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8/14/2019 Asthma; Basis of Current Management
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Basis of Current Management in
Asthma
AE Orimadegun AE Orimadegun
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OUTLINE…
DefinitionDefinitionEpidemiologyEpidemiologyPathogenesis/PathophysiologyPathogenesis/PathophysiologyRisk FactorsRisk FactorsMechanismsMechanisms
Diagnosis and ClassificationDiagnosis and ClassificationEducation and Delivery of CareEducation and Delivery of CareSix Part Asthma Management PlanSix Part Asthma Management Plan
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Definition of Asthma
Asthma is a chronic inflammatory disorder of theAsthma is a chronic inflammatory disorder of theairways in which many cells and cellular elements playairways in which many cells and cellular elements playa rolea role
Chronic inflammation causes an associated increase inChronic inflammation causes an associated increase inairway hyperresponsiveness that leads to recurrentairway hyperresponsiveness that leads to recurrentepisodes of wheezing, breathlessness, chest tightness,episodes of wheezing, breathlessness, chest tightness,and coughing, particularly at night or in the earlyand coughing, particularly at night or in the early
morningmorningThese episodes are usually associated withThese episodes are usually associated withwidespread but variable airflow obstruction that is oftenwidespread but variable airflow obstruction that is oftenreversible either spontaneously or with treatmentreversible either spontaneously or with treatment
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Most common chronic illness in childhoodworldwide
Between 100 - 150 million people suffer fromasthma worldwide 1
Worldwide prevalence rates are increasing, onaverage, by 50% per decade 1
Worldwide costs of asthma greater is than HIV /AIDS and tuberculosis combined 1
1. WHO, Bronchial Asthma Fact Sheet 20002. GINA Guidelines 1998
Facts and figures
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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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7070
6060
5050
4040
3030
20208585 8686 8787 8888 8989 9090 9191 9292 9393 9494
Rate/1,000 PersonsRate/1,000 Persons
Year Year
<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
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44
33
11
19801980
Rate/100,000 PersonsRate/100,000 Persons
Year Year
22
0019851985 19901990 19951995 20002000
Black MaleBlack Male
White FemaleWhite Female
White MaleWhite Male
Black FemaleBlack Female
Death Rates for AsthmaDeath Rates for AsthmaBy Race, Sex,By Race, Sex, U.S., 1980-1998U.S., 1980-1998
55
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Pathogenesis/PathophysiologyPathogenesis/Pathophysiology
Complex, chronic inflammatory disorder of the airwayComplex, chronic inflammatory disorder of the airwayImmunopathologic features include:Immunopathologic features include:
Denudation of airway epithelium
Collagen deposition beneath the basement membraneOedema
Mast cell activation
Inflammatory cell infiltration Neutrophils
Eosinophils
Lymphocytes (TH2-like cells)
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Pathogenesis/PathophysiologyPathogenesis/Pathophysiology
Airway inflammation results in:Airway inflammation results in:HyperresponsivenessHyperresponsiveness
Limitation of airfowLimitation of airfow
Airway oedemaAirway oedema
Acute bronchoconstrictionAcute bronchoconstriction
Mucus plug formationMucus plug formation
Disease chronicityDisease chronicity
Atopy is the strongest predisposing factor Atopy is the strongest predisposing factor for asthmafor asthma
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MucushypersecretionHyperplasia
Eosinophil
Mast cell
Allergen
Th2 cell
VasodilatationNew vessels
Plasma leakOedema
Neutrophil
Mucus plug
Macrophage/ dendritic cell
BronchoconstrictionHypertrophy / hyperplasia
Cholinergicreflex
Epithelial shedding
Subepithelialfibrosis
Sensory nerveactivation
Nerve activat ion
Modern view of pathophysiology…
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Inflammatory processes
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Pathogenesis/PathophysiologyPathogenesis/Pathophysiology
