Asthma Lecture Cagayan De Oro Pediatric A 2008

UPDATES IN THE DIAGNOSIS, MANAGEMENT AND PREVENTION OF ASTHMA IN CHILDREN Raymund L. Manuel M.D., D.P.P.S.,D.P.A.P.P. Pediatric Pulmonologist

OBJECTIVES • To present and compare the GINA 2002 with GINA 2006 guidelines • To update clinicians with the newer approach to the management asthma in children

GLOBAL INITIATIVE FOR ASTHMA (G.I.N.A.)

Initiated in 1989 • US National Heart, Lung and Blood Institute • National Institute of Health • World Health Organization • Undergone 3 major revisions (1995, 2002, 2006) OBJECTIVES: • To increase appreciation for global public health perspectives of asthma • Recommend diagnostic and management strategies • Identify areas for future investigations

GLOBAL INITIATIVE FOR ASTHMA (G.I.N.A.)

Undergone 3 major revisions (1995, 2002, 2006) Why was a revision necessary ? 5. Current level of control around the world fall short of GINA goals 7. The Philippines is also “missing the mark”

Global Initiative for Asthma (GINA) 2006 Updates The cost to control asthma seems high, but the cost of not treating asthma correctly is even higher. Concept of “Difficult to treat Asthma” is introduced. Patients with difficult to treat asthma are often rarely insensitive to the effects of glucocorticoid medications and may sometimes be unable to achieve the same level of control as other asthma patients.

GINA ASTHMA GUIDELINES: 2002

2006

OPERATIONAL DEFINITION: “ Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. The chronic inflammation is associated with airway hyper responsiveness 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 within the lung that is often reversible either spontaneously or with treatment”

GINA ASTHMA GUIDELINES: 2002

2006

PATHOLOGY: Acute and Chronic Inflammation Inflammation is persistent Inflammation affects more in the medium

all airways sized bronchi

GINA ASTHMA GUIDELINES: 2002 Pathophysiology:

2006

Airway Narrowing : - Airway smooth muscle contraction - Airway edema - Airway thickening - Mucus hyper secretion Airway Hyper responsiveness

GINA ASTHMA GUIDELINES: 2002

2006

Factors Influencing the Development and Expression of Asthma HOST FACTORS Genetic, e.g., Genes pre-disposing to atopy Genes pre-disposing to airway hyperresponsiveness Obesity Sex ENVIRONMENTAL FACTORS Allergens Indoor: Domestic mites, furred animals(dogs, cats, mice) cockroach allergen, fungi, molds, yeast Outdoor: Pollens, fungi, molds, yeasts Infections (predominantly viral) Occupational sensitizers Tobacco smoke Passive smoking Active smoking Outdoor/Indoor Air Pollution Diet

Global Initiative for Asthma (GINA) 2006 updates Lung function testing by spirometry of Peak expiratory flow (P.E.F.) continues to be recommended as an aid to the diagnosis and monitoring. Measuring the variability of airflow is the key to both asthma diagnosis and the assessment of asthma control.

ASTHMA: Diagnosis Predicted normal PEFR in Filipino Children between 6 – 17 years with height of at least 100 cms. 3) Males: (Height in cm. – 100) 5 + 175 2) Females: (Height in cm – 100) 5 + 170

ASTHMA: Diagnosis

Peak Flow Variability =

Highest reading - Lowest reading Highest Reading

X 100

Global Initiative for Asthma (GINA) 2006 updates

The previous classification by asthma severity into Intermittent, Mild Persistent, Moderate Persistent and Severe Persistent is now recommended only for research purposes.

GINA ASTHMA GUIDELINES: 2 002

Diagnosis and Classification Classification of Asthma Severity by Clinical Features Before Treatment Intermittent: Symptoms less than once a week Brief exacerbations Nocturnal symptoms NOT more than twice a month FEV1 or PEF≥80% Predicted PEF or FEV1 variability 20-30%

Mild Persistent: Symptoms more Than once a week But less than once A day Exacerbations may Affect activity and Sleep Nocturnal symptoms More than twice a Month FEV1 or PEF≥ 80% Predicted PEF or FEV1 variability 20-30%

Moderate Persistent: Symptoms daily Exacerbations may Affect activity and sleep Nocturnal symptoms more than once a week Daily use of inhaled short acting β2-agonist FEV1 or PEF 60-80% Predicted PEF or FEV1 variability>30% variability>30

Severe Persistent: Symptoms daily Frequent exacerbations Frequent Nocturnal asthma symptoms Limitation of physical activities FEV1 or PEF ≤60% Predicted PEF or FEV1 Variability > 30%

Classification of Asthma Based on Severity: (GINA 2002)

Severity PERSISTENT

INTERMITTENT Mild

Moderate

Severe Daytime Symptoms

< 1x a week

≥1x/wk

Daily Affects daily

Daily Limits

daily activities activities Nighttime Symptoms Frequent

≤ 2x/month

PEF

≥ 80% predicted

PEF Variability

≤ 20%

>2x/month ≥80% predicted 20-30%

>1x/week

>60-<79% predicted >30%

<60% predicted

Global Initiative for Asthma (GINA) 2006 updates Instead, the GINA report of 2006, recommends a classification of asthma by level of control: Controlled, Partly Controlled, or Uncontrolled. This reflects the understanding that asthma severity does not only involve the severity of the underlying disease but also its responsiveness to treatment.

LEVEL OF CONTROL

REDUCE

GINA 2006, 2007

TREATMENT OF ACTION maintain and find lowest controlling step

partly controlled

consider stepping up to gain control

uncontrolled

exacerbation

INCREASE

controlled

step up until controlled

treat as exacerbation

GINA ASTHMA GUIDELINES: 2002 EMPHASIS:

CLASSIFICATION OF PATIENT BY SEVERITY

DEFINITION: IMPACT OF THE DISEASE ON LUNG FUNCTION - airflow limitation - its reversibility - airway hyperresponsiveness

2006 ASTHMA MANAGEMENT BASED ON CLINICAL CONTROL

CLINICAL,PHYSIOLOGICAL AND PATHOLOGICAL CHARACTERISTICS - episodic shortness of breathing - wheezing - cough

GINA ASTHMA GUIDELINES 2002, 2006, 2007

DIAGNOSIS: 2002 Reversibility of measurements of lung function enhances confidence in making a diagnosis of asthma

Asthma severity: Amount of daily medications required for optimal treatment

2006 - 07 Often prompted by symptoms: episodic breathlessness wheezing cough chest tightness Assessment of the severity of airflow limitation Reversibility and variability confirms the Diagnosis of asthma Asthma severity is measured NOT by severity of the underlying disease BUT its responsiveness to treatment

Measurement of allergic state helps to identify Risk factors that causes asthma symptoms in patients

How do I Implement it in my Clinic ?

Asthma Patient

Exacerbation ?

