G lobal

INitiative for
A sthma
What is ASTHMA ?
 Definition of Asthma

 A chronic inflammatory disorder of the airways

 Many cells and cellular elements play a role
 Chronic inflammation is associated with airway
hyperresponsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest
tightness, and coughing
 Widespread, variable, and often reversible
airflow limitation
Asthma Inflammation: Cells and
Mediators

Source: Peter J. Barnes, MD

Mechanisms: Asthma
Inflammation

Source: Peter J. Barnes, MD

 Factors that Exacerbate Asthma

 Allergens
 Respiratory infections
 Exercise and hyperventilation
 Weather changes
 Sulfur dioxide
 Food, additives, drugs
 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
 Factors that Influence Asthma
Development and Expression

Host Factors Environmental Factors

 Indoor allergens
 Genetic
 Outdoor allergens
- Atopy
 Occupational sensitizers
- Airway
 Tobacco smoke
hyperresponsiveness
 Air Pollution
 Gender
 Respiratory Infections
 Obesity  Diet
 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
 Asthma Diagnosis
 History and patterns of symptoms
 Measurements of lung function
- Spirometry
- Peak expiratory flow
 Measurement of airway responsiveness
 Measurements of allergic status to identify
risk factors
 Extra measures may be required to
diagnose asthma in children 5 years and
younger and the elderly
 Typical Spirometric (FEV11)
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
TRIGGERS of ASTHMA ?
 Asthma Management and Prevention Program
Component 2: Identify and Reduce
Exposure to Risk Factors

 Measures to prevent the development of asthma,

and asthma exacerbations by avoiding or reducing
exposure to risk factors should be implemented
wherever possible.
 Asthma exacerbations may be caused by a variety
of risk factors – allergens, viral infections,
pollutants and drugs.
 Reducing exposure to some categories of risk
factors improves the control of asthma and
reduces medications needs.
 Asthma Management and Prevention Program
Component 2: Identify and Reduce
Exposure to Risk Factors

 Reduce exposure to indoor allergens

 Avoid tobacco smoke
 Avoid vehicle emission
 Identify irritants in the workplace
 Explore role of infections on asthma
development, especially in children and
young infants
 REDUCE EXPOSURE TO
INDOOR ALLERGENS
• Mites
• Furred Animals
• Cockroaches
• Fungi
 REDUCE EXPOSURE TO
INDOOR ALLERGENS
• Mites
– Keep humidity below 50% (aircon)
– Remove carpets
– Encase mattress & pillows
– Wash beddings weekly
– Vacuum weekly
 REDUCE EXPOSURE TO
INDOOR ALLERGENS
• Furred animals
– The most effective way to combat symptoms
of animal allergy is to REMOVE THE PET
from the home to avoid any contact.
 REDUCE EXPOSURE TO
INDOOR ALLERGENS
• Cockroaches
– Block areas where cockroaches can enter the
home.
– Fix leaks & seal leaky faucets
– Keep home clean and dry & keep food in tight
lid containers
 REDUCE EXPOSURE TO
INDOOR ALLERGENS
• Molds
– Repair leaks
– Clean with Zonrox regularly
CLASSIFICATION
 Asthma Classification Based on
Severity
Mild Moderate Severe
Intermittent Persistent Persistent Persistent
Daytime < > 1x / week Daily Daily Limits
Symptoms 1x/week but < daily Affects daily daily
activities activities

Nighttime
Symptoms < 2x / month > 2x / month > 1x / week > 1x / week
> 80% > 80%
PEFR predicted predicted 60 – 79% < 60%

PEFR < 20% 20 – 30 % > 30% > 30%

Variability
> 80% > 80%
FEV 1 predicted predicted 60 – 79% < 60%
 Levels of Asthma
Control
Characteristic Controlled Partly controlled Uncontrolled
(All of the following) (Any present in any week)

Daytime symptoms None (2 or less / More than 3 or more

week) twice / week features of partly
controlled
Limitations of activities None Any asthma present
in any week
Nocturnal symptoms / None Any
awakening

Need for rescue / None (2 or less / More than

“reliever” treatment week) twice / week
Lung function Normal < 80% predicted or
(PEF or FEV1) personal best (if known)
on any day
Exacerbation None One or more / year 1 in any week
 Long Term Asthma
Management
( Based on Level of Control )
 Global Strategy for Asthma
Management and Prevention
Evidence Category Sources of Evidence