Risk FactorsRisk Factors(for development of asthma)(for development of asthma)
INFLAMMATIONNFLAMMATION
AirwayAirway
HyperresponsivenessHyperresponsivenessAirflow ObstructionAirflow Obstruction
Risk FactorsRisk Factors(for exacerbations)(for exacerbations)
SymptomsSymptoms
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Risk Factors for AsthmaRisk Factors for Asthma
Host factors: predispose individuals to,or protect them from, developing
asthmaEnvironmental factors: influencesusceptibility to development of asthma
in predisposed individuals, precipitateasthma exacerbations, and/or causesymptoms to persist
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Risk Factors for AsthmaRisk Factors for AsthmaHost Factors
Genetic predispositionAtopy – IgE mediated response to allergenAirway hyperresponsivenessGender
Race/EthnicityEnvironmental 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 toRisk Factors that Lead toAsthma DevelopmentAsthma 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 AsthmaFactors that Exacerbate Asthma
AllergensAllergens
Air PollutantsAir Pollutants
Respiratory infectionsRespiratory infections
Exercise and hyperventilationExercise and hyperventilation
Weather changesWeather changesSulfur dioxideSulfur dioxide
Food, additives, drugsFood, additives, drugs
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Is it Asthma?Is it 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 pollutantspollutantsColds “go to the chest” or take moreColds “go to the chest” or take morethan 10 days to clear than 10 days to clear
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Asthma DiagnosisAsthma Diagnosis
History and patterns of symptoms
Physical examination
Measurements of lung function
Reversibility test
Diurnal variation
Measurements of allergic status toidentify risk factors
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Reversibility of airways’ obstruction – increased PEF >15% 15-20 minutes after inhaling ß 2-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 – Pc 20 FEV 1 methacholine and histamine
GINA Guidelines 1998 **not covered by GINA
v v wlimitation
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Classification of SeverityClassification of Severity
CLASSIFY SEVERITYClinical Features Before Treatment
SymptomsSymptoms NocturnalNocturnalSymptomsSymptoms
FEVFEV 11 or PEFor PEF
STEP 4STEP 4
SevereSeverePersistentPersistent
STEP 3STEP 3
ModerateModeratePersistentPersistent
STEP 2STEP 2
MildMildPersistentPersistent
STEP 1STEP 1IntermittentIntermittent
ContinuousContinuous
Limited physicalLimited physicalactivityactivity
DailyDailyAttacks affect activityAttacks affect activity
> 1 time a week> 1 time a week
but < 1 time a daybut < 1 time a day
< 1 time a week< 1 time a week
AsymptomaticAsymptomaticand normal PEFand normal PEFbetween attacksbetween attacks
FrequentFrequent
> 1 time week> 1 time week
> 2 times a month> 2 times a month
≤ 2 times a2 times amonthmonth
≤ 60% predicted60% predicted
Variability > 30%Variability > 30%
60 - 80% predicted60 - 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.
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1. Educate Patients
2. Assess and Monitor Severity
3. Avoid Exposure to Risk Factors4. Establish Medication Plans for Chronic
Management
5. Establish Plans for Managing Exacerbations
6. Provide Regular Follow-up Care
Six-Part Asthma ManagementProgram
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Six-part Asthma Management ProgramSix-part Asthma Management Program
Goals of Long-term ManagementGoals of Long-term Management
Achieve and maintain control of symptomsPrevent asthma episodes or attacksMaintain pulmonary function as close to normallevels as possibleMaintain normal activity levels, includingexercise
Avoid adverse effects from asthma medicationsPrevent development of irreversible airflowlimitationPrevent asthma mortality
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Six-Part Asthma ManagementSix-Part Asthma ManagementProgramProgram
The most effective management is toprevent airway inflammation byeliminating the causal factors
Asthma can be effectively controlled inmost patients, although it can not becured
The major factors contributing to asthmamorbidity and mortality are under-diagnosis and inappropriate treatment
.