Yes

Management of Therapy Exacerbation

No

Chronic

Level of Control

Chronic Therapy

ASTHMA CONTROL (GINA 2006)

• Refers to control of the clinical symptoms of the disease • Treatment is aimed at controlling the clinical features of disease

GINA ASTHMA GUIDELINES: 2002

2006-07 Clinical Control of asthma is defined as: • No (twice or less/weekly) daytime symptoms • No limitations of daily activities, including exercise • No nocturnal symptoms or awakening because of asthma • No (twice or less/week) need for reliever treatment • Normal or near normal lung function • No exacerbations

GINA ASTHMA GUIDELINES: 2006 Levels of Asthma Control Characteristic

Controlled (All of the ff)

Partly Controlled (Any measure present in any week)

Daytime symptoms

None (2x or
More than 2x/wk

Limitations of activities

None

Any

Nocturnal symptoms/ awakening

None

Any

Need for reliever/rescue tx

None (2x or less/week)

More than 2x/ wk

Lung function (PEF or FEV1)+

Normal

<80% predicted or personal best (if known)

Exacerbations

None

One or more/ yr*

Uncontrolled

Three or more features of partly controlled asthma present in any week

One in any wk╪

Global Initiative for Asthma (GINA) 2006 updates Treatment options are organized into five “Steps” reflecting the intensity of treatment. At all steps, a reliever medication should be provided for as needed use. At steps 2 through 5, a variety of controller medications are available.

Global Initiative for Asthma (GINA) 2006 Updates Entry Point ? Step 2: Is the initial treatment for most treatment naïve patients with persistent asthma symptoms Step 3: Commence treatment here if symptoms at the initial consult suggest that asthma is severely uncontrolled

Treating to Achieve Asthma Contr 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  A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A)  Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids

Treating to Achieve Asthma Control Step 3 – Reliever medication plus one or two controllers  For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled longacting β2-agonist either in a combination inhaler device or as separate components (Evidence A)  Inhaled long-acting β2-agonist must not be used as monotherapy  For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)

CAUTION Long acting β 2 agonists should be used regularly only with inhaled steroids. Long acting β 2 agonists should not be used as a rescue therapy.

TOLERANCE • Subsensitivity/down-regulation of β2 receptors

CLINICAL SIGNIFICANCE OF TOLERANCE Decreased bronchoprotection Increased vulnerability to attacks Normal lung function in between attacks

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 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 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 β2agonist, 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 longacting β2-agonist (Evidence D)

Treating to Maintain Asthma Control Stepping up treatment in response to loss of control

 Rapid-onset, short-acting inhaled β2agonist 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 Patient

Exacerbation ?

Yes

Management of Therapy Exacerbation

No

Chronic

Level of Control

GINA ASTHMA GUIDELINES: 2002

2006-07

Asthma in Acute Exacerbation

INA 2002, 2006, 2007

Severity of Asthma MILD MODERATE Exacerbations Breathless

Walking

SEVERE

Can lie flat

Talking Infants – softer shorter cry Prefers sitting

Talks in

Sentences

Phrases

Words

Alertness

May be agitated

Usually agitated

Usually agitated

Respiratory Rate

Increased

Increased

*Often >30/min

RESPIRATORY ARREST IMMINENT

At rest Infants- Stops feeding *Hunched forward

GUIDE TO RATES OF BREATHING ASSOCIATED WITH RESPIRATORY DISTRESS IN AWAKE CHILDREN AGE NORMAL RATE > 2 months < 60/min 2-12 months < 50/min 1-5 years < 40/min 6-8 years < 30/min

Bradypnea

INA 2002, 2006, 2007

Severity of Asthma Exacerbations MILD Accessory Muscles & Suprasternal Retraction Wheeze

Pulses/min

MODERATE

SEVERE

None

Present

Present

Audible with stethoscope

Audible with stethoscope

Audible w/o stethoscope

<100

100-120

>120

RESPIRATORY ARREST IMMINENT Present Thoraco-abdominal Movement Absence of wheeze with decreased to absent breathe sounds Bradycardia

GUIDE TO LIMITS OF NORMAL PULSE RATE IN CHILDREN Age Normal Limits Infants 2-12 months <160/min Preschool 1-2 years <120/min School Age 2-6 years <110/min

GINA 2002,2006,2007

Severity of Asthma Exacerbations MILD MODERATE Pulses Paradoxus Absent <10mm Hg

May be present 10—20mm Hg

SEVERE

Often present 20-40mm Hg

PEF %predicted Or %personal best

≥ 80%

60-79%

PaO2 RA

Normal test NOT usually necessary

≥60mm Hg

<60mmHg Possible Cyanosis

PaCO2

≤45 mm Hg

≤45 mm Hg

>45 mm Hg possible respiratory failure

SaO2 RA

≥95%

90-94%

RESPIRATORY ARREST IMMINENT Absence suggests respiratory muscle fatigue

<60%

<90%

Hypercapnea (hypoventilation) develops more rapidly in young children

GINA ASTHMA GUIDELINES: (2002, 2006,2007) Management of Asthma Exacerbation in Acute Care Initial Assessment History, Physical Examination(auscultation, use of accessory muscles, HR, RR, PEF or FEV1, O2 saturation, ABG’s if patient in extremis)

Initial Treatment Oxygen to achieve O2 saturation ≥90% (95% in children) Inhaled rapid β2-agonist continuously for one hour Systemic GCS, if no immediate response, or if patient recently took Oral GCS, of if episode is severe SEDATION is CONTRAINDICATED in the treatment of an exacerbation

Reassess after 1 hour : PE, PEF, O2 saturation & other tests as needed

Criteria for MODERATE Episode: • PEF 60-80% predicted/personal best • Physical exam: moderate symptoms, • Accessory muscle use Treatment: O2, Inhaled β2 agonist + anticholinergic every 60 min Oral GCS Continue treatment for 1-3 hours,provided There is improvement

Criteria for SEVERE Episode: • History of risk factors for near fatal asthma • PEF < 60% predicted/personal best • PE: severe symptoms at rest, chest retraction NO improvement after initial treatment Treatment: O2, Inhaled β2 agonist + anticholinergic Systemic GCS IV Magnesium

Continuation next slide

GINA ASTHMA GUIDELINES: (2002, 2006,2007) Management of Asthma Exacerbation in Acute Care Reassess after 1 – 2 hours

Good Response within 1-2 hours: Response sustained 60 minutes after last treatment PE normal: no distress PEF > 70% O2 saturation > 90% (95% in children)

Incomplete Response within 1-2 hours: Risk Factors for near fatal asthma PE : mild to moderate signs PEF < 60% O2 saturation: NOT IMPROVING ADMIT to ACUTE CARE Setting • Oxygen • Inhaled β2-agonist ± anticholinergic • Systemic GCS • Intravenous Magnesium •Monitor PEF, O2 saturation, Pulse

Improved: Criteria for Discharging Home PEF > 60% predicted / personal best Sustained on oral/inhaled medications HOME TREATMENT: • Continue inhaled β2 agonist •Consider in most cases, oral GCS •Consider adding a combination inhaler •Patient education: take medicine correctly review action plan close medical check up

Poor Response within 1-2 hours: Risk factors fro near fatal asthma PE : symptoms severe, drowsiness, confusion PEF : < 30% PCO2 : > 45mmHg PO2: < 60mmHg ADMIT to INTENSIVE Care • Oxygen • Inhaled β2agonist+anticholinergic • IV GCS •Consider IV β2 agonist • Consider IV theophylline • Possible intubation • mechanical ventilation

Reassess at Intervals

Improved

Poor Response: • Admit to intensive Care Incomplete response in 6-12 hours • Consider admission to Intensive Care •If No improvement within hours

Inhaled short acting β2-agonists are the mainstay of therapy in acute asthma.

