Basis of Current Management in

Asthma

AE Orimadegun

06/06/09 1
 OUTLINE…

 Definition
 Epidemiology

 Pathogenesis/Pathophysiology

 Risk Factors

 Mechanisms

 Diagnosis and Classification

 Education and Delivery of Care

 Six Part Asthma Management Plan

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 Definition of Asthma
 Asthma is a chronic inflammatory disorder of the
airways in which many cells and cellular elements play
a role
 Chronic inflammation causes an associated increase in
airway hyperresponsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest tightness,
and coughing, particularly at night or in the early
morning
 These episodes are usually associated with
widespread but variable airflow obstruction that is often
reversible either spontaneously or with treatment
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 Facts and figures
 Most common chronic illness in childhood
worldwide
 Between 100 - 150 million people suffer from
asthma worldwide1

 Worldwide prevalence rates are increasing, on

average, by 50% per decade1
 Worldwide costs of asthma greater is than HIV /
AIDS and tuberculosis combined1
1. WHO, Bronchial Asthma Fact Sheet 2000
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2. GINA Guidelines 1998
 Facts and figures…
 Prevalence rates in Nigeria:
 Sofowora & Clark - 2.4% in a school survey at Ibadan.
 Falade et al using ISAAC Questionnaire found 16.7%
(13-14yrs) and 7.2% (6-7yrs) in Ibadan.
 Okoromah reported 3% in Enugu (6-13yrs)
 Oviawe - 0.7% in a rural community at Edo
 Highest prevalence reported from UK, New Zealand,
and Australia (Isaac)
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 Trends in Prevalence of Asthma
By Age, U.S., 1985-1996
80 Rate/1,000 Persons
Age (years)
70
<18
60 18-44
45-64
50
65+
Total (All Ages)
40

30

20
85 86 87 88 89 90 91 92 93 94 95 96
Year
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 Death Rates for Asthma
By Race, Sex, U.S., 1980-1998

Rate/100,000 Persons
5
Black Female

4
Black Male

3
White Female

White Male
1

0
1980 1985 1990 1995 2000
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Year
 Pathogenesis/Pathophysiology
 Complex, chronic inflammatory disorder of the airway
 Immunopathologic features include:
 Denudation of airway epithelium
 Collagen deposition beneath the basement membrane
 Oedema
 Mast cell activation
 Inflammatory cell infiltration
 Neutrophils
 Eosinophils
 Lymphocytes (TH2-like cells)
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 Pathogenesis/Pathophysiology
 Airway inflammation results in:
 Hyperresponsiveness
 Limitation of airfow
 Airway oedema
 Acute bronchoconstriction
 Mucus plug formation
 Disease chronicity
 Atopy is the strongest predisposing factor
for asthma
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 Modern view of
pathophysiology… Allergen

Macrophage/
dendritic cell Mast cell

Th2 cell Neutrophil

Eosinophil
Mucus plug
Epithelial shedding
Nerve activation

Subepithelial
fibrosis
Plasma leak
Sensory nerve
Oedema activation
Vasodilatation Cholinergic
Mucus New vessels reflex
hypersecretion
Hyperplasia Bronchoconstriction
Hypertrophy / hyperplasia

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Inflammatory processes

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Pathogenesis/Pathophysiology
Risk Factors
(for development of asthma)

INFLAMMAT ION

Airway
Hyperresponsiveness Airflow Obstruction

Risk Factors Symptoms

(for exacerbations)
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 Risk 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
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 Risk Factors for Asthma
Host Factors
 Genetic predisposition
 Atopy – IgE mediated response to allergen
 Airway hyperresponsiveness
 Gender
 Race/Ethnicity
Environmental Factors
• Indoor allergens – dust mites, animal dander,
cockroaches, fungi
• Outdoor allergens – pollens, fungi
• Occupational sensitizers
• Tobacco smoke – passive, active
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 Risk Factors that Lead to
Asthma Development
Environmental Factors (cont’d)
• Air Pollution – outdoor, indoor
• Respiratory Infections
• Parasitic infections
• Socioeconomic factors
• Family size
• Diet and drugs
• Obesity

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 Factors that Exacerbate Asthma

 Allergens
 Air Pollutants
 Respiratory infections
 Exercise and hyperventilation
 Weather changes
 Sulfur dioxide
 Food, additives, drugs
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 Is it Asthma?