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Six-Part Asthma ManagementSix-Part Asthma ManagementProgramProgram
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
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Six-part Asthma Management Program
Part 1: Educate Patients toDevelop a Partnership
Patient education involves a partnershipbetween the patient and health care
professional(s) with frequent revision andreinforcement
Aim is guided self-management – givingpatients the ability to control their asthma
Interventions, including use of writtenaction plans, have been shown to reducemorbidity in both children and adults
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Six-part Asthma Management Program
Part 1: Educate Patients toDevelop a Partnership
Guidelines on asthma management shouldbe available but adapted and adopted for
local use by local asthma planning teamsClear communication between health careprofessionals and asthma patients is key toenhancing compliance
Educate continually
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Part 2: Assess and Monitor Asthma Severity withSymptom Reports and Measures of Lung Function
Symptom reportsUse of reliever medicationNighttime symptomsActivity limitations
Spirometry for initial assessment. PeakExpiratory Flow for follow-up:
Assess severityAssess response to therapy
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Part 2: Assess and Monitor Asthma Severity withSymptom Reports and Measures of LungFunction
• 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
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Si A h M P
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Six-part Asthma Management Program
Part 3: Avoid Exposure to RiskFactors
Methods to prevent onset of asthma arenot yet available but this remains an
important goalMeasures to reduce exposure to causesof asthma exacerbations ( e.g. allergens,
pollutants, foods and medications) shouldbe implemented whenever possible
Si A h M P
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Six-part Asthma Management Program
Part 3: Avoid Exposure to RiskFactors
Reduce exposure to indoor allergensReduce exposure to indoor allergens
Avoid tobacco smokeAvoid tobacco smoke
Avoid vehicle emissionAvoid vehicle emission
Explore role of infections on asthmaExplore role of infections on asthma
development, especially in children anddevelopment, especially in children andyoung infantsyoung infants
Si t A th M g t P g
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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 inhaledglucocorticosteroids markedly reduces thefrequency and severity of exacerbations
Six part Asthma Management Program
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Six-part Asthma Management Program
Part 4: Establish Medication Plans for Long-Term Asthma Management
A stepwise approach to pharmacologicalA stepwise approach to pharmacologicaltherapy is recommendedtherapy 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
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Part 4: Long-term Asthma Management
Pharmacologic Therapy
Reliever Medications:
Rapid-acting inhaled β 2-agonists
Systemic glucocorticosteroids
Anticholinergics
MethylxanthinesShort-acting oral β 2-agonists
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Part 4: Long-term Asthma Management
Allergen-specific Immunotherapy
Greatest benefit of specific immunotherapyusing allergen extracts has been obtained inthe treatment of allergic rhinitis
Specific immunotherapy should beconsidered only after strict environmental
avoidance and pharmacologic interventionhave failed to control asthma
Perform only by trained physician
Six part Asthma Management Program
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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.
Six-part Asthma Management Program
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Six-part Asthma Management Program
Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and
ChildrenLong-term treatment with inhaledglucocorticosteroids has not been shownto be associated with any increase inosteoporosis or bone fractureStudies including a total of over 3,500children treated for periods of 1 – 13 yearshave found no sustained adverse effect of inhaled glucocorticosteroids on growth
Six-part Asthma Management Program
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Six-part Asthma Management Program
Part 4: Establish Medication Plans for Long-Term Asthma Management in
Infants and Children
Rapid-acting inhaled β 2- agonists are
the most effective reliever therapy for childrenThese medications are the most
effective bronchodilators available andare the treatment of choice for acuteasthma symptoms
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Recommended Asthma MedicationsRecommended Asthma MedicationsStep 1: Children Younger Than 5yrsStep 1: Children Younger Than 5yrs
• NoneNone • NoneNone Step 1:Step 1:IntermittentIntermittent
Other OptionsOther Options (in order (in order of cost)of cost)
Daily Controller Daily Controller MedicationsMedications
SeveritySeverity
Reliever Medication: Rapid-acting inhaledReliever Medication: Rapid-acting inhaled ββ 22- agonist prn, not more- agonist prn, not morethan 3-4 times a day. Once control is achieved and maintained for atthan 3-4 times a day. Once control is achieved and maintained for atleast 3 months, gradual reduction of therapy should be tried.least 3 months, gradual reduction of therapy should be tried.
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Recommended Asthma MedicationsRecommended Asthma MedicationsStep 2: Children Younger Than 5 yrsStep 2: Children Younger Than 5 yrs
• Sustained-releaseSustained-releasetheophylline,theophylline, or or
• Cromone,Cromone, or or
•Leukotriene modifier Leukotriene modifier
• Low-dose inhaledLow-dose inhaledglucocorticosteroidglucocorticosteroid
Step 2:MildPersistent
Other OptionsOther Options (in order (in order of cost)of cost)
Daily Controller Daily Controller MedicationsMedications
SeveritySeverity
Reliever Medication: Rapid-acting inhaledReliever Medication: Rapid-acting inhaled ββ 22 - agonist prn, not more- agonist prn, not morethan 3-4 times a day. Once control is achieved and maintained for atthan 3-4 times a day. Once control is achieved and maintained for atleast 3 months, gradual reduction of therapy should be tried.least 3 months, gradual reduction of therapy should be tried.
