Cme Asthma

G lobal INitiative for A sthma

GINA Program Objectives  Increase appreciation of asthma as a global public health problem  Present key recommendations for diagnosis and management of asthma  Provide strategies to adapt recommendations to varying health needs, services, and resources  Identify areas for future investigation of particular significance to the global community

Global Strategy for Asthma Management and Prevention Definition and Overview  Diagnosis and Classification  Asthma Medications  Asthma Management and Prevention Program 

Updated 2007

Apa itu Asthma ? Adalah penyakit paru paru melibatkan radangan ( inflamasi) yang kronik pada saluran.

Apa yang berlaku pada saluran tersebut •

Radang pada saluran pernafasan

•

Saluran pernafasan terlalu sensitif

•

Penyempitan saluran pernafasan (Bronchoconstriction)

Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD

PERUBAHAN PERUBAHAN YANG BERLAKU PADA SALURAN PERNAFASAN Faktor Sekitaran dan Biologi ( Penyebab )

RADANG SALURAN

Saluran pernafasan terlalu sensitif

Penyempitan saluran pernafasan Faktor pencetus serangan

Tanda / gejala

hidung tekak farink Trakea bronkiol Bronkus

alveolus diafragm

SALURAN PERNAFASAN NORMAL

OTOT KERATAN RENTAS

The picture below shows what your lungs look like when everything is working normally. The muscles that are wrapped around the airways are very thin and loose, and the airway is wide open. This makes it easy to move air in and out of the air sacs.

SALURAN PERNAFASAN ASTHMA KERATAN RENTAS

SEMPIT

SEMPIT & BENGKAK

SEMPIT,BENGKA K & LENDIR

During an asthma attack, the muscles around the airways tighten, or "spasm" (like when you make a fist) and the lining inside the airways swell or thicken, and get clogged with lots of thick mucous. This makes the airways much skinnier than usual so it is harder to move air in and out of the air sacs. This makes it hard to breathe! The picture below shows what your lungs would look like during an asthma attack.

This animation shows normal breathing. As you breathe in, red air that contains lots of oxygen is pulled into the lungs. The oxygen slowly moves out of the lungs and into the blood, and then blue air that contains carbon dioxide is pushed out of the lungs. When things are working normally, the amount of air we breathe in is about the same as the amount of air we breathe out.

This animation shows breathing during an asthma attack. Notice that the airways are narrowed so less air can move in and out of the lungs. When things are working normally, the amount of air we breathe in is about the same as the amount of air we breathe out however during an asthma attack air gets trapped inside the lungs making it harder and harder to breathe. During an asthma attack, it is actually harder to breathe out than it is to breathe in. This means that during an asthma attack, it takes much longer to breathe out (expire) than it does to breathe in (inspire

Burden of Asthma 

Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals



Prevalence increasing in many countries, especially in children



A major cause of school/work absence

Risk Factors for Asthma 

Host factors: predispose individuals to, or protect them from, developing asthma



Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist

Factors that Exacerbate Asthma 

Allergens



Respiratory infections



Exercise and hyperventilation



Weather changes



Sulfur dioxide



Food, additives, drugs

Factors that Influence Asthma Development and Expression Host Factors  Genetic - Atopy - Airway hyperresponsiveness  Gender  Obesity

Environmental Factors  Indoor allergens  Outdoor allergens  Occupational sensitizers  Tobacco smoke  Air Pollution  Respiratory Infections  Diet

Is it Asthma? 