A Randomized clinical trials

Rich body of data

B Randomized clinical trials

Limited body of data

C Non-randomized trials
Observational studies

D Panel judgment consensus

 Asthma Management and Prevention Program

Goals of Long-term
Management
 Achieve and maintain control of
symptoms
 Maintain normal activity levels,
including exercise
 Maintain pulmonary function as close
to normal levels as possible
 Prevent asthma exacerbations

 Avoid adverse effects from asthma

medications
 Prevent asthma mortality
 Asthma
Asthma Management
Management and
and Prevention
Prevention Program
Program
Component 3: Assess,
Treat and Monitor
Asthma
The goal of asthma treatment, to
achieve and maintain clinical
control, can be achieved in a
majority of patients with a
pharmacologic intervention strategy
developed in partnership between
the patient/family and the health
care professional
 Asthma Classification Based on
Severity
Mild Moderate Severe
Intermittent Persistent Persistent Persistent
Daytime < > 1x / week Daily Daily Limits
Symptoms 1x/week but < daily Affects daily daily
activities activities

Nighttime
Symptoms < 2x / month > 2x / month > 1x / week > 1x / week
> 80% > 80%
PEFR predicted predicted 60 – 79% < 60%

PEFR < 20% 20 – 30 % > 30% > 30%

Variability
> 80% > 80%
FEV 1 predicted predicted 60 – 79% < 60%
 Levels of Asthma
Control
Characteristic

Daytime symptoms

Limitations of activities

Nocturnal symptoms /
awakening

Need for rescue /

“reliever” treatment
Lung function
(PEF or FEV1)

Exacerbation
 Levels of Asthma
Control
Characteristic Controlled
(All of the following)

Daytime symptoms None (2 or less /

week)
Limitations of activities None

Nocturnal symptoms / None

awakening

Need for rescue / None (2 or less /

“reliever” treatment week)
Lung function Normal
(PEF or FEV1)

Exacerbation None
 Levels of Asthma
Control
Characteristic Controlled Partly controlled
(All of the following) (Any present in any week)

Daytime symptoms None (2 or less / More than

week) twice / week
Limitations of activities None Any

Nocturnal symptoms / None Any

awakening

Need for rescue / None (2 or less / More than

“reliever” treatment week) twice / week
Lung function Normal < 80% predicted or
(PEF or FEV1) personal best (if known)
on any day
Exacerbation None One or more / year
Characte- Controlled Partly Uncontrolled
ristics Controlled
Daytime Sx None (<2x/wk) >2x /wk Three or more
features of
partly
Nocturnal Sx None Any controlled
asthma prese
Need for None >2x/ wk in any wk
rescue Rx (<2x/wk)
Lung Fx Normal <80%

Limit actvties None Any

Exacerbation None >1 / yr One in any wk
 Asthma Management and Prevention Program

Component 3: Assess,
Treat and Monitor Asthma
 Depending on level of asthma control,
the patient is assigned to one of five
treatment steps
 Treatment is adjusted in a continuous
cycle driven by changes in asthma
control status. The cycle involves:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control
 Asthma Management and Prevention Program

Component 3: Assess,
Treat and Monitor Asthma
 A stepwise approach to pharmacological
therapy is recommended
 The aim is to accomplish the goals of
therapy with the least possible medication
 Although in many countries traditional
methods of healing are used, their efficacy
has not yet been established and their use
can therefore not be recommended
 Asthma Management and Prevention Program

Component 3: Assess,
Treat and Monitor Asthma
The choice of treatment should be guided by:
 Level of asthma control
 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
 Component 4: Asthma Management and Prevention Program

Controller Medications
 Inhaled glucocorticosteroids
 Leukotriene modifiers

 Long-acting inhaled β -agonists

2
 Systemic glucocorticosteroids
 Theophylline

 Cromones

 Long-acting oral β -agonists

2
 Anti-IgE
 Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose (µ g) Medium Daily Dose (µ g) High Daily Dose (µ g)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400

