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National Institute of Health National Institute of Health 2007 Asthma Guideline2007 Asthma Guideline
Expert Panel Report (EPR) -3Expert Panel Report (EPR) -3
Bronchial AsthmaBronchial Asthma is a chronic is a chronic inflammatory inflammatory disorder of the airways characterized by disorder of the airways characterized by bronchial hyper-responsivenessbronchial hyper-responsiveness to a variety of to a variety of stimuli which lead to episodes of wide spread stimuli which lead to episodes of wide spread bronchial narrowing which is largely bronchial narrowing which is largely reversiblereversible either spontaneously or with treatment. either spontaneously or with treatment.
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PathogenesisPathogenesis
1)1) Lumen: Lumen: Mucus plugsMucus plugs
2)2) Mucosa: Mucosa: SwellingSwelling
3)3) Smooth Muscles: Smooth Muscles: SpasmSpasm
– Atopy, the genetic predisposition for the development of an immunoglobulin E (IgE)-mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma.
– However, not all people with allergies have asthma, and not all not all people with allergies have asthma, and not all cases of asthma can be explained by allergic response.cases of asthma can be explained by allergic response.
– Viral respiratory infections are one of the most important causes of asthma exacerbation.
– In some patients, persistent changes in airway structure occur, including sub-basement fibrosis, mucus hypersecretion, injury to epithelial cells, smooth muscle hypertrophy, and angiogenesis (remodeling)
Old Old && New Asthma Guidelines: New Asthma Guidelines:What has What has notnot changed changed
Initial therapyInitial therapy is determined by assessment of is determined by assessment of asthma severityasthma severity– Ideally, before the patient is on a long-term controllerIdeally, before the patient is on a long-term controller
Stepping therapyStepping therapy up or down is based on how well up or down is based on how well asthma controlasthma control is achieved.is achieved.
Inhaled corticosteroids (ICS)Inhaled corticosteroids (ICS) are the preferred first-line therapy for are the preferred first-line therapy for asthmaasthma
Systemic steroidsSystemic steroids can still be used to treat asthma exacerbations can still be used to treat asthma exacerbations Peak flows and written asthma action plans are recommended for Peak flows and written asthma action plans are recommended for
asthma self managementasthma self management – Especially in moderate and severe persistent asthma, or for those Especially in moderate and severe persistent asthma, or for those
with a history of severe exacerbations or poorly controlled asthmawith a history of severe exacerbations or poorly controlled asthma
4 Components of Asthma Management 4 Components of Asthma Management
Component 1Component 1:: Measures of Asthma Measures of Asthma Diagnosis & AssessmentDiagnosis & Assessment• DiagnosisDiagnosis• Differential diagnosisDifferential diagnosis• Assessment of severity Assessment of severity (intrinsic disease intensity)(intrinsic disease intensity)• Assessment of control Assessment of control (response to treatment)(response to treatment)• Assessment of risk Assessment of risk (probability of future morbid events)(probability of future morbid events)
Component 2Component 2:: EducationEducation for a Partnership in asthma care for a Partnership in asthma care
Component 3Component 3:: Control of Control of Environmental Factors & Environmental Factors & Comorbid ConditionsComorbid Conditions
Component 4Component 4:: MedicationsMedications
Component 1Component 1
Measures of Asthma Measures of Asthma Diagnosis & AssessmentDiagnosis & Assessment
Diagnosis of AsthmaDiagnosis of AsthmaTo establish a diagnosis of To establish a diagnosis of
asthma the clinician should asthma the clinician should determine thatdetermine that::
– Episodic symptoms of Episodic symptoms of airflow obstruction or airflow obstruction or airway hyperresponsiveness airway hyperresponsiveness are presentare present
– Airflow obstruction is at Airflow obstruction is at least partially reversibleleast partially reversible
– Alternative diagnoses are Alternative diagnoses are excluded.excluded.