Recurrent episodes of wheezing



Troublesome cough at night



Cough or wheeze after exercise



Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants



Colds “go to the chest” or take more than 10 days to clear

Asthma Diagnosis 

History and patterns of symptoms



Measurements of lung function - Spirometry - Peak expiratory flow



Measurement of airway responsiveness



Measurements of allergic status to identify risk factors



Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly

Clinical Control of Asthma  No (or minimal)* daytime symptoms

 No limitations of activity  No nocturnal symptoms  No (or minimal) need for rescue medication  Normal lung function  No exacerbations _________

Levels of Asthma Control Controlled

Partly controlled

(All of the following)

(Any present in any week)

Daytime symptoms

None (2 or less / week)

More than twice / week

Limitations of activities

None

Any

Nocturnal symptoms / awakening

None

Any

Need for rescue / “reliever” treatment

None (2 or less / week)

More than twice / week

Lung function (PEF or FEV1)

Normal

< 80% predicted or personal best (if known) on any day

Exacerbation

None

One or more / year

Characteristic

Uncontrolled

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

1 in any week

Asthma Management and Prevention Program: Five Components 1. Develop Patient/Doctor Partnership 2. Identify and Reduce Exposure to Risk Factors 3. Assess, Treat and Monitor Asthma Revised 2006

4. Manage Asthma Exacerbations 5. Special Considerations

Asthma Management and Prevention Program: Five Interrelated Components

1. Develop Patient/Doctor Partnership 2. Identify and Reduce Exposure to Risk Factors 3. Assess, Treat and Monitor Asthma 4. Manage Asthma Exacerbations

Asthma Management and Prevention Program

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

Asthma Management and Prevention Program

.



Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms



Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.

Asthma Management and Prevention Program 

Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control

Example Of Contents Of An Action Plan To Maintain Asthma Control Your Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________ WHEN TO INCREASE TREATMENT Assess your level of Asthma Control In the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No Yes If you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment. HOW TO INCREASE TREATMENT STEP-UP your treatment as follows and assess improvement every day: ____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number] WHEN TO CALL THE DOCTOR/CLINIC. Call your doctor/clinic: _______________ [provide phone numbers] If you don’t respond in _________ days [specify number] ______________________________ [optional lines for additional instruction] EMERGENCY/SEVERE LOSS OF CONTROL If you have severe shortness of breath, and can only speak in short sentences, If you are having a severe attack of asthma and are frightened, If you need your reliever medication more than every 4 hours and are not improving. 1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid] 3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________ 4. Continue to use your _________[reliever medication] until you are able to get medical help.

Asthma Management and Prevention Program

Factors Involved in Non-Adherence Medication Usage

Non-Medication Factors



Difficulties associated with inhalers



Misunderstanding/lack of information



Complicated regimens



Fears about side-effects

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Fears about, or actual side effects

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Inappropriate expectations

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Underestimation of severity



Attitudes toward ill health

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Cultural factors

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Poor communication

Asthma Management and Prevention Program

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

Asthma Management and Prevention Program

Component 2: Identify and Reduce Exposure to Risk Factors 

Reduce exposure to indoor allergens



Avoid tobacco smoke



Avoid vehicle emission



Identify irritants in the workplace

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Explore role of infections on asthma development, especially in children and young infants

Asthma Management and Prevention Program

Component 3: Assess, Treat and Monitor Asthma The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional

Asthma Management and Prevention Program

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

Levels of Asthma Control Partly controlled

Characteristic

Controlled

Daytime symptoms

None (2 or less / week)

More than twice / week

Limitations of activities

None

Any

Nocturnal symptoms / awakening

None

Any

Need for rescue / “reliever” treatment

None (2 or less / week)

More than twice / week

Lung function (PEF or FEV1)

Normal

< 80% predicted or personal best (if known) on any day

Exacerbation

None

One or more / year

(Any present in any week)

Uncontrolled

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

1 in any week

Component 4: Asthma Management and Prevention Program

Controller Medications        

Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists Systemic glucocorticosteroids Theophylline Long-acting oral β2-agonists Anti-IgE Systemic glucocorticosteroids

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age Drug

Low Daily Dose (µg) > 5 y Age < 5 y

Medium Daily Dose (µg) > 5 y Age < 5 y

Beclomethasone

200-500

100-200

>500-1000

>200-400

Budesonide

200-600 200

100-

600-1000

>200-400

Budesonide-Neb Inhalation Suspension Ciclesonide Flunisolide Fluticasone Mometasone furoate Triamcinolone acetonide