However, once response to the initial β2-agonists is minimal, incomplete or poor COMBINATION of INHALED β2AGONIST and INHALED ANTICHOLINERGIC is RECOMMENDED

What is the role of Salbutamol – Ipratropium in acute asthmatic attacks?

INTERMITTENT No added benefit over Salbutamol alone if attack is mild However, any moderate to severe attack of asthma regardless of severity classification can benefit from the combination.

GINA ASTHMA PHARMACOLOGIC TREATMENT GUIDELINES (2002, 2006, 2007)

Medicines in Childhood Asthma Relievers Rapid-acting inhaled Beta (B)2 agonist Inhaled anticholinergics Short acting theophylline Short acting B2 agonist (SABA)

Controllers Inhaled and systemic

corticosteroids Leukotriene modifiers Long-acting B2 agonist (LABA) with Inhaled Corticosteroid ICS Sustained release theophyllines Cromones

GINA ASTHMA PHARMACOLOGIC TREATMENT GUIDELINES (2002, 200607)

Inhaled Corticosteroids: Cornerstone in the Management Of Asthma

Inhaled Corticosteroids • Most effective long-term control for persistent asthma • Small risk for adverse events at recommended dosage • Benefits of daily use – Reduction of • • • • •

asthma symptoms frequency of exacerbations airway inflammation airway responsiveness asthma mortality

– Improvement of • lung function • quality of life

Inhaled Corticosteroids Adverse Events • Small risk for adverse events at recommended doses • Reduce potential for adverse events by: – Using spacer – Rinsing mouth

GINA ASTHMA GUIDELINES 2002,2006,2007

Maintenance Therapy: Stepping Down When asthma is controlled with: • IGCS alone in medium to high dose a 50% reduction in dose should be attempted at 3 months interval (Evidence B) • IGCS in low dose of alone treatment may be switched to oncedaily dosing (Evidence A) • Combination of IGCS and LABA, reduce dose of IGCS by 50% while continuing LABA (Evidence B) If control is maintained, further reduce IGCS until low dose is reached, then LABA may be stopped. (Evidence D) OR switch the combination treatment to once daily dosing OR discontinue the LABA at an earlier stage and substitute the combination with IGCS monotherapy. In some patients these alternative approaches lead to loss of asthma control (Evidence B)

GINA ASTHMA GUIDELINES 2002,2006,2007 cont.

Maintenance Therapy: Stepping Down

IGCS and controllers other the LABA, reduce dose of IGCS by 50% until low dose of IGCS is reached, then may stop combination treatment (Evidence D) Controller treatment may be stopped if the patient’s asthma remains controlled on the lowest dose of controller and no recurrence of symptoms for ONE YEAR (Evidence D)

GINA ASTHMA GUIDELINES 2002,2006,2007

Maintenance Therapy: Stepping Up When asthma is NOT controlled with: • Rapid onset, short acting or long acting β2 agonist bronchodilators. Repeated dosing with bronchodilators in this class provides temporary relief until the cause of the days signals the need for review and possible increase of controller therapy. • Inhaled glucocorticosteroids. Temporarily doubling the dose of IGCS has not been demonstrated to effective and is no longer recommended (Evidence A).

GINA ASTHMA GUIDELINES 2002,2006,2007

Maintenance Therapy: Stepping Up • Combination of Inhaled Glucocorticosteroids and rapid and LABA (formoterol) for combined relief and control. The use of the combination of a rapid and long acting β2agonist(formoterol) and an inhaled glucocorticosteroid (budesonide) in a single inhaler both as a controller and a r reliever is effective in maintaining a high level of asthma control and reduces exacerbation requiring systemic GCS and hospitalization (Evidence A)

GINA ASTHMA GUIDELINES 2002, 2006, 2007

Maintenance Therapy:

IGCS + LABA

2002

2006

Not mentioned As form of therapy

Not recommended For children ≤ 5 years

2007 As maintenance and rescue Medication has shown to reduce exacerbations in children ≥ 4 years with moderate & severe asthma

GINA ASTHMA GUIDELINES 2002, 2006

Estimated Equipotent Daily Doses of Inhaled Corticosteroids for Children Drug

omethasone opionate

sonide

sonide

Low Daily Dose (µg) 100 – 200

casone

etasone te

mcinolone onide

400-800

>400

>160-320 500-750

100-200

>400

>200- 400

80-160

100-200

High Daily Dose (µg)

>200 – 400

100-200

solide

Medium Daily Dose (µg)

>320 > 750-1250

> 200 – 500 >200 – 500 >800 – 1200

> 1250 >500 >400 > 1200

oosing an Inhaler Device for Children with Asth Age Group

Preferred device

Alternate Device

Younger than 4 years

Pressurized metered dose inhaler plus dedicated spacer with face mask

Nebulizer with face mask

4 – 6 years

Pressurized metered dose inhaler plus dedicated spacer with mouth piece

Nebulizer with mouth piece

Older than 6 years

Dry powder inhaler, or breath-actuated pressurized metereddose inhaler or pressurized metered dose inhaler with spacer mouth piece

Nebulizer with mouth piece

Leukotriene Pathway

GINA ASTHMA GUIDELINES: LEUKOTRIENE MODIFIER 2002

“ADD-ON” Treatment Option

2006-07

Controller Option

LEUKOTRIENE MODIFIER (Children Younger than 5 Years) • Provide clinical benefit at all levels of severity (but less than ICS) • Partial protection against exerciseinduced bronchoconstriction within hours after adminsitration • Add on in children where asthma is insufficiently controlled by low dose of ICS

LEUKOTRIENE MODIFIER (Children Older than 5 Years) • Provide clinical benefit at all levels of severity (but less than ICS) • Partial protection against exercise-induced bronchoconstriction within hours after adminsitration • Add on in children where asthma is insufficiently controlled by low dose of ICS • Reduce viral induced asthma exacerbation

Global Initiative for Asthma (GINA) 2006 Updates 1. The cost to control asthma seems high, but the cost of not treating asthma correctly is even higher. 2. Concept of “Difficult to treat Asthma” is introduced. Patients with difficult to treat asthma are often rarely insensitive to the effects of glucocorticoid medications and may sometimes be unable to achieve the same level of control as other asthma patients.