AsthmaAsthma COPDCOPD
EpisodicEpisodicWorse early Worse early
morningmorningMucoid sputumMucoid sputum
History of other History of other allergiesallergies
PersistentPersistentConstant all Constant all
daydayMucopurulentMucopurulent
sputumsputumHistory of History of smokingsmoking
Methods to Establish Diagnosis Methods to Establish Diagnosis
– Medical historyMedical history: Atopy, provoking factors: Atopy, provoking factors– Physical exam:Physical exam: respiratory distress respiratory distress– Spirometry:Spirometry: Obstructive hypoventilation, BD Obstructive hypoventilation, BD
reversibility, bronchial provocation.reversibility, bronchial provocation.– PFM:PFM: (Peak Flow Meter) (Peak Flow Meter)– ABG.ABG.
Key Indicators: Diagnosis of AsthmaKey Indicators: Diagnosis of Asthma
Has/does the patient:Has/does the patient:– had an attack or recurrent attacks of wheezing?had an attack or recurrent attacks of wheezing?– have a troublesome cough at night?have a troublesome cough at night?– wheeze or cough after exercise?wheeze or cough after exercise?– experience wheezing, chest tightness, or cough experience wheezing, chest tightness, or cough
after exposure to airborne allergens or after exposure to airborne allergens or pollutants?pollutants?
– symptoms improved by appropriate asthma symptoms improved by appropriate asthma treatment?treatment?
Classification of Asthma Severity in Adults Classification of Asthma Severity in Adults >> 12 Years 12 Years
IntermittentPersistent
Mild Moderate Severe
Before starting medications, severity assessed by impairment
Symptoms < 2 d/w > 2 d/w daily continuous
Nighttime Awakening
< 2 x/m > 2 x/m > 1 x/w nightly
Activity Limitation
None Minor Moderate Extreme
SABA Use < 2 d/w > 2 d/w daily daily
FEV1 > 80% P > 80% P 60 – 80% P < 60% P
FEV1/FVC Normal Normal Reduced < 5% Reduced>5%
On medications, severity assessed by lowest level of treatment required to maintain control
Step 1 Step 2 Step 3 or 4 Step 5 or 6
Risk: Expected Exacerbations requiring Systemic Steroids/Year
0 - 1 > 2 > 2 > 2
and consider short course oforal systemic corticosteroids
Step 4 or 5Step 3Step 2Step 1
Recommended Stepfor Initiating Treatment
(See figure 4 5 for treatment steps.)In 2 6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly.
• Normal FEV1between exacerbations
Extremely limitedSome limitationMinor limitationNoneInterference with normal activity
Several timesper day
Daily>2 days/weekbut not daily, and
not more than1x on any day
2 days/weekShort-actingbeta2-agonist use for symptom control (not
prevention of EIB)
2/year (see note)0 1/year (see note)
• FEV1 <60% predicted
• FEV1 >60% but <80% predicted
• FEV1 >80% predicted
• FEV1 >80% predicted
• FEV1/FVCreduced >5%
• FEV1/FVC reduced 5%
• FEV1/FVC normal• FEV1/FVC normal
Risk
Relative annual risk of exacerbations may be related to FEV1.
Classification of Asthma Severity12 years of age
Consider severity and interval since last exacerbation.Frequency and severity may fluctuate over time for patients in any severity category.