Budesonide-Neb Inhalation 250-500 >500-1000 >1000

Suspension
Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250

Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500

Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400

Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200

 Component 4: Asthma Management and Prevention Program

Reliever Medications

 Rapid-acting inhaled β2-agonists

 Anticholinergics
 Theophylline
 Short-acting oral β2-agonists
 REDUCE
LEVEL OF CONTROL TREATMENT OF ACTION

maintain and find lowest

controlled
controlling step
consider stepping up to
partly controlled gain control

INCREASE
uncontrolled step up until controlled

exacerbation treat as exacerbation

REDUCE INCREASE
TREATMENT STEPS
STEP STEP STEP STEP STEP
1 2 3 4 5
 Treating to Achieve Asthma
Control
Step 1 – As-needed reliever medication
 Patients with occasional daytime symptoms of
short duration
 A rapid-acting inhaled β2-agonist is the
recommended reliever treatment ( Evidence A )
 When symptoms are more frequent, and/or
worsen periodically, patients require regular
controller treatment (step 2 or higher)
 Treating to Achieve Asthma
Control
Step 2 – Reliever medication plus a single
controller
 Initial controller Rx: low-dose inhaled
glucocorticosteroid for patients of all ages
(Evidence A )
 Alternative controller medications :
leukotriene modifiers ( Evidence A )
 Treating to Achieve Asthma
Control
Step 3 – Reliever medication plus one or two
controllers
 Adults and adolescents: combine a low-dose
inhaled glucocorticosteroid with an inhaled long-
acting β2-agonist ( Evidence A )
 Inhaled long-acting β2-agonist must not be used
as monotherapy
 For children, increase to a medium-dose inhaled
glucocorticosteroid ( Evidence A )
 Treating to Achieve Asthma
Control
Additional Step 3 Options for Adolescents and Adults
 Increase to medium-dose inhaled
glucocorticosteroid ( Evidence A )
 Low-dose inhaled glucocorticosteroid
combined with leukotriene modifiers
( Evidence A )
 Low-dose inhaled glucocorticosteroid plus
low-dose sustained-release theophylline
( Evidence B )
 Treating to Achieve Asthma
Control
Step 4 – Reliever medication plus two or more
controllers
 Selection of treatment at Step 4 depends
on prior selections at Steps 2 and 3
 Where possible, patients not controlled on
Step 3 treatments should be referred to a
health professional with expertise in the
management of asthma
 Treating to Achieve Asthma
Control
Step 4 – Reliever medication plus two or more controllers
 Medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled β2-agonist
( Evidence A )
 Medium- or high-dose inhaled glucocorticosteroid
combined with leukotriene modifiers ( Evidence A )
 Low-dose sustained-release theophylline added to
medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled β2-agonist (
Evidence B )
 Treating to Achieve Asthma
Control
Step 5 – Reliever medication plus additional controller options

 Addition of oral glucocorticosteroids to other

controller medications may be effective
( Evidence D ) but is associated with severe
side-effects ( Evidence A )
 Addition of anti-IgE treatment to other
controller medications improves control of
allergic asthma when control has not been
achieved on other medications ( Evidence A )
 Treating to Maintain Asthma
Control

 When control as been achieved,

ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
 Asthma control should be monitored
by the health care professional and
by the patient
 Treating to Maintain Asthma
Control
Stepping down treatment when asthma is controlled

 When controlled on medium- to high-dose

inhaled glucocorticosteroids: 50% dose
reduction at 3 month intervals ( Evidence B )
 When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily
dosing ( Evidence A )
 Treating to Maintain Asthma
Control
Stepping down treatment when asthma is controlled
 When controlled on combination inhaled
glucocorticosteroids and long-acting
inhaled β2-agonist, reduce dose of inhaled
glucocorticosteroid by 50% while
continuing the long-acting β2-agonist
( Evidence B )
 If control is maintained, reduce to low-
dose inhaled glucocorticosteroids and
stop long-acting β2-agonist ( Evidence D )
 Treating to Maintain Asthma
Control
Stepping up treatment in response to loss of control
 Rapid-onset, short-acting or long-
acting inhaled β2-agonist
bronchodilators provide temporary
relief.
 Need for repeated dosing over more
than one/two days signals need for
possible increase in controller therapy
 Treating to Maintain Asthma
Control
Stepping up treatment in response to loss of control
 Use of a combination rapid and long-acting
inhaled β2-agonist (e.g., formoterol) and an
inhaled glucocorticosteroid (e.g., budesonide)
in a single inhaler both as a controller and
reliever is effective in maintaining a high level
of asthma control and reduces exacerbations
( Evidence A )
 Doubling the dose of inhaled glucocortico-
steroids is not effective, and is not
recommended ( Evidence A )
 Asthma
Asthma Management
Management and Prevention
Prevention Program
Program
Component 3: Assess, Treat and
Monitor Asthma – Children 5
Years and Younger