Global Initiative for Asthma (GINA) 2006 updates 3. Lung function testing by spirometry of Peak expiratory flow (P.E.F.) continues to be recommended as an aid to the diagnosis and monitoring. Measuring the variability of airflow is the key to both asthma diagnosis and the assessment of asthma control.

Global Initiative for Asthma (GINA) 2006 updates

4. The previous classification by asthma severity into Intermittent, Mild Persistent, Moderate Persistent and Severe Persistent is now recommended only for research purposes.

Global Initiative for Asthma (GINA) 2006 updates 5. Instead, the GINA report of 2006, recommends a classification of asthma by level of control: Controlled, Partly Controlled, or Uncontrolled. This reflects the understanding that asthma severity does not only involve the severity of the underlying disease but also its responsiveness to treatment.

Global Initiative for Asthma (GINA) 2006 updates 6. The goal of asthma treatment is to achieve and maintain control. Asthma control is defined as: -No (twice or less/week) daytime symptoms -No limitations of daily activities -No nocturnal symptoms or awakening because of asthma -No (twice or less/week) need for reliever treatment -Normal or near-normal lung function results -No exacerbations

Global Initiative for Asthma (GINA) 2006 updates 7. Increased use, especially daily use, of reliever medication is a warning of deterioration of asthma control and indicates the need to reassess treatment 8. The roles in therapy of several medications have evolved: 1. A possible risk of asthma related death associated with the use of long acting β-2 agonists in a small group of individuals has resulted to the recommendation that long acting β-2 agonists should not be used as monotherapy in asthma, and must only be used in combination with appropriate dose of inhaled glucocorticosteroid.

Global Initiative for Asthma (GINA) 2006 updates 8. The roles in therapy of several medications have evolved: 2. Leukotriene modifiers now have a more prominent role as controller treatment in asthma, particularly in adults. Long acting oral β-2 agonists alone are no longer presented as an option for add-on treatment at any step of therapy, UNLESS accompanied by inhaled glucocorticosteroids 3. Monotherapy with cromones is no longer given as an alternative to monotherapy with a low dose of inhaled corticosteroids in adults

Global Initiative for Asthma (GINA) 2006 updates

9. Treatment options are organized into five “Steps” reflecting the intensity of treatment. At all steps, a reliever medication should be provided for as needed use. At steps 2 through 5, a variety of controller medications are available.

Global Initiative for Asthma (GINA) 2006 Updates 10. If asthma is not controlled on the current treatment regimen, treatment should be stepped up until control is achieved. When control is maintained, can be stepped down in order to find the lowest step and dose of treatment that maintains control.

lobal Initiative for Asthma (GINA) 2006 Update 11. The emphasis of GINA 2006-07 is the

classification of asthma disease based on control rather than severity

12. Inhaled B2 agonist is still the mainstay treatment of patients in acute exacerbation across all severity classification. In non-responders, combination of B2 agonist and an anticholinergic is recommended. 13. Inhaled Steroids remain the cornerstone in the long term management of asthma

14. GINA 2006-07 places Montelukast a controller option in the management of asthma

THANK YOU

Immunomodulation in Asthma Anti-IgE: Omalizumab (Xolair) Recombinant humanized monoclonal IgG Binds to IgE preventing binding to target cells (mast cells, basophils) Indications: Moderate-severe persistent atopic asthmatics uncontrolled by steroids Age 12 and above

•

Risk of anaphylaxis is similar to specific immunotherapy

ASTHMA: Diagnosis In mild asthmatics whose pulmonary function and response to B2-agonist are equivocal: 1. Methacholine/Histamine bronchoprovocation test; 2. Exercise challenge test; 3. Twice daily recording of peak flow to determine diurnal variation; or 4. A therapeutic trial of five days steroid and bronchodilator course

ASTHMA: Diagnosis

Peak Flow Variability =

Highest reading - Lowest reading Highest Reading

X 100

MANAGEMENT OF ACUTE EXACERBATIONS

LONG TERM MANAGEMENT OF BRONCHIAL ASTHMA

Specific Immunotherapy • Immunotherapy: subcutaneous injection over time of gradually increasing doses of specific allergic extracts • Should be considered when avoiding allergens is not possible or when less than complete control of asthma symptoms is achieved with bronchodilator drugs or inhaled corticosteroids. When used in appropriate patients, it reduces the degree of allergy and thereby reduces

Specific Immunotherapy The decision to initiate immunotherapy should be guided by the following considerations: –

There must be a convincing history that natural exposure to aeroallergens induces clinically significant symptoms

–

An immediate hypersensitivity response to relevant environmental allergens by appropriate diagnostic tests (skin test, IgE antibody) should

Specific Immunotherapy The decision to initiate immunotherapy should be guided by the following considerations: 3) The symptoms are severe enough to be disabling or interfering with the patient’s quality of life 4)

Inability to control symptoms by avoidance procedures or when pharmacotherapy has been only

Specific Immunotherapy 5) There is progression of allergic rhinitis to asthma; and 6) Can be administered in children above 5 years of age. In general, immunotherapy is more effective in children and young adults than in later life.

Asthma Action Plan

Action Plan The asthma action plan is a written asthma management plan that is jointly prepared by the doctor and the patient. This written instruction to the patient should be updated every visit as changes in peak flow measurements or asthma severity category may occur.

ASTHMA ACTION PLAN Name_________________________ Parent________________________ Guardian______________________ Address_______________________ Home phone___________________ Work phone____________________ Peak Flow Monitoring Personal Best Peak Flow_____ Monitoring times ____ ____ ____ DATE ACCOMPLISHED________ This plan will help you control your - asthma and know what to do if you have an asthma episode. - Keeping your asthma under control will help you: - Take part in normal physical activity like being active in exercise and in sports. -Sleep through the night without having asthma episodes. - Prevent asthma attacks. - Have the best possible peak flow number. - Avoid side effects from medicines.

Instructions to ER Physician_____________________ Phone No. __________________ Hospital _____________________ Phone No. __________________

Whenever possible, stay away from the things that bring on your asthma symptoms. Identify triggers (check all that apply) ___Exercise ___Stress ___Respiratory infections ___Strong odor ___Changes in temperature ___Tobacco/smoke ___Allergen ___Others Three ways to control your asthma: 1. Follow your GREEN zone plan everyday to prevent most asthma symptoms from starting. 2. Recognize your symptoms of an an acute asthma attack. Follow the YELLOW zone plan to prevent a asthma attack from getting worse. 3. In cases of emergency , follow the RED zone plan. * See your doctor regularly. * This action plan will need to be updated as the patient’s condition changes

ASTHMA ACTION PLAN Name_________________________ Parent________________________Guardian______________________ Address_______________________ Home phone___________________Work phone____________________ Peak Flow Monitoring Personal Best Peak Flow ________Monitoring times ____ ____ ____ DATE ACCOMPLISHED________ This plan will help you control your asthma and know what to do if you have an asthma episode. Keeping your asthma under control will help you: • Take part in normal physical activity like being active in exercise and in sports. • Sleep through the night without having asthma episodes. • Prevent asthma attacks. • Have the best possible peak flow number. • Avoid side effects from medicines.