Impairment
Normal FEV1/ FVC:8 19 yr 85%
20 39 yr 80%40 59 yr 75%60 80 yr 70%
PersistentComponents of Severity
Exacerbationsrequiring oral
systemic corticosteroids
Lung function
Often 7x/week>1x/week butnot nightly
3 4x/month2x/monthNighttime awakenings
Throughout the dayDaily>2 days/week but not daily
2 days/weekSymptoms
SevereModerateMildIntermittent
FE
V1/
FV
C
Classification of Asthma Control in Adults Classification of Asthma Control in Adults >> 12 Years 12 Years
Well Controlled
Not Well Controlled
Poorly Controlled
Symptoms < 2 d/w > 2 d/w continuous
Nighttime Awakening
< 2 x/m 1 – 3 x/w > 4x/w
Activity Limitation
None Moderate Extreme
SABA Use < 2 d/w > 2 d/wSeveral times
daily
FEV1 > 80% P 60 – 80% P < 60% P
PFR > 80% PB 60 – 80% PB < 60% PB
ATAQ 0 1 - 2 > 3
ATAQ: Asthma Therapy Assessment Questionnaire
PB: Personal Best
Asthma Therapy Assessment Questionnaire (ATAQ)Asthma Therapy Assessment Questionnaire (ATAQ)
0 :0 : Well Controlled Well Controlled 1 - 2 :1 - 2 : Not Well Controlled Not Well Controlled >> 3 : 3 : Poorly Controlled Poorly Controlled
>5 > 5
Component 2Component 2
Education for a Partnership in Education for a Partnership in Asthma CareAsthma Care
Key Educational MessagesKey Educational Messages– Significance of diagnosisSignificance of diagnosis– Inflammation as the underlying cause Inflammation as the underlying cause – Controllers vs. quick-relieversControllers vs. quick-relievers– How to use medication delivery devicesHow to use medication delivery devices– Triggers, including 2Triggers, including 2ndnd hand smoke hand smoke– PFM (peak flow monitoring) can be helpful to:PFM (peak flow monitoring) can be helpful to:
1.1. Detect early changes in asthma control that require Detect early changes in asthma control that require adjustments in treatmentEvaluate responses to changes adjustments in treatmentEvaluate responses to changes in treatmentin treatment
2.2. Provide a quantitative measure of impairmentProvide a quantitative measure of impairment
– Need for continuous, on-going interaction w/the clinician to Need for continuous, on-going interaction w/the clinician to step up/down therapystep up/down therapy
– Annual influenza vaccine Annual influenza vaccine
How to Use Metered Dose Inhalers
The health-care provider should evaluate inhaler technique at each visit.
MDI with Spacer (Holding Chamber) Spacers can help patients who
have difficulty with inhaler use.
The mouth piece may be equipped with a mask or a valve
Properly used MDI with VHC is as effective as nebulizer therapy.
Nebulizer
Machine produces a mist of the medication
Used for small children or for severe asthma episodes
No evidence that it is more effective than an inhaler used with a spacer
Peak Flow ChartPeak Flow Chart
People with People with moderate or moderate or severe asthma severe asthma should take should take readings:readings:– Every morningEvery morning– Every eveningEvery evening– After an After an
exacerbationexacerbation– Before inhaling Before inhaling
certain certain medicationsmedications
Self management education is Self management education is essential and should be integrated essential and should be integrated into all aspects of care; requires into all aspects of care; requires repetition and reinforcementrepetition and reinforcement
Provide Provide allall patients with a patients with a writtenwritten asthma action plan (esp if astma is asthma action plan (esp if astma is severe or poorly controlled) that severe or poorly controlled) that includes 2 aspects:includes 2 aspects:– Daily managementDaily management– How to recognize & How to recognize &
handle worsening asthma handle worsening asthma symptomssymptoms
Regular review of the status of Regular review of the status of patients asthma controlpatients asthma control
Develop an active partnership with Develop an active partnership with the patient and family.the patient and family.
Tailor the plan to needs of each Tailor the plan to needs of each patient.patient.
