G lobal INitiative for A sthma
Definition of Asthma
A chronic inflammatory disorder of the airways
Many cells and cellular elements play a role
Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing
Widespread, variable, and often reversible airflow limitation
Asthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, MD
Mechanisms: Asthma Inflammation
Source: Peter J. Barnes, MD
Asthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, MD
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
Burden of Asthma
Health care expenditures very high
Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma. Developing economies likely to face increased demand
Poorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care
Asthma Prevalence and Mortality
Source: Masoli M et al. Allergy 2004
Countries should enter their own data on burden of asthma.
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
Typical Spirometric (FEV1) Tracings Volume FEV1 Normal Subject Asthmatic (After Bronchodilator) Asthmatic (Before Bronchodilator)
1
2 3 4 Time (sec)
5
Note: Each FEV1 curve represents the highest of three repeat measurements
Measuring Variability of Peak Expiratory Flow
Measuring Airway Responsiveness
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
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams Clear communication between health care professionals and asthma patients is key to enhancing compliance
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership
Educate continually
Include the family
Provide information about asthma
Provide training on self-management skills
Emphasize a partnership among health care providers, the patient, and the patient’s family
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership Key factors to facilitate communication: Friendly demeanor Interactive dialogue Encouragement and praise Provide appropriate information Feedback and review
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
Difficulties associated with inhalers
Non-Medication Factors
Misunderstanding/lack of information
Complicated regimens
Fears about side-effects
Fears about, or actual side effects
Inappropriate expectations
Cost
Underestimation of severity
Distance to pharmacies
Attitudes toward ill health
Cultural factors
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
Explore role of infections on asthma development, especially in children and young infants
Asthma Management and Prevention Program
Influenza Vaccination
Influenza vaccination should be provided to patients with asthma when vaccination of the general population is advised However, routine influenza vaccination of children and adults with asthma does not appear to protect them from asthma exacerbations or improve asthma control
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
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
A stepwise approach to pharmacological therapy is recommended
The aim is to accomplish the goals of therapy with the least possible medication
Although in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommended
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma The choice of treatment should be guided by:
Level of asthma control
Current treatment
Pharmacological properties and availability of the various forms of asthma treatment
Economic considerations
Cultural preferences and differing health care systems need to be considered
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
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma The choice of treatment should be guided by:
Level of asthma control
Current treatment
Pharmacological properties and availability of the various forms of asthma treatment
Economic considerations
Cultural preferences and differing health care systems need to be considered
Component 4: Asthma Management and Prevention Program
Controller Medications
Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists Systemic glucocorticosteroids Theophylline Cromones 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
Component 4: Asthma Management and Prevention Program
Allergen-specific Immunotherapy
Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis
The role of specific immunotherapy in asthma is limited
Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma
Perform only by trained physician
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 Achieve Asthma Control Step 1 – As-needed reliever medication Patients with occasional daytime symptoms of short duration A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A) When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)
Treating to Achieve Asthma Control Step 2 – Reliever medication plus a single controller 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)
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 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)
Treating to Maintain Asthma Control Stepping down treatment when asthma is controlled
When controlled on combination inhaled glucocorticosteroids and long-acting inhaled β2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β2-agonist (Evidence B) If control is maintained, reduce to lowdose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D)
Treating to Maintain Asthma Control Stepping up treatment in response to loss of control
Rapid-onset, short-acting or longacting inhaled β2-agonist bronchodilators provide temporary relief. Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy
Treating to Maintain Asthma Control Stepping up treatment in response to loss of control
Use of a combination rapid and long-acting inhaled β2-agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations (Evidence A) Doubling the dose of inhaled glucocorticosteroids is not effective, and is not recommended (Evidence A)
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger Childhood and adult asthma share the same underlying mechanisms. However, because of processes of growth and development, effects of asthma treatments in children differ from those in adults.
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger Many asthma medications (e.g. glucocorticosteroids, β2- agonists, theophylline) are metabolized faster in children than in adults, and younger children tend to metabolize medications faster than older children
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger Long-term treatment with inhaled glucocorticosteroids has not been shown to be associated with any increase in osteoporosis or bone fracture Studies including a total of over 3,500 children treated for periods of 1 – 13 years have found no sustained adverse effect of inhaled glucocorticosteroids on growth
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger Rapid-acting inhaled β2-agonists are the most effective reliever therapy for children These medications are the most effective bronchodilators available and are the treatment of choice for acute asthma symptoms
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 Treatment of exacerbations depends on: The patient Experience of the health care professional Therapies that are the most effective for the particular patient Availability of medications Emergency facilities
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
Special Considerations Special considerations are required to manage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma
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
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.