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.
 Asthma
Asthma Management
Management and Prevention
Prevention Program
Program
Component 3: Assess, Treat and
Monitor Asthma – Children 5
Years and Younger

Many asthma medications (e.g.

glucocorticosteroids, β2- agonists,
theophylline) are metabolized faster in
children than in adults, and younger
children tend to metabolize medications
faster than older children
 Asthma
Asthma Management
Management and Prevention
Prevention Program
Program
Component 3: Assess, Treat and
Monitor Asthma – Children 5
Years and Younger

 Glucocorticosteroids has not been shown

to be associated with any increase in
osteoporosis in long-term treatment with
inhaled 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
 Asthma Management and
Prevention Program: Summary

 A stepwise approach to pharmacologic therapy

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

 The availability of varying forms of treatment,

cultural preferences, and differing health care
systems need to be considered
MANAGEMENT of

EXACERBATION
 Asthma
Asthma Management
Management and
and Prevention
Prevention Program
Program
Component 4: Manage Asthma
Exacerbations

 Exacerbations of asthma
 Episodes of progressive ↑ in shortness of
breath, cough, wheezing, or chest
tightness
 Characterized by ↓ in expiratory airflow,
can quantified and monitored by
measurements of lung function (FEV1 or
PEF)
 Aims of Treatment of Acute
Asthma Exacerbation

• Relieve airway obstruction as quickly as possible

• Relieve hypoxemia as quickly as possible

• Plan the prevention of future relapses

 A s s e s sm e n t o f S e v e rity o f
A sth m a E x a c e rb a tio n s
M IL D M O D E R ATE SEVERE R E S P . AR R E S T
IM M IN E N T

B reath le ss w h en W alkin g T alking A t rest M a y b e c yan o tic ,

C an lie d o w n P refers s itting H u n c h ed fo rw ardexh a usted
Ta lk s in S en te n ce s P h rase s W o rd s
A lertn es s M ay be U su ally U su ally a g ita ted D row s y/ co n fu se d
ag ita ted ag ita ted o r co m ato se
R es p. rate Increa sed In crea sed O fte n > 3 0 /m in
U se o f ac ces so ry U su ally n o t U su ally U su ally P arad o xica l
m u scles ores
f p b reath in g
W hee z e M o d . o ften Loud U su ally lo u d A bse n t
en d-exp irato r y
 Can lie down Prefers sitting Hunched forward exhausted
Talks in Sentences Phrases Words
Alertness
AMay
s sbe
e
agitated
s sm e
Usually
agitated
n t o f S e v eorrity of
Usually agitated Drowsy/ confused
com atose
Resp. rate A sth mIncreased
Increased a E x aOften
c e rb a tio n s
> 30/min
Use of accessory Usually not Usually Usually Paradoxical
muscles ofresp breathing
M IL D M O D E R ATE SEVERE R E S P . AR R E S T
Wheeze Mod. often Loud Usually loud Absent
IM M IN E N T

Pulse
Assessment
end-expiratory
of Severity of
B reathrate
le ss/ min
w h en <W100/min
alkin g 100-200
T alking /m in >A t120/min
rest Bradycardia
M a y b e c yan o tic ,
PulsusparadoxusAsthma Absent PExacerbations
C an lie d o w n May
refers
be s itting Often ed fo rw ardexh
H u n c hpresent a usted
Absence suggests
< 10 te
mmHg present > respm uscle fatigue
Ta lk s in S en n ce s P h rase s W25
o rdmmHg
s
MILD 10-25 mmHg
MODERATE SEVERE RESP.
A lertn es s M ay be U su ally U su ally a g ita ted D row s y/ co n fu se d
PEF after initial > 80% 60 - 80 % < 60 % ARREST
ag ita ted ag ita ted o r co m ato se
bronchodilator IMMINENT
R es p. on
PaO rate
room air Increa
Normalsed In crea
> 60 mm sed
Hg O fte n mm
< 60 > 3Hg,
0 /m in PCRADM 1996
2
GINA 2002
U se o f ac ces so ry U su ally n o t U su ally cyanosis
U su ally P arad o xica l
m u scles
PaCO 2 ores
f p < 45 mm Hg < 45 mm Hg b reath in g
> 45 mm Hg, poss.
respiratory failure
W hee z e M o d . o ften Loud U su ally lo u d A bse n t
SaO 2 on room air > 95 %
en d-exp irato r y 91-95 % < 91 %
 Asthma
Asthma Management
Management and
and Prevention
Prevention Program
Program
Component 4: Manage Asthma
Exacerbations