Asthma Action Plan
Component 3Component 3
Control of Environmental Factors Control of Environmental Factors && Comorbid Conditions that Affect AsthmaComorbid Conditions that Affect Asthma
Environmental FactorsEnvironmental Factors Patients should:Patients should:– Reduce exposure to allergens & irritants. Reduce exposure to allergens & irritants. – Avoid exertion outdoors when levels of air Avoid exertion outdoors when levels of air
pollution are high.pollution are high.– Avoid use of nonselective beta-blockers.Avoid use of nonselective beta-blockers.Clinicians shouldClinicians should::– Look for other chronic co-morbid conditions, Look for other chronic co-morbid conditions,
particularly when asthma control is not achieved.particularly when asthma control is not achieved.– Look for occupational exposures, particularly in Look for occupational exposures, particularly in
those with new onset work related asthma.those with new onset work related asthma.– Encourage patients to receive a yearly influenza Encourage patients to receive a yearly influenza
vaccine (inactivated).vaccine (inactivated).– Consider allergen immunotherapy when Consider allergen immunotherapy when
appropriate.appropriate.
Component 4Component 4
MedicationsMedications
22 general classes:general classes: Long-term control medications:Long-term control medications:
– Corticosteroids (mainly ICS, occasionally OCS).Corticosteroids (mainly ICS, occasionally OCS).– Long Acting Beta Agonists (LABA’s)Long Acting Beta Agonists (LABA’s)– Leukotriene Modifiers (LTM)Leukotriene Modifiers (LTM)– Cromolyn & NedocromilCromolyn & Nedocromil– Methylxanthines:Methylxanthines: ( (Sustained-release theophylline) Sustained-release theophylline)
Quick- relief medications:Quick- relief medications:– Short acting Beta Agonists (SABA’s)Short acting Beta Agonists (SABA’s)– Systemic corticosteroidsSystemic corticosteroids– AnticholinergicsAnticholinergics
Safety of Inhaled CorticosteroidsSafety of Inhaled Corticosteroids– ICS’s are the most effective long-term therapy available, ICS’s are the most effective long-term therapy available, – well tolerated & safe at recommended doseswell tolerated & safe at recommended doses– The potential but small risk of adverse events from the use The potential but small risk of adverse events from the use
of ICS treatment is well balanced by their efficacyof ICS treatment is well balanced by their efficacy– Local SE: hoarseness, oral candidiasis.Local SE: hoarseness, oral candidiasis.– Systemic SE: delayed linear growth in children, other Systemic SE: delayed linear growth in children, other
steroid effects.steroid effects.
Patients should rinse their mouths (rinse and spit) after Patients should rinse their mouths (rinse and spit) after (ICS) inhalation(ICS) inhalation
Use the lowest dose of ICS that maintains asthma control: Use the lowest dose of ICS that maintains asthma control: – Evaluate patient adherence and inhaler technique as well as Evaluate patient adherence and inhaler technique as well as
environmental factors before increasing the dose of ICSenvironmental factors before increasing the dose of ICS Monitor linear growth in childrenMonitor linear growth in children
Safety of Long-Acting BetaSafety of Long-Acting Beta22-Agonists -Agonists (LABA’s)(LABA’s)– Adding a LABA to the treatment of patients whose asthma is not well Adding a LABA to the treatment of patients whose asthma is not well
controlled on low- or medium-dose ICS improves lung function, controlled on low- or medium-dose ICS improves lung function, decreases symptoms, and reduces exacerbations and use of SABA for decreases symptoms, and reduces exacerbations and use of SABA for quick relief. quick relief.
– However, FDA analysis of studies showed an However, FDA analysis of studies showed an increased risk of severe increased risk of severe exacerbationsexacerbations of asthma symptoms and of asthma symptoms and death death associated with LABA use. associated with LABA use.
– For patients who have asthma not sufficiently controlled with ICS alone, For patients who have asthma not sufficiently controlled with ICS alone, the option to increase the ICS dose should be given the option to increase the ICS dose should be given equal weightequal weight to the to the option of the addition of a LABA to ICSoption of the addition of a LABA to ICS
– It is not currently recommended that LABA be used for treatment of It is not currently recommended that LABA be used for treatment of acute symptoms or exacerbationsacute symptoms or exacerbations
– LABAs are not to be used as monotherapy for long-term control. LABAs are not to be used as monotherapy for long-term control. Combined preparations ensure compliance for this, eg Symbicort Combined preparations ensure compliance for this, eg Symbicort (Formoterol + Budesonide).(Formoterol + Budesonide).