Whenever possible, stay away from the things that bring on your asthma symptoms. Identify triggers (check all that apply) ___Exercise ___Respiratory infections ___Changes in temperature ___Allergen

___Stress ___Strong odor ___Tobacco/smoke ___Others

Three ways to control your asthma: 1. Follow your GREEN zone plan everyday to prevent most asthma symptoms from starting. 2. Recognize your symptoms of an an acute asthma attack. Follow the YELLOW zone plan to prevent a asthma attack from getting worse. 3. In cases of emergency , follow the RED zone plan. * See your doctor regularly. * This action plan will need to be updated as the patient’s condition changes

Action Plan GREEN ZONE: Doing Well - No symptoms day and night (cough, wheeze, chest tightness and shortness of breath) - Can do usual activities - Peak flow meter __________ (>80 % of your personal best or predicted) ACTION: - Continue with your current medication as prescribed below:

YELLOW ZONE: Acute Attack - Presence of at least 1 of the following: (cough, wheeze, chest tightness or shortness of breath) - Waking at night due to asthma - Can do some but not all usual activities - Peak flow meter: _____ to _____ (60 to 79% of your personal best) ACTION: -Take your quick-relief inhaled brochodilator_______________ every 20 minutes up to 3 doses until relieved - Proceed to ER for further evaluation & possible admission if: 1. getting worse at anytime 2. if no relief after 3 doses of inhaled β2 agonist On your way to ER, continue your quick relief inhaled bronchodilator every 20 minutes and take 1 dose of oral steroids as follows:__________________

RED ZONE: EMERGENCY!!! - Presence of any:(Trouble walking or talking due to shortness of breath, lips and fingernails are blue) -Quick relief medicines have not helped -Cannot do usual activities -Symptoms are getting worse -Peak flow meter: _____ (< 60 % of your personal best) ACTION: - Proceed to ER - Take immediately 1 dose of your quick relief inhaled bronchodilator and continue your inhaled bronchodilator every 20 minutes while in transit - Take 1 dose oral steroids as follows:

How will I know if my baby has ASTHMA? • Infantile asthma is recurrent wheezing in infants who are at risk of developing persistent symptoms beyond infancy. • Considered a syndrome that starts during infancy and persists up to adulthood. • AVan duration of at least 6 months Bever.Indian Pediatrics 2004; 41: frequency 1101-1104 of at least 3 and attacks.

Is there a way of predicting if my baby will have asthma later in life? ASTHMA PREDICTIVE INDEX

• Recurrent episodes of wheezing: >3 episodes in the past year that lasted >1day and affected sleep. • Major criteria: 1. Physician-diagnosed atopic dermatitis 2. Physician-diagnosed parental asthma • Minor criteria: 1. Peripheral blood eosinophilia ≥ 4% 2. Wheezing apart from colds

How is infantile asthma managed?

When do you start steroids in infantile asthma?

Asthma Diagnosis: Cough Causes Post Nasal Drip Asthma GER Chronic Bronchitis Bronchiectasis MISC.

Percentage (%) 41 24 21 5 4 5

Representative Causes of Chronic Cough from a Prospective Study Irwin et al. Ann. Rev. Resp. Dis. 1990

GINA ASTHMA GUIDELINES 2002,200607

Estimated Equipotent Daily Doses of Inhaled Corticosteroids for Children Drug

omethasone opionate

sonide

sonide

Low Daily Dose (µg) 100 – 200

casone

etasone te

mcinolone onide

400-800

>400

>160-320 500-750

100-200

>400

>200- 400

80-160

100-200

High Daily Dose (µg)

>200 – 400

100-200

solide

Medium Daily Dose (µg)

>320 > 750-1250

> 200 – 500 >200 – 500 >800 – 1200

> 1250 >500 >400 > 1200

Asthma Triggers

Asthma Triggers 1. 2. 3. 4. 5. 6.

Viruses House Dust Mites Cockroach Cat and Dog dander Pollens Mold Allergens

Triggers of Asthma in Various Age Groups Infancy

Early Childhood

Late Childhood

Adulthood

++++

+++

++

+++

Exercise

+

++

+++

+++

Irritants

+

++

+++

+++

++

+

+

+

+

++

+++

+++

++

+++

+++

+

+

+

Viral Infections

Foods Indoor Inhalants Pollens Emotions

House Dust Mite

Cockroach Exposure to >0.05 mcg/gm of cockroach allergen increases the risk of asthma. Arruda et al J of Allergy & Clin Immunol 2000

Sensitization to cockroach increased the prevalence of allergic rhinitis & bronchial asthma by 2 times. Binas VWE, Andaya AG PSAAI 2002

Irritants • Paint odors • Perfumes • Pollutants

• Hair sprays • Chemicals • Cigarette smoke

Asthma Education Objectives of an asthma education program: 1) Increase level of knowledge regarding asthma, its prevention and its management 2) Recognize signs and symptoms of asthma 3) Identify his/her asthma triggers and measures to avoid them 4) Demonstrate correct technique of using inhalers and peak flow meters 5) Follow personalized asthma action plan

Immunomodulation in Asthma Anti-IgE: Omalizumab (Xolair) Recombinant humanized monoclonal IgG Binds to IgE preventing binding to target cells (mast cells, basophils) Indications: Moderate-severe persistent atopic asthmatics uncontrolled by steroids Age 12 and above Risk of anaphylaxis is similar to specific immunotherapy

Updates on Childhood Asthma from Global Initiative for Asthma (GINA ) 2006 Report

Global Initiative for Asthma (GINA) 2006 Updates 1. The cost to control asthma seems high, but the cost of not treating asthma correctly is even higher. 2. Concept of “Difficult to treat Asthma” is introduced. Patients with difficult to treat asthma are often rarely insensitive to the effects of glucocorticoid medications and may sometimes be unable to achieve the same level of control as other asthma patients.

Global Initiative for Asthma (GINA) 2006 updates 3. Lung function testing by spirometry of Peak expiratory flow (P.E.F.) continues to be recommended as an aid to the diagnosis and monitoring. Measuring the variability of airflow is the key to both asthma diagnosis and the assessment of asthma control.