 Recurrent episodes of wheezing

 Troublesome cough at night
 Cough or wheeze after exercise
 Cough, wheeze or chest tightness after
exposure to airborne allergens or
pollutants
 Colds “go to the chest” or take more
than 10 days to clear
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 Asthma Diagnosis

 History and patterns of symptoms

 Physical examination
 Measurements of lung function
 Reversibility test
 Diurnal variation
 Measurements of allergic status to
identify risk factors
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 Reversible and variable airflow
limitation
 Reversibility of airways’ obstruction
– increased PEF >15% 15-20 minutes after inhaling ß2-agonist

 Variability of airways’ obstruction

– PEF varies between morning and evening
>20% in patients taking bronchodilator
>10% in patients not taking bronchodilator

 Exercise-induced airways’ obstruction

– decreased PEF >15% after 6 minutes of exercise
 **Bronchoprovocative challenge test
– Pc20 FEV1 methacholine and histamine
06/06/09 19
GINA Guidelines 1998 **not covered by GINA
 Classification of Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment

Symptoms Nocturnal FEV1 or PEF

Symptoms
STEP 4 Continuous ≤ 60% predicted
Limited physical Frequent
Severe Variability > 30%
Persistent activity

STEP 3 Daily 60 - 80% predicted

> 1 time week
Moderate Attacks affect activity Variability > 30%
Persistent
STEP 2 ≥ 80% predicted
> 1 time a week > 2 times a month
Mild but < 1 time a day Variability 20 - 30%
Persistent

< 1 time a week

STEP 1 ≥ 80% predicted
Asymptomatic ≤ 2 times a
Intermittent month Variability < 20%
and normal PEF
between attacks
The presence of one feature of severity is sufficient to place patient in that category.
06/06/09 20
 Six-Part Asthma Management
Program

1. Educate Patients
2. Assess and Monitor Severity
3. Avoid Exposure to Risk Factors
4. Establish Medication Plans for Chronic
Management
5. Establish Plans for Managing Exacerbations
6. Provide Regular Follow-up Care

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 Six-part Asthma Management Program

Goals 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
06/06/09 22
 Six-Part Asthma Management
Program
.
 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
06/06/09 23
 Six-Part Asthma Management
Program

 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
06/06/09 24
 Six-part Asthma Management Program
Part 1: Educate Patients to
Develop a Partnership

 Patient education involves a partnership

between the patient and health care
professional(s) with frequent revision and
reinforcement
 Aim is guided self-management – giving
patients the ability to control their asthma
 Interventions, including use of written
action plans, have been shown to reduce
morbidity in both children and adults
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 Six-part Asthma Management Program
Part 1: Educate Patients to
Develop a Partnership

 Guidelines on asthma management should

be available but adapted and adopted for
local use by local asthma planning teams
 Clear communication between health care
professionals and asthma patients is key to
enhancing compliance
 Educate continually
06/06/09 26
Part 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

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Part 2: Assess and Monitor Asthma Severity with
Symptom Reports and Measures of Lung
Function
• 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

06/06/09 28
 Typical Spirometric (FEV1)
Tracings
Volume

FEV1

Normal Subject

Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)

1 2 3 4 5
Time (sec)

Note: Each FEV1 curve represents the highest of three repeat measurements
06/06/09 29
 Six-part Asthma Management Program
Part 3: Avoid Exposure to Risk
Factors

 Methods to prevent onset of asthma are

not yet available but this remains an
important goal
 Measures to reduce exposure to causes
of asthma exacerbations (e.g. allergens,
pollutants, foods and medications) should
be implemented whenever possible

06/06/09 30
 Six-part Asthma Management Program
Part 3: Avoid Exposure to Risk
Factors

 Reduce exposure to indoor allergens

 Avoid tobacco smoke
 Avoid vehicle emission
 Explore role of infections on asthma
development, especially in children and
young infants

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Six-part Asthma Management Program
Part 4: Establish Medication Plans for Long-
Term Asthma Management in Infants and
Children

 At present, inhaled glucocorticosteroids

are the most effective controller
medications and are recommended for
persistent asthma at any step of severity
 Long-term treatment with inhaled
glucocorticosteroids markedly reduces the
frequency and severity of exacerbations
06/06/09 32
 Six-part Asthma Management Program
Part 4: Establish Medication Plans for
Long-Term Asthma Management

 A stepwise approach to pharmacological

therapy is recommended
 The aim is to accomplish the goals of
therapy with the least possible medication

06/06/09 33
 Part 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
care systems need to be considered.
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Part 4: Long-term Asthma Management

Pharmacologic Therapy
Controller Medications:
 Inhaledglucocorticosteroids
 Systemic glucocorticosteroids

 Cromones

 Methylxanthines

 Long-acting inhaled β -agonists

2

 Long-acting oral β2-agonists

 Leukotriene modifiers
 Anti-IgE
06/06/09 35
 Part 4: Long-term Asthma Management

Pharmacologic Therapy

Reliever Medications:
 Rapid-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Anticholinergics