– SABAs are the most effective medication for relieving SABAs are the most effective medication for relieving acute bronchospasm.acute bronchospasm.
– Only selective Only selective 2 2 agonists are recommended.agonists are recommended.– SABA administered by the inhaled route provide as SABA administered by the inhaled route provide as
great or greater bronchodilatation with fewer SE than great or greater bronchodilatation with fewer SE than either the parenteral or oral routes.either the parenteral or oral routes.
– Increasing use of SABA treatment or using SABA >2 days Increasing use of SABA treatment or using SABA >2 days a week for symptom relief (not prevention of EIB) a week for symptom relief (not prevention of EIB) indicates inadequate control of asthma.indicates inadequate control of asthma.
– Regularly scheduled, daily, chronic use of SABA is Regularly scheduled, daily, chronic use of SABA is notnot recommended.recommended.
Safety of Short-Acting BetaSafety of Short-Acting Beta22-Agonists -Agonists (SABA’s)(SABA’s)
Managing Asthma Long Term Managing Asthma Long Term ““The Stepwise Approach”The Stepwise Approach”
““The goal of asthma therapy is to maintain The goal of asthma therapy is to maintain long-term control of asthma with the least long-term control of asthma with the least amount of medications and hence minimal amount of medications and hence minimal
risk for adverse effects”risk for adverse effects”..
Principles of Step Therapy to Maintain ControlPrinciples of Step Therapy to Maintain Control
Step up medication dose if symptoms are not Step up medication dose if symptoms are not controlledcontrolled
If very poorly controlled, consider an increase by 2 If very poorly controlled, consider an increase by 2 steps, add oral corticosteroids, or bothsteps, add oral corticosteroids, or both
Before increasing medication therapy, evaluate:Before increasing medication therapy, evaluate:– Exposure to environmental triggers Exposure to environmental triggers – Adherence to therapyAdherence to therapy– Technique of device use.Technique of device use.– Co-morbiditiesCo-morbidities
Follow-up AppointmentsFollow-up Appointments
Visits every 2-6 weeks until asthma control is achievedVisits every 2-6 weeks until asthma control is achieved When control is achieved, follow-up every 3-6 monthsWhen control is achieved, follow-up every 3-6 months Step-down in therapyStep-down in therapy::
– When asthma is well-controlled for at least 3 monthsWhen asthma is well-controlled for at least 3 months Patients may relapse with total discontinuation or Patients may relapse with total discontinuation or
reduction of inhaled corticosteroidsreduction of inhaled corticosteroids
IntermittentAsthma
Persistent Asthma: Daily MedicationConsult asthma specialist if step 4 care or higher is required.
Consider consultation at step 3
Step 1
Preferred:SABA PRN
Step 2
Preferred:Low dose ICS
Alternative: Cromolyn, LTRA, Nedocromil or Theophylline
Step 3Preferred:
Low-dose ICS + LABA OR – Medium dose ICS
Alternative: Low-dose ICS + either LTRA, Theophylline, or Zileuton
Step 4
Preferred:Medium Dose ICS + LABA
Alternative:Medium-dose ICS + either LTRA, Theophylline, or Zileuton
Step 5
PreferredHigh Dose ICS + LABA
AND
Consider Omalizumab for patients who have allergies
Step 6
PreferredHigh dose ICS + LABA + oral corticosteroid
AND
Consider Omalizumab for patients who have allergies
Each Step: Patient Education and Environmental Control and management of comorbiditiesSteps 2 – 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma
Stepwise Approach for Managing Asthma in Youths >12 Years of Age & Adults
•Quick-relief medication for ALL patients -SABA as needed for symptoms: up to 3 tx @ 20 minute intervals prn. Short course of o systemic corticosteroids may be needed.• Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control & the need to step up treatment.