ASTHMA: Diagnosis Predicted normal PEFR in Filipino Children between 6 – 17 years with height of at least 100 cms. 3) Males: (Height in cm. – 100) 5 + 175 2) Females: (Height in cm – 100) 5 + 170

ASTHMA: Diagnosis

Peak Flow Variability =

Highest reading - Lowest reading Highest Reading

X 100

Diagnosis of Asthma

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

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

Asthma Diagnosis Therapeutic Trial 5 days SABA + steroids Indications: 1. Children 5 years and younger 2. Pulmonary function tests like spirometry and PEFR measurement are not feasible/available.

Characteristic Daytime symptoms Limitations of activities Nocturnal symptoms / awakening Need for rescue / “reliever” treatment

Levels of Asthma Control Controlled Partly controlled Uncontroll (All of the following)

(Any present in any week)

None (2 or less / week)

More than twice / week

None

Any

None

Any

None (2 or less / week)

Lung function (PEF or FEV1)

Normal

Exacerbation

None

More than twice / week < 80% predicted or personal best (if known) on any day One or more / year week

ed

3 or more features of partly controlled asthma present in any week

1 in any

Global Initiative for Asthma (GINA) 2006 updates 6. The goal of asthma treatment is to achieve and maintain control. Asthma control is defined as: -No (twice or less/week) daytime symptoms -No limitations of daily activities -No nocturnal symptoms or awakening because of asthma -No (twice or less/week) need for reliever treatment -Normal or near-normal lung function results -No exacerbations

REDUCE

LEVEL OF CONTROL

TREATMENT OF ACTION maintain and find lowest controlling step

partly controlled

consider stepping up to gain control INCREASE

controlled

uncontrolled exacerbation

REDUCE

step up until controlled treat as exacerbation

INCREASE

TREATMENT STEPS

STEP

STEP

STEP

STEP

STEP

1

2

3

4

5

Global Initiative for Asthma (GINA) 2006 updates 7. Increased use, especially daily use, of reliever medication is a warning of deterioration of asthma control and indicates the need to reassess treatment 8. The roles in therapy of several medications have evolved: 1. A possible risk of asthma related death associated with the use of long acting β-2 agonists in a small group of individuals has resulted to the recommendation that long acting β-2 agonists should not be used as monotherapy in asthma, and must only be used in combination with appropriate dose of inhaled glucocorticosteroid.

INDICATIONS FOR USE OF LONG ACTING β2 AGONIST • Exercise-induced asthma • Nocturnal asthma

SALMETEROL VS. THEOPHYLLINE: SLEEP AND EFFICACY OUTCOMES IN PATIENTS WITH NOCTURNAL ASTHMA Salmeterol was superior to theophylline in: • Sustained improvement in morning PEF • Protection from night time lung function deterioration • Reduction in salbutamol use • Improvement in patient perception of Wiegand, L Chest sleep 1999

PHARMACOLOGICAL PROFILES OF FORMOTEROL AND SALMETEROL FORMOTEROL

SALMETEROL

Chemical class Formanilide

Saligenin

Lipid solubility Moderate

High

Selectivity for High B2-adrenoceptor

Very high

Receptor High affinity, binding reversible Agonist activity Fullagonist

High affinity, poorly reversible Partialagonist

Onset of action 3 minutes

10-20 minutes

FDA approved dose

>6yrs. old: 6ug BID >4yrs. old: 50ug >12yrs. old: 12ug BID BID

Rapid Acting Inhaled β2 Agonists

Rapid acting inhaled β 2 agonists are the medications of choice for relief of bronchoconstriction and for the treatment of exercise-induced bronchoconstriction, in both adults and children of all ages.

Rapid Acting Inhaled β2 Agonists

Rapid acting inhaled β 2 agonists are the medications of choice for relief of bronchoconstriction and for the treatment of exercise-induced bronchoconstriction, in both adults and children of all ages.

Global Initiative for Asthma (GINA) 2006 Updates

10. If asthma is not controlled on the current treatment regimen, treatment should be stepped up until control is achieved. When control is maintained, can be stepped down in order to find the lowest step and dose of treatment that maintains control.

Immediate Care of Asthma Exacerbations

Asthma Exacerbation  Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness.  Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF).  Severe exacerbations are potentially lifethreatening and treatment requires close supervision.

Severity of Asthma Exacerbations

Clinical Features

Mild Breathless

Walking Can lie down

Moderate

Severe

Talking Infant – softer, shorter cry; difficulty feeding Prefers sitting

At rest Infant – stops feeding

Resp. Arrest Imminent

Hunched forward

Talks in

Sentences

Phrases

Words

Alertness

May be agitated

Usually agitated

Usually agitated

Drowsy or confused

Respiratory rate

Increased

Increased

Often >30/min

Bradypnea

Acc muscles& suprasternal retractions

None

Present

Present

Paradoxical thoracoabdominal movement

Wheeze

Audible with stethoscope

Audible with stethoscope

Audible without stethoscope

(-) wheeze with ↓ /(-) breath sounds

Pulse/min

< 100

100-120

> 120

Bradycardia

Severity of Asthma Exacerbations Objective Measures Mild

Moderate

Severe

Pulsus Paradoxus

Absent <10 mm Hg

May be present 10-20 mm Hg

Often present 20-40 mm Hg

PEF %predicted or %personal best

≥ 80%

60-79%

< 60 %

paO2 (on air)

Normal Test not usually necessary ≤ 45 mm Hg

≥60 mm Hg

< 60 mm Hg Possible cyanosis ≥ 45 mm Hg Possible resp failure

≥ 95%

90-94%

and/or paCO2

SaO2% (on air)

≤ 45 mm Hg

< 90%

Respiratory Arrest Imminent Absence suggests respiratory muscle fatigue

Figure 4.4-2: Management of Asthma Exacerbation in Acute Care Setting

Initial Assessment (see Figure 4.4-1) • History,

physical examination (auscultation, use of accessory muscles, heart rate, PEF or FEV1, oxygen saturation, arterial blood gas if patient in extremis)

Initial Treatment • Oxygen to achieve O2 saturation > 90% (95% in children) • Inhaled rapid- acting B2 agonist continuously for one hour • Systemic glucocorticosteroids if no immediate response, or if patient recently took oral glucocorticosteroids, or if episode is severe • Sedation is contraindicated in the treatment of an exacerbation

Reassess after 1 Hour Physical Examination, PEF, O2 saturation and other tests as needed

Reassess after 1 Hour Physical Examination, PEF, O2 saturation and other tests as needed Criteria for Moderate Episodes: •PEF 60-80% predicted/personal best •Physical Exam: moderate symptoms, accessory muscle use

Treatment •Oxygen •Inhaled B2-agonist and inhaled anticholinergic every 60 min •Oral glucocorticosteroids •Continue treatment for 1-3 hours, provided there is improvement

Criteria for Severe Episodes: •History of risk factors for near fatal asthma •PEF <60% predicted/personal best •Physical Exam: severe symptoms at rest, chest retraction •No improvement after initial treatment