 Methylxanthines

 Short-acting oral β2-agonists

06/06/09 36
 Part 4: Long-term Asthma Management

Allergen-specific Immunotherapy

Greatest benefit of specific immunotherapy
using allergen extracts has been obtained in
the treatment of allergic rhinitis
Specific immunotherapy should be
considered only after strict environmental
avoidance and pharmacologic intervention
have failed to control asthma
 Perform only by trained physician
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Six-part Asthma Management Program
Part 4: Establish Medication Plans for
Long-Term Asthma Management in Infants
and Children

 Childhood and adult asthma share the

same underlying mechanisms.
However, because of processes of
growth and development, effects of
asthma treatments in children differ from
those in adults.
06/06/09 38
Six-part Asthma Management Program
Part 4: Establish Medication Plans for Long-
Term Asthma Management in Infants and
Children
 Long-term treatment with inhaled
glucocorticosteroids has not been shown
to be associated with any increase in
osteoporosis or bone fracture
 Studies including a total of over 3,500
children treated for periods of 1 – 13 years
have found no sustained adverse effect of
inhaled glucocorticosteroids on growth
06/06/09 39
 Six-part Asthma Management Program
Part 4: Establish Medication Plans for
Long-Term Asthma Management in
Infants and Children

 Rapid-acting inhaled β2- agonists are

the most effective reliever therapy for
children
 These medications are the most
effective bronchodilators available and
are the treatment of choice for acute
asthma symptoms
06/06/09 40
 Recommended Asthma Medications
Step 1: Children Younger Than 5yrs

Severity Daily Controller Other Options (in order

Medications of cost)
Step 1: • None • None
Intermittent

Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more

than 3-4 times a day. Once control is achieved and maintained for at
least 3 months, gradual reduction of therapy should be tried.
06/06/09 41
 Recommended Asthma Medications
Step 2: Children Younger Than 5 yrs
Severity Daily Controller Other Options (in order
Medications of cost)
Step 2: • Low-dose inhaled • Sustained-release
Mild glucocorticosteroid theophylline, or
Persistent
• Cromone, or

• Leukotriene modifier

Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more

than 3-4 times a day. Once control is achieved and maintained for at
least 3 months, gradual reduction of therapy should be tried.
06/06/09 42
 Recommended Asthma Medications
Step 3: Children Younger Than 5yrs
Severity Daily Controller Other Options (in order of cost)
Medications
Step 3: • Medium-dose inhaled • Medium-dose inhaled glucocorticosteroid
Moderate glucocorticosteroid plus sustained-release theophylline, or
persistent
• Medium-dose inhaled glucocorticosteroid
plus long-acting inhaled β2- agonist, or

• High-dose inhaled glucocorticosteroid, or

• Medium-dose Inhaled
glucocorticosteroid plus leukotriene
modifier
Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more
than 3-4 times a day. Once control is achieved and maintained for at43
06/06/09
least 3 months, gradual reduction of therapy should be tried.
 Recommended Asthma Medications
Step 4: Children Younger Than 5yrs
Severity Daily Controller Medications Other
Options
Step 4 • High-dose inhaled glucocorticosteroid
Severe plus one or more of the following, if
persistent needed:
- Sustained-release theophylline
- Leukotriene modifier
- Long-acting inhaled β2- agonist
- Oral glucocorticosteroid

Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more

than 3-4 times a day. Once control is achieved and maintained for at
06/06/09 44
least 3 months, gradual reduction of therapy should be tried.
 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 supplementation
Closely monitor response to treatment
with serial measures of lung function
06/06/09 45
 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
06/06/09 46
 Acute Asthma

Initial Assessment
History, Physical Examination, PEF or FEV1

Initial Therapy
Bronchodilators; O2 if needed
Good Response
Incomplete/Poor Response Respiratory Failure

Observe for at Add Systemic Glucocorticosteroids

least 1 hour
Good Response Poor Response
If Stable,
Discharge to Discharge Admit to Hospital Admit to ICU
Home

06/06/09 47
 Six-part Asthma Management Program

Part 6: Provide Regular

Follow-up Care
Continual monitoring is essential to assure that
therapeutic goals are met. Frequent follow-up visits
are necessary to review:
 Home PEF and symptom records
 Techniques in use of medications
 Risk factors and their control
Once asthma control is established, follow-up
visits should be scheduled (at 1 to 6 month intervals
as appropriate)
06/06/09 48
 Six-part Asthma Management
Program: Summary

 Asthma can be effectively controlled, although it

cannot be cured
 Effective asthma management programs include
education, objective measures of lung function,
environmental control, and pharmacologic therapy
 A stepwise approach to pharmacologic therapy is
recommended. The aim is to accomplish the
goals of therapy with the least possible medication

06/06/09 49
 Six-part Asthma Management
Program: Summary (continued)

 Anything more than mild, occasional asthma is

more effectively controlled by suppressing
inflammation than by only treating acute
bronchospasm
 The availability of varying forms of treatment,
cultural preferences, and differing health care
systems need to be considered

06/06/09 50
 Thank you for listening…

06/06/09 51