Step down if
possible
(and asthma is well
controlled at least 3
months)
Assess control
Step up if needed
(first check adherence, environmental control & comorbid conditions)
Managing Exacerbations of AsthmaManaging Exacerbations of Asthma
ExacerbationsExacerbations are acute or subacute episodes of are acute or subacute episodes of progressively worsening shortness of breath, progressively worsening shortness of breath, cough, and wheezing.cough, and wheezing.
Are characterized by decreases in expiratory Are characterized by decreases in expiratory airflow that can be documented and quantified by airflow that can be documented and quantified by spirometry or peak expiratory flow.spirometry or peak expiratory flow.
Indications of a Severe AttackIndications of a Severe Attack
Breathless at restBreathless at rest Leaning forwardLeaning forward Speaks in words rather than complete Speaks in words rather than complete
sentences sentences AgitatedAgitated Peak flow rate less than 60% of normalPeak flow rate less than 60% of normal
Early treatment of asthma exacerbations is the best strategy for managementEarly treatment of asthma exacerbations is the best strategy for management::
Patient education includes a written asthma action plan (AAP) to guide patient Patient education includes a written asthma action plan (AAP) to guide patient self management of exacerbations‑self management of exacerbations‑– especially for patients who have moderate or severe persistent asthma especially for patients who have moderate or severe persistent asthma
and any patient who has a history of severe exacerbationsand any patient who has a history of severe exacerbations A peak flow based plan for patients who have difficulty perceiving airflow ‑ ‑A peak flow based plan for patients who have difficulty perceiving airflow ‑ ‑
obstruction and worsening asthma is recommendedobstruction and worsening asthma is recommended
– Recognition of early signs of worsening asthma & taking Recognition of early signs of worsening asthma & taking prompt actionprompt action
– Appropriate intensification of therapy, often including a Appropriate intensification of therapy, often including a short course of oral corticosteroidsshort course of oral corticosteroids
– Removal or avoidance of the environmental factors Removal or avoidance of the environmental factors contributing to the exacerbationcontributing to the exacerbation
– Prompt communication between patient and clinician.Prompt communication between patient and clinician.
Classifying Severity of Asthma ExacerbationsClassifying Severity of Asthma Exacerbations
SeveritySeverity Dyspnoea FEV1 %POr PEF/PB
Clinical Course
MildExertional 2 / tachypnoea
> 70
Usually cared for at home Prompt relief with inhaled SABA
Moderate Exertional 340 – 70
Usually requires office or Emergency Department visit
Relief from freq. inhaled SABA Oral systemic corticosteroids
Severe Exertional 4 (at rest)25 - 40
Usually requires ED visit and likely hospitalization
Partial relief from frequent inhaled SABA
PO systemic corticosteroids; some symptoms last >3 days after treatment is begun
Adjunctive therapies are helpful
Life Threatening Too dyspneic to speak
< 25
Requires ED/hospitalization; possible ICU
Minimal or no relief w/ frequent inhaled SABA
Intravenous corticosteroids Adjunctive therapies are helpful
What the EPR -3 Does What the EPR -3 Does NOTNOT Recommend Recommend
– Drinking large volumes of liquids or breathing warm, Drinking large volumes of liquids or breathing warm, moist air moist air (e.g., the mist from a hot shower)(e.g., the mist from a hot shower)
– Using over-the-counter products such as antihistamines Using over-the-counter products such as antihistamines or cold remediesor cold remedies
– Although pursed-lip and other forms of controlled Although pursed-lip and other forms of controlled breathing may help to maintain calm during respiratory breathing may help to maintain calm during respiratory distress, these methods do distress, these methods do not not bring about bring about improvement in lung functionimprovement in lung function