Treatment •Oxygen •Inhaled B2-agonist and inhaled anticholinergic •Systemic glucocorticosteroids •IV magnesium

Reassess after 1-2 Hours

Good Response within 1-2 Hours:

Incomplete Response within 1-2 Hours:

Poor Response within 1-2 Hours:

•Response sustained 60 min after last treatment •Physical Exam normal: No distress •PEF>70% •O2 saturation> 90% (95% children)

•Risk Factors for near fatal asthma •Physical exam: mild to moderate signs •PEF <60% •O2 saturation not improving

•Risk Factors for near fatal asthma •Physical exam: symptoms severe, drowsiness, confusion •PEF <30% •PO2 >45 mm Hg •PO2 <60 mm Hg

Admit to Acute Care Setting:

Improved: Criteria for Discharge Home •PEF>60% predicted/personal best •Sustained on oral/inhaled medication

Admit to Intensive Care:

•Oxygen •Inhaled B2-agonist+anticholinergic •Systemic glucocorticosteroid •IV Magnesium •Monitor PEF, O2 saturation, pulse

Home Treatment: •Continue inhaled B2-agonist •Consider, in most cases, oral glucocorticosteroids •Consider adding a combination inhaler •Patient education: 1.Take Medicine correctly 2. Review action plan 3. Close medical follow-up

•Oxygen •Inhaled B2-agonist+anticholinergic •IV glucocorticosteroid •Consider IV B2-agonist •Consider IV theophylline •Possible intubation and mechanical ventilation

Reassess at intervals Poor Response (see above): •Admit to Intensive Care

Incomplete response in 6-12 hours (see above) •Consider Admission to Intensive Care if no improvement w/in 6-12 hrs

Improved (see opposite)

Particular attention should be given to patients who present with the following features, as they are the ones most prone to develop acute respiratory failure: 1) 2) 3) 4) 5) 6)

cyanosis absence of wheeze bradycardia and bradypnea paradoxical thoraco-abdominal movement drowsiness or confusion a normal or elevated pCO2 in a patient with severe distress

High Risk Patients  special attention should be given to patients who are considered high risk: 1) infants in moderate/severe exacerbation 2) current use or recent withdrawal (< 1 week) from systemic corticosteroids 3) hospitalization for moderate or severe asthma in the past year 4) prior intubation or history of impending respiratory failure from asthma 5) psychiatric disease or psychosocial problems 6) difficulty perceiving airflow obstruction or its severity, and 7) non-compliance with asthma medication plan.

High Risk Patients:  These are the patients who have the potential to go into sudden and severe airway obstruction which may lead to respiratory failure or death.  They should be educated to seek medical care early during an exacerbation.

Advanced Care of Asthma Exacerbations

Hospitalization

The following features can serve as guides on whether the patient requires hospitalization:  1) severity of attack - severe exacerbation or impending respiratory failure 2) persistent severe airflow obstruction (PEFR < 60%) 3)  history of severe exacerbations 4)current use or recent withdrawal from systemic corticosteroids 5)  inadequacy of support and home conditions

Admission to Intensive Care Unit Admission to the ICU is recommended in the following situations:  1) progressive worsening of asthma symptoms despite initial management 2) presence of sensorial changes (drowsiness, confusion) or loss of consciousness 3) signs of respiratory fatigue (e.g. declining respiratory rate) 4) impending respiratory arrest (paO2 < 60 mmHg on

Patient Discharge From the Emergency Room 1) symptoms are absent or minimal 2) PEFR > 80% predicted 3) sustained response for at least four (4) hours ( GOOD RESPONDERS)

Patient Discharge From the Hospital 1) physical examination is normal or near normal 2) no nocturnal awakenings 3) PEFR > 80% predicted 4) sustained response to inhaled short-acting β 2 agonist (at least 4 hours)

Global Initiative for Asthma (GINA) 2006 updates 9. The six-part asthma management program has been changed. The current program has 5 components: Component 1: Develop Doctor Patient Relationship Component 2: Identify and Reduce Exposure to Risk Factors Component 3: Assess, Treat, and Monitor Asthma Component 4: Manage Asthma Exacerbations Component 5: Special Considerations

Severity of Asthma Exacerbations Objective Measures Mild

Moderate

Severe

Pulsus Paradoxus

Absent <10 mm Hg

May be present 10-20 mm Hg

Often present 20-40 mm Hg

PEF %predicted or %personal best

≥ 80%

60-79%

< 60 %

paO2 (on air)

Normal Test not usually necessary ≤ 45 mm Hg

≥60 mm Hg

< 60 mm Hg Possible cyanosis ≥ 45 mm Hg Possible resp failure

≥ 95%

90-94%

and/or paCO2

SaO2% (on air)

≤ 45 mm Hg

< 90%

Respiratory Arrest Imminent Absence suggests respiratory muscle fatigue

Figure 4.4-2: Management of Asthma Exacerbation in Acute Care Setting

Initial Assessment (see Figure 4.4-1) • History,

physical examination (auscultation, use of accessory muscles, heart rate, PEF or FEV1, oxygen saturation, arterial blood gas if patient in extremis)

Initial Treatment • Oxygen to achieve O2 saturation > 90% (95% in children) • Inhaled rapid- acting B2 agonist continuously for one hour • Systemic glucocorticosteroids if no immediate response, or if patient recently took oral glucocorticosteroids, or if episode is severe • Sedation is contraindicated in the treatment of an exacerbation

Reassess after 1 Hour Physical Examination, PEF, O2 saturation and other tests as needed

Reassess after 1 Hour Physical Examination, PEF, O2 saturation and other tests as needed Criteria for Moderate Episodes: •PEF 60-80% predicted/personal best •Physical Exam: moderate symptoms, accessory muscle use

Treatment •Oxygen •Inhaled B2-agonist and inhaled anticholinergic every 60 min •Oral glucocorticosteroids •Continue treatment for 1-3 hours, provided there is improvement

Criteria for Severe Episodes: •History of risk factors for near fatal asthma •PEF <60% predicted/personal best •Physical Exam: severe symptoms at rest, chest retraction •No improvement after initial treatment

Treatment •Oxygen •Inhaled B2-agonist and inhaled anticholinergic •Systemic glucocorticosteroids •IV magnesium

Reassess after 1-2 Hours

Good Response within 1-2 Hours:

Incomplete Response within 1-2 Hours:

Poor Response within 1-2 Hours:

•Response sustained 60 min after last treatment •Physical Exam normal: No distress •PEF>70% •O2 saturation> 90% (95% children)

•Risk Factors for near fatal asthma •Physical exam: mild to moderate signs •PEF <60% •O2 saturation not improving

•Risk Factors for near fatal asthma •Physical exam: symptoms severe, drowsiness, confusion •PEF <30% •PO2 >45 mm Hg •PO2 <60 mm Hg

