Prof. Mohamad Fawzy Ismail Consultant Pulmonist Dallah Hospitals Professor of Chest Diseases

1. Bronchial Asthma Management Prof. Mohamad Fawzy Ismail Consultant Pulmonist Dallah Hospitals Professor of Chest Diseases Faculty of Medicine Zagazig University

2. Bronchial asthma • Definition and Overview • Diagnosis and Classification • Asthma Medications • Asthma Management and Prevention Program • Implementation of Asthma Guidelines in Health Systems

3. 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

4. Asthma Inflammation: Cells and Mediators Source: Peter J. Barnes, MD

5. Source: Peter J. Barnes, MD Mechanisms: Asthma Inflammation

6. Asthma Inflammation: Cells and Mediators Source: Peter J. Barnes, MD

7. 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

8. Asthma Prevalence and Mortality Source: Masoli M et al. Allergy 2004

9. 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

10. Factors that Exacerbate Asthma • Allergens • Respiratory infections • Exercise and hyperventilation • Weather changes • Sulfur dioxide • Food, additives, drugs

11. 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

12. 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

13. 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

14. Typical Spirometric (FEV1) Tracings Volume FEV1 Normal Subject Asthmatic (After Bronchodilator) Asthmatic (Before Bronchodilator) 1 2 3 4 5 Time (sec) Note: Each FEV1 curve represents the highest of three repeat measurements

15. Measuring Variability of Peak Expiratory Flow

16. Measuring Airway Responsiveness

17. Levels of Asthma Control

18. 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 4. Manage Asthma Exacerbations 5. Special Considerations

19. 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

20. 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.

21. 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

22. 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

23. 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

24. Component 1: Develop Patient/Doctor Partnership Key factors to facilitate communication: • Friendly demeanor • Interactive dialogue • Encouragement and praise • Provide appropriate information • Feedback and review

26. Factors Involved in Non-Adherence • Medication Usage • Difficulties associated with inhalers • Complicated regimens • Fears about, or actual side effects • Cost • Distance to pharmacies • Non-Medication Factors • Misunderstanding/lack of information • Fears about side-effects • Inappropriate expectations • Underestimation of severity • Attitudes toward ill health • Cultural factors • Poor communication

27. 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.

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. Controller Medications • Inhaled glucocorticosteroids • Leukotriene modifiers • Long-acting inhaled β2-agonists • Systemic glucocorticosteroids • Theophylline • Cromones • Long-acting oral β2-agonists • Anti-IgE • Systemic glucocorticosteroids

35. Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g) > 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

36. Reliever Medications • Rapid-acting inhaled β2-agonists • Systemic glucocorticosteroids • Anticholinergics • Theophylline • Short-acting oral β2-agonists

37. 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

38. LEVEL OF CONTROL TREATMENT OF ACTION REDUCE maintain and find lowest controlling step controlled consider stepping up to gain control partly controlled uncontrolled step up until controlled INCREASE exacerbation treat as exacerbation REDUCE INCREASE TREATMENT STEPS STEP 1 STEP 2 STEP 3 STEP 4 STEP 5

41. 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)

43. 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

45. 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 long-acting 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)

46. 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)

48. 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

49. 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)