Treatment of exacerbations depends on:

 The patient
 Experience of the health care
professional
 Therapies that are the most effective for
the particular patient
 Availability of medications
 Emergency facilities
 Management of asthma exacerbation in acute
care setting

Initial assessment
History, PE (auscultation, use of accessory
muscles, HR, RR, PEF or FEV1, O2 saturation, ABG

Initial Treatment
-Oxygen to achieve saturation to >95% in children
-Inhaled acting beta-2 agonist continuously for 1H
-Systemic glucocorticosteroids if no immediate
response
-Sedation contraindicated in the treatment of acute
exacerbation
Criteria for moderate episode
• PEF 60-80% predicted /
personal best
• PE: moderate symptoms,
accessory muscle use
Treatment
• O2; Inhaled beta-2 agonist &
anticholinergic for 1 Hr
• Oral glucocorticosteroids
• Continue for 1-3H, provided
with improvement
Criteria for severe episode
• RFs for near fatal asthma
• PEF <60% predicted /
personal best
• PE: severe sx at rest, chest
retractions
• No improvement after initial
treatment
Treatment
• O2
• Inhaled beta-2 agonist &
inhaled anticholinergic
• Oral glucocorticosteroids
• Intravenous magnesium
 Re-assess after 1-2 H
Good response within 1-2H
Response sustained 1H after treatment
PE Normal: No distress
PEF >70%; O2 sat 95%

Improved: Criteria for Discharge Home

PEF >60% predicted/ personal best
Sustained on oral/inhaled medication

Home Treatment: Inhaled beta-2 agonist

and oral GC; consider combination inhaler
Patient education
 Re-assess after 1-2H
Incomplete response
within 1-2H
• RFs for near fatal asthma
• PEF <60%
• PE: mild to moderate sx
• O2 sat not improving
Admit to Acute Care setting
• O2
• Inhaled beta-2 agonist ±
inhaled anticholinergic
• IV glucocorticosteroids
• Intravenous magnesium
• Monitor PEF O2 sat pulse
Poor response within 1-2H
• RFs for near fatal asthma
• PEF <30%
• PE: severe, drowsy,
confused child
• pCO2 >45 mm Hg
• pO2 <60 mm Hg
Admit to Intensive Care
• O2; Inhaled beta-2 agonist ±
inhaled anticholinergic
• IV glucocorticosteroids
• T/C IV beta-2 agonist,
theophylline
• Possible intubation/MV
• Re-assess at intervals
– Incomplete to poor response  Intensive Care

– Incomplete response in 6-12H

• Consider admission to Intensive Care

– Improved
• Consider discharge criteria
 Asthma
Asthma Management
Management and
and Prevention
Prevention Program
Program
Component 4: Manage Asthma
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.
 Criteria for Discharge from the
Emergency Department vs. Hospitalization

• Patients with pre-treatment FEV1 or PEF <25% predicted

or personal best or post treatment FEV1 or PEF < 40%
predicted or personal best require hospitalization.

• Patients with post-treatment lung function of 40-60%

(need adequate follow up and compliance!)

