thoracic deformation.

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

Classification of asthma control ( 12 years of age)* Components of control

Well controlled Not well controlled Very poorly controlled Impairment Symptoms 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 week Interference with normal None Some limitation Extremely limited activity Short-acting beta agonist use 2 days per week > 2 days per week Several times per day for symptom control (not for prevention of exerciseinduced bronchospasm) FEV1 or peak flow > 80 percent of 60 to 80 percent of < 60 percent of predicted/personal best predicted/personal best predicted/personal best Risk Exacerbations requiring oral 0 to 1 time per year 2 times per year 2 times per year systemic corticosteroids Consider severity and interval since last exacerbation Progressive loss of lung Evaluation requires long-term follow-up care function Treatment-related adverse Medication adverse effects can vary in intensity from none to very troublesome and effects worrisome; the level of intensity does not correlate to specific levels of control, but should be considered in the overall assessment of risk Recommended action for Maintain current step; regular Step up one step and Consider short course of oral treatment (see Figure 1 for follow-up every one to six reevaluate in two to six systemic corticosteroids; step treatment steps) months to maintain control; weeks; for adverse effects, up one to two steps, and consider step down if well consider alternative reevaluate in two weeks; for controlled for at least three treatment options adverse effects, consider months alternative treatment options

Asthma Control
Levels of Asthma Control
Characteristics Controlled
(All of the following) Day time symptoms Limitations of activity Nocturnal symptoms/ awakening Need for relievers Lung function(PEF or FEV1) Exacerbation None (twice or less/week) None None

Partly Controlled
(any measure present in any week)

Uncontrolled

> Twice /w Any Any

Three or more of partly controlled asthma present in any week

None (twice or less/week) Normal None

> Twice / week < 80% of predicted One or per year One in any week

Classification of asthma control ( 12 years of age)* Components of control

Well controlled Not well controlled Very poorly controlled Impairment Symptoms 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 week Interference with normal None Some limitation Extremely limited activity Short-acting beta agonist use 2 days per week > 2 days per week Several times per day for symptom control (not for prevention of exerciseinduced bronchospasm) FEV1 or peak flow > 80 percent of 60 to 80 percent of < 60 percent of predicted/personal best predicted/personal best predicted/personal best Risk Exacerbations requiring oral 0 to 1 time per year 2 times per year 2 times per year systemic corticosteroids Consider severity and interval since last exacerbation Progressive loss of lung Evaluation requires long-term follow-up care function Treatment-related adverse Medication adverse effects can vary in intensity from none to very troublesome and effects worrisome; the level of intensity does not correlate to specific levels of control, but should be considered in the overall assessment of risk Recommended action for Maintain current step; regular Step up one step and Consider short course of oral treatment (see Figure 1 for follow-up every one to six reevaluate in two to six systemic corticosteroids; step treatment steps) months to maintain control; weeks; for adverse effects, up one to two steps, and consider step down if well consider alternative reevaluate in two weeks; for controlled for at least three treatment options adverse effects, consider months alternative treatment options

Management
Avoiding the contact with allergen.

Elimination of trigger factors (rational job placement, changing the residence, psychological and physical adaptation, careful drug using) is the second condition for successful asthma treatment. Optimally selected medical care is the base of asthma management.

Treatment:

Bases of treatments: one way is to relaxes the muscles during expiration.

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Drug therapy
2 drug categories are used: Antiinflammatory drugs Bronchodilators (basic) Are divided into: 3 groups: b2-agonists anticholinergic drugs methylxanthines

hormone-containing (corticosteroids) nonhormone-containing (cromones, leukotriene receptor antagonists)

Corticosteroids
The working mechanism lays in:
cell membrane

stabilization
inhibition of

inflammatory mediators
restoring the sensivity

of b2-receptors.

Inhaled corticosteroids (beclamethazone, inhacort, budesonide, flixotid, fluticazone, asmacort, asthmanex) are the most effective and safe and considered to be the first line drugs for asthma treatment. Systemic are used during short courses, mainly in case of severe persistent asthma or asthmatic status.

Cromones
(cromolyn sodium intal, and nedocromil tiled)
stabilize cell membranes, used mainly in pediatric

Leukotriene receptor antagonists

(montelukast, zafirlukast)
have the moderate

practice (in childhood) in case of intermittent or mild persistent asthma.

intiinflammatory activity used in case of aspirininduced asthma and asthma of physical exertion.

 Inhaled b2-agonists are the basic drug group among bronchodilators.