250500 80 – 160

High Daily Dose (µg) > 5 y Age < 5 y >1000 >1000

>500-

>400 >400 >1000

1000 80-160

>160-320

>160-320

>320-1280

500-1000 750 100-250 200 200-400 200

500-

>1000-2000

>750-1250

>2000

100-

>250-500

>200-500

>500

100-

> 400-800

>200-400

>800-1200

400-1000 800

400-

>1000-2000

>800-1200

>2000

>320 >1250 >500 >400 >1200

Component 4: Asthma Management and Prevention Program

Reliever Medications  Rapid-acting inhaled β2-agonists  Systemic glucocorticosteroids  Anticholinergics  Theophylline  Short-acting oral β2-agonists

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

Treating to Maintain Asthma Control  When control as been achieved, ongoing monitoring is essential to: - maintain control - establish lowest step/dose treatment

 Asthma control should be monitored by the health care professional and by the patient

Treating to Maintain Asthma Control Stepping down treatment when asthma is controlled

 When controlled on medium- to highdose 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)

Asthma Management and Prevention Program

Component 4: Manage Asthma Exacerbations  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

Asthma Management and Prevention Program

Component 4: Manage Asthma Exacerbations Primary therapies for exacerbations: • Repetitive administration of rapid-acting inhaled β2-agonist • Early introduction of systemic glucocorticosteroids • Oxygen supplementation Closely monitor response to treatment with serial measures of lung function

Asthma Management and Prevention Program: Summary 

Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms



Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control

Asthma Management and Prevention Program: Summary  A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication  The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered

A. PERSEDIAAN PERALATAN • • • • • • • • • • • • • • • • • • •

Kad pesakit asthma Buku pendaftaran pesakit luar Peralatan ukur timbang/ tinggi Blood Pressure set Peak flow meter (adult/ paediatric) Pulse oxymeter Nebuliser and face mask Inhaler placebo - ( untuk tujuan pendidikan kesihatan) Ubatan reliever- Salbutamol MDI/ Bricanyl MDI Ubatan controller – Budesonide/ Beclomethasone MDI, Budesonide Turbohaler Ubatan bronchodilator – untuk acute case ( Salbutamol, Bricanyl, Combivent, Atrovent) Oxygen supply Oral steroids prednisolone, Intravenous Steroids ( hydrocortisone) Flow chart untuk management of acute asthma Flow chart untuk asthma assessment Carta pengkelasan asthma control Bahan pendidikan kesihatan asthma Written asthma plan

Alternate Slides for Asthma Treatment

Levels of Asthma Control Characteristic

Controlled (All of the following)

Daytime symptoms

None (twice or less/week) None

Limitations of activities

Partly Controlled (Any measure present in any week)

Uncontrolled

More than twice/week Any

Nocturnal symptoms/awakeni ng Need for reliever/ rescue treatment

None

Any

None (twice or less/week)

More than twice/week

Lung function (PEF or FEV1)

Normal

< 80% predicted or personal best (if known)

Exacerbations

None

One or more/year*

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

One in any week†

* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate. † By definition, an exacerbation in any week makes that an uncontrolled asthma week.

Asthma Control: Treatment Steps Children Older than Five Years, Adolescents, Adults

Example Of Contents Of An Action Plan To Maintain Asthma Control Your Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________ WHEN TO INCREASE TREATMENT Assess your level of Asthma Control In the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No Yes If you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment. HOW TO INCREASE TREATMENT STEP-UP your treatment as follows and assess improvement every day: ____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number] WHEN TO CALL THE DOCTOR/CLINIC. Call your doctor/clinic: _______________ [provide phone numbers] If you don’t respond in _________ days [specify number] ______________________________ [optional lines for additional instruction] EMERGENCY/SEVERE LOSS OF CONTROL If you have severe shortness of breath, and can only speak in short sentences, If you are having a severe attack of asthma and are frightened, If you need your reliever medication more than every 4 hours and are not improving. 1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid] 3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________ 4. Continue to use your _________[reliever medication] until you are able to get medical help.