• Patients with post-treatment lung function > 60%

predicted
 For patients discharged from the emergency
department

• Shorter course (3-5 days) should be prescribed +

continuation of bronchodilator therapy
• Bronchodilator can be prn, based on symptomatic and
objective measurement
• Ipratropium bromide unlikely to provide additional
benefit beyond the acute phase
• Continue inhaled glucocorticosteroids!
• Review of patient’s inhaler technique and use of peak
flow meter
• Review of action plan with written guidance
SPECIAL CONSIDERATIONS
 Asthma
Asthma Management
Management and
and Prevention
Prevention Program
Program
Special Considerations
Special considerations are required to
manage asthma in relation to:
 Pregnancy
 Surgery
 Rhinitis, sinusitis, and nasal polyps
 Occupational asthma
 Respiratory infections
 Gastroesophageal reflux
 Aspirin-induced asthma
 Anaphylaxis and Asthma
 Rhinitis
• Majority of patients with asthma have a
history or evidence of rhinitis
• 30% of patients with persistent rhinitis
have or develop asthma.
• Rhinitis and asthma share risk factors:
common indoor and outdoor allergens,
animal dander, pollens
• Treatment of rhinitis may improve
asthma symptoms
 Rhinitis
• Allergic Rhinitis and its impact on asthma
(ARIA)
• Classification: Intermittent or Persistent; Mild
or Moderate-Severe
• Treatment: H1- antagonists (oral and
intranasal), decongestant, steroids
(intranasal, oral), cromones, leukotriene
modifiers.
• Allergen avoidance, Immunotherapy,
Education
 Sinusitis
• A complication of URI, AR,
nasal polyps and other forms of
nasal obstruction
• Antibiotic therapy for 10 days
• Topical nasal decongestants,
topical nasal steroids, systemic
glucocorticosteroids
 Respiratory Infections
• RSV, most common cause of wheezing in
infancy
• Rhinovirus, principal trigger of wheezing and
worsening of asthma in older children &
adults
• Role of chronic infection with
Chlamydia/Mycoplasma pneumoniae in the
pathogenesis or worsening of asthma is
uncertain
• Treatment of an infectious exacerbation
follows the same principles as treatment of
other asthma exacerbations
 Gastroesophageal Reflux

• 3x as prevalent in patients with asthma

compared o the general population
• Advise smaller frequent meals, avoid
fatty meals, alcohol, theophylline, oral β2
agonists
• Use proton pump inhibitors or H2
antagonists
• Elevate the head of the head
 Anaphylaxis and Asthma
• Anaphylaxis is a potentially life-threatening
condition that can both mimic and complicate
severe asthma
• Allergen Immunotherapy, Food intolerance,
Avian-based vaccines, insect stings and
bites, NSAIDS, ACE inhibitors, exercise
• Epinephrine should be the bronchodilator of
choice
 Case

R.J., a 7-year old male child, newly

diagnosed to have bronchial
asthma last March 2007, came in at
the emergency room for cough and
coryza the past 3 days. Few hours
prior to consult, child was noted to
have sudden onset of shortness of
breath.
 Case

At the ER, pertinent PE revealed a

wheezy chest with alar flaring. Vital
signs were: heart rate = 120 beats
per minute and respiratory rate = 30
breaths per minute. O2 saturation was
93% and peak expiratory flow rate
(PEFR) was 75%.
 Case

Pertinent medical history revealed

poor compliance with the anti-asthma
maintenance medications (inhaled
long acting beta-2 agonist and
corticosteroid combination).
 Case

1. What is your initial assessment?

2. What will be your initial treatment?

 BRONCHIAL ASTHMA UNCONTROLLED
in MODERATE EXACERBATION

Treatment
• O2
• Inhaled beta-2 agonist & anticholinergic for
1 Hr
• Oral glucocorticosteroids
• Continue for 1-3H, provided with
improvement
 Case

After continuous nebulization for one

hour. He was drowsy. Vital signs
revealed: heart rate= 180 beats/min,
respiratory rate= 50 breaths/min with
Oxygen saturation was 50% at
2L/minute O2 via nasal cannula.
 Case

P.E. :C/L findings revealed severe

retractions with use of accessory
muscles and absent breath sounds.
ABG showed Pc02 : 50 mm Hg and
P02 : 60 mm Hg
 Case

1. What is your assessment?

2. What will be your treatment?

 Poor response within 1-2H
• RFs for near fatal asthma
• PEF <30%
• PE: severe, drowsy, confused child
• pCO2 >45 mm Hg
• pO2 <60 mm Hg

Admit to Intensive Care

• O2; Inhaled beta-2 agonist ± inhaled anticholinergic
• IV glucocorticosteroids
• T/C IV beta-2 agonist, theophylline
• Possible intubation/MV