Short-acting (duration of action 5-6 h) b2-

agonists - salbutamol used for quick relief of asthma symptoms. Long-acting (> 12 h) b2-agonists - salmoterol, formoterol - for prevention of asthma symptoms occurring.

 Anticholinergic drugs (ipratropium bromide,

atrovent, troventol) are used predominantly in nighttime asthma and in elderly patients because of the least cardiotoxic effect.
Methylxanthines in comparison with other

bronchodilators have the less bronchodilating potential. There are long-acting (>12 h) - (theopec, theolong, theodur, euphilong) as well as shortacting (aminophylline, theophylline) drugs in this group.

Combined inhaled drugs (corticosteroids with b2agonists) seretid, simbicort with use of delivery devices (nebulizers, turbuhalers, spacers) enhance the effectiveness of asthma therapy.

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.

Reducing Exposure to House Dust Mites

Use bedding encasements Wash bed linens weekly Limit stuffed animals to

those 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 Asthma Created and funded by NIH/NHLBI, 1995

Reducing Exposure to Tobacco Smoke

Evidence suggests an association between environmental tobacco smoke exposure and exacerbations of asthma among school-aged, older children, and adults.

Evidence shows an association between environmental tobacco smoke exposure and asthma development among pre-school aged children.

Tool Kit for Achieving Management Goals

Relievers Preventers Peak Flow meter Patient education

What Are Relievers?

- Rescue medications - Quick relief of symptoms - Used during acute attacks - Action lasts 4-6 hrs - Not for regular use

RELIEVERS
Short acting b2 agonists Salbutamol

Levosalbutamol Anti-cholinergics Ipratropium bromide

Xanthines Theophylline Adrenaline injections

Relievers (Bronchodilators)
Relaxes muscles in the airways to help relieve asthma

symptoms Should be taken as needed for symptoms Need 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

What are Preventers?

- Prevent future attacks - Long term control of asthma - Prevent airway remodeling

PREVENTERS
Corticosteroids Prednisolone, Betamethasone Beclomethasone, Budesonide Fluticasone Anti-leukotrienes Montelukast, Zafirlukast Xanthines Theophylline SR Mast cell stabilisers Sodium cromoglycate

Long acting b2 agonists Bambuterol, Salmeterol Formoterol

COMBINATIONS Salmeterol/Fluticasone Formoterol/Budesonide Salbutamol/Beclomethasone

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

Steroid Phobia: Unfounded!

Inhaled steroids in doses most often prescribed

are very safe Inhaled meds delivered directly to lungs where they are needed Little systemic absorption if proper technique used

ICS + LABA
Which LABA ? Formoterol: Immediate relief (as fast as salbutamol)-----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 )

Combination Medication
Advair (Flovent + Serevent)
Combo corticosteroid and long acting beta-agonist 3 strengths: 100/50, 250/50, 500/50 Strengths based on Flovent doses, Serevent dose

remains the same in all three strengths. Usual dosing, 1 inhalation every 12 hours Has remaining-dose counter

Why inhalation therapy?

Oral Slow onset of action Large dosage used Greater side effects Not useful in acute symptoms Inhaled route Rapid onset of action

Less amount of drug used Better tolerated

Treatment of choice in acute symptoms

MDI

Metered dose inhalers (MDI)

The health-care provider should evaluate inhaler technique at each visit.

How MDI Technology Works

spacers
Spacers can help patients who have difficulty with inhaler use and can reduce potential for adverse effects from medication.
No co-ordination required
Reduced oro-pharyngeal

deposition
Increased drug deposition in

the lungs

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 exercise Potential adverse effects None (Tilade tastes bad) Therapeutic issues Must be taken up to 4 times a day, maximum benefit after 4-6 weeks

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 in moderate to severe persistent asthma
Potential adverse effects

None significant elevation of liver enzymes

Therapeutic issues

Drug interactions, monitor hepatic enzymes (esp. Zyflo)

Methylzanthines
Theophyline
For 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 acute

exacerbations, absorption and metabolism affected by many factors

Systemic Corticosteroids
Prednisone
Prevents progression of moderate to severe exacerbations, reduces inflammation

Potential adverse effects

Short-term- increased appetite, fluid retention, mood

changes, facial flushing, stomachache. Long termgrowth suppression, hypertension, glucose intolerance, muscle weakness, cataracts

CASE SCENARIO
Khalid 14 years old come to the clinic c/o shortness of breath for one day duration. He is a known asthmatic patient for more than 8 years, he visited A/E frequently. His school performance is below average, with frequent absence from school due to his illness.

how you will proceed during this consultation ?

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.

 Risk factors for the development of asthma

include 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 of known allergens.