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Recommended Asthma MedicationsRecommended Asthma MedicationsStep 3: Children Younger Than 5yrsStep 3: Children Younger Than 5yrs
• Medium-dose inhaled glucocorticosteroidMedium-dose inhaled glucocorticosteroid plus plus sustained-release tsustained-release t heophylline,heophylline, or or
• Medium-dose inhaled glucocorticosteroidMedium-dose inhaled glucocorticosteroid plus plus long-acting inhaledlong-acting inhaled ββ 22- agonist,- agonist, or or
• High-dose inhaled glucocorticosteroidHigh-dose inhaled glucocorticosteroid ,, or or
• Medium-doseMedium-dose InhaledInhaledglucocorticosteroidglucocorticosteroid plus plus leukotrieneleukotrienemodifier modifier
• Medium-dose inhaledMedium-dose inhaledglucocorticosteroidglucocorticosteroid
Step 3:Step 3:ModerateModeratepersistentpersistent
Other Options (in order of cost)Other Options (in order of cost)Daily Controller Daily Controller MedicationsMedications
SeveritySeverity
Reliever Medication: Rapid-acting inhaledReliever Medication: Rapid-acting inhaled ββ 22- agonist prn, not more- agonist prn, not morethan 3-4 times a day. Once control is achieved and maintained for atthan 3-4 times a day. Once control is achieved and maintained for atleast 3 months, gradual reduction of therapy should be tried.least 3 months, gradual reduction of therapy should be tried.
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Recommended Asthma MedicationsRecommended Asthma MedicationsStep 4: Children Younger Than 5yrsStep 4: Children Younger Than 5yrs
• High-dose inhaled glucocorticosteroidHigh-dose inhaled glucocorticosteroid plus plus one or more of the following, if one or more of the following, if
needed:needed:- Sustained-release theophylline- Sustained-release theophylline- Leukotriene modifier - Leukotriene modifier - Long-acting inhaled- Long-acting inhaled ββ 22 - agonist- agonist
- Oral glucocorticosteroid- Oral glucocorticosteroid
Step 4Step 4SevereSevere
persistentpersistent
Other Other OptionsOptions
Daily Controller MedicationsDaily Controller MedicationsSeveritySeverity
Reliever Medication: Rapid-acting inhaledReliever Medication: Rapid-acting inhaled ββ 22- agonist prn, not more- agonist prn, not morethan 3-4 times a day. Once control is achieved and maintained for atthan 3-4 times a day. Once control is achieved and maintained for at
least 3 months, gradual reduction of therapy should be tried.least 3 months, gradual reduction of therapy should be tried.
Six-part Asthma Management Program
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Six part Asthma Management Program
Part 5: Establish Plans for ManagingExacerbations
Primary therapies for exacerbations:• Repetitive administration of rapid-acting
inhaled β 2-agonist• Early introduction of systemic
glucocorticosteroids
• Oxygen supplementationClosely monitor response to treatmentwith serial measures of lung function
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Acute Asthma
Good Response
Observe for atleast 1 hour
If Stable,Discharge to
Home
Initial AssessmentHistory, Physical Examination, PEF or FEV 1
Initial TherapyBronchodilators; O 2 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
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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 recordsTechniques in use of medicationsRisk factors and their control
Once asthma control is established, follow-upvisits should be scheduled (at 1 to 6 month intervalsas appropriate)
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Six-part Asthma ManagementProgram: Summary (continued)
Anything more than mild, occasional asthma isAnything more than mild, occasional asthma ismore effectively controlled by suppressingmore effectively controlled by suppressinginflammation than by only treating acuteinflammation than by only treating acutebronchospasmbronchospasm
The availability of varying forms of treatment,The availability of varying forms of treatment,cultural preferences, and differing health carecultural preferences, and differing health caresystems need to be consideredsystems need to be considered
Recommended