Admit to Acute Care Setting:

Improved: Criteria for Discharge Home •PEF>60% predicted/personal best •Sustained on oral/inhaled medication

Admit to Intensive Care:

•Oxygen •Inhaled B2-agonist+anticholinergic •Systemic glucocorticosteroid •IV Magnesium •Monitor PEF, O2 saturation, pulse

Home Treatment: •Continue inhaled B2-agonist •Consider, in most cases, oral glucocorticosteroids •Consider adding a combination inhaler •Patient education: 1.Take Medicine correctly 2. Review action plan 3. Close medical follow-up

•Oxygen •Inhaled B2-agonist+anticholinergic •IV glucocorticosteroid •Consider IV B2-agonist •Consider IV theophylline •Possible intubation and mechanical ventilation

Reassess at intervals Poor Response (see above): •Admit to Intensive Care

Incomplete response in 6-12 hours (see above) •Consider Admission to Intensive Care if no improvement w/in 6-12 hrs

Improved (see opposite)

Particular attention should be given to patients who present with the following features, as they are the ones most prone to develop acute respiratory failure: 1) 2) 3) 4) 5) 6)

cyanosis absence of wheeze bradycardia and bradypnea paradoxical thoraco-abdominal movement drowsiness or confusion a normal or elevated pCO2 in a patient with severe distress

High Risk Patients  special attention should be given to patients who are considered high risk: 1) infants in moderate/severe exacerbation 2) current use or recent withdrawal (< 1 week) from systemic corticosteroids 3) hospitalization for moderate or severe asthma in the past year 4) prior intubation or history of impending respiratory failure from asthma 5) psychiatric disease or psychosocial problems 6) difficulty perceiving airflow obstruction or its severity, and 7) non-compliance with asthma medication plan.

High Risk Patients:  These are the patients who have the potential to go into sudden and severe airway obstruction which may lead to respiratory failure or death.  They should be educated to seek medical care early during an exacerbation.

Advanced Care of Asthma Exacerbations

Hospitalization

The following features can serve as guides on whether the patient requires hospitalization:  1) severity of attack - severe exacerbation or impending respiratory failure 2) persistent severe airflow obstruction (PEFR < 60%) 3)  history of severe exacerbations 4)current use or recent withdrawal from systemic corticosteroids 5)  inadequacy of support and home conditions

Admission to Intensive Care Unit Admission to the ICU is recommended in the following situations:  1) progressive worsening of asthma symptoms despite initial management 2) presence of sensorial changes (drowsiness, confusion) or loss of consciousness 3) signs of respiratory fatigue (e.g. declining respiratory rate) 4) impending respiratory arrest (paO2 < 60 mmHg on

Patient Discharge From the Emergency Room 1) symptoms are absent or minimal 2) PEFR > 80% predicted 3) sustained response for at least four (4) hours ( GOOD RESPONDERS)

Patient Discharge From the Hospital 1) physical examination is normal or near normal 2) no nocturnal awakenings 3) PEFR > 80% predicted 4) sustained response to inhaled short-acting β 2 agonist (at least 4 hours)

Global Initiative for Asthma (GINA) 2006 updates 9. The six-part asthma management program has been changed. The current program has 5 components: Component 1: Develop Doctor Patient Relationship Component 2: Identify and Reduce Exposure to Risk Factors Component 3: Assess, Treat, and Monitor Asthma Component 4: Manage Asthma Exacerbations Component 5: Special Considerations

WHAT DETERMINES DISEASE CLASSIFICATION IN GINA 2002 • Worst feature determines the severity classification • Useful when decisions are being made about management at the initial assessment of a patient

ASTHMA SEVERITY (GINA 2002)

• Involves both the severity of the underlying disease and its responsiveness to treatment. • May change over months or years

VALUE OF GINA 2002 GUIDELINES • Cross sectional means of characterizing patients with asthma who are not on inhaled corticosteroids treatment –No maintenance –Newly diagnosed –No previous consult

• No longer recommended as basis for ongoing treatment

GINA ASTHMA GUIDELINES: Questions to consider in the Diagnosis of Asthma • Has the patient had an attack or recurrent attacks of wheezing? • Does the patient have a troublesome cough at night? • Does the patient wheeze or cough after exercise? • Does the patient experience wheezing, chest tightness or cough after exposure to airborne allergens or pollutants? • Do the patient’s colds “go to the chest” or take more than 10 days to clear up? • Are symptoms improved by appropriate asthma treatment?

GINA ASTHMA GUIDELINES: 2002

Recommended Medications by Level of Severity: Children All Steps: In addition to daily controller therapy, rapid-acting inhaled β2 agonist* should be taken as needed to relieve symptoms, but should not be taken more than 3 to 4 times a day.

PERSISTENT

INTERMITTENT MILD Daily Controller • None Medications necessary

Other Treatment Options

• IGCS 100-400mcg BUD

• Sustainedrelease Theophylline, OR • Cromone, OR • Leukotriene modifier

MODERATE

SEVERE

IGCS 400-800µg BUD

• IGCS >800µg BUD PLUS one or more of the following:

•IGCS< 800µg BUD PLUS Sustained released theophylline OR

• Sustainedrelease theophylline

• IGCS <800µg BUD •PLUS LABA OR • IGCS >800µg OR •IGCS <800mcg PLUS • Leukotriene modifier

• Long Acting Inhaled β-2 agonist • Leukotriene modifier • Oral glucocortico steroid

In all steps: Once control of asthma is achieved and maintained for at least 3months, a gradual reduction of the maintenance therapy should be tried in order to identify the minimum therapy required to maintain control

LEVEL OF CONTROL

REDUCE

GINA 2006, 2007

TREATMENT OF ACTION maintain and find lowest controlling step

partly controlled

consider stepping up to gain control

uncontrolled

exacerbation

INCREASE

controlled

step up until controlled

treat as exacerbation

GINA 2006, 2007

asthma education environmental control

CONTROLLER OPTIONS

as needed rapid acting β2agonist

as needed rapid acting β2SELECT SELECT ONE ADD ONE OR ADD ONE OR agonist ONE

low-dose ICS* leukotriene modifier**

low-dose ICS plus LABA

Medium- or high-dose ICS ICS low-dose plus leukotriene modifier low-dose ICS plus leukotriene * Inhaled glucocorticosteroid modifier

MORE

BOTH

Medium- or high-dose ICS plus LABA leukotriene modifier

Oral glucocorticosteroid

sustainedrelease theophylline

** receptor antagonist or synthesis inhibitors

Anti-IgE treatment

Montelukast+Budesonide vs. Double Dose of Budesonide

Price, D.B. et. Al., Thorax 2003; 58: 211-216

Montelukast vs. Corticosteroid based on Quality of Life

Price, D.B. et. Al., Thorax 2003; 58: 211-216