Asthma Control: Guideline Based
1 / 38

Michael P. Pietila, MD Pulmonary, Critical Care and Internal Medicine Yankton Medical Clinic, P.C. Assistant Professor S - PowerPoint PPT Presentation

  • Uploaded on

Asthma Control: Guideline Based American Thoracic Society (ATS), National Asthma Education and Prevention Program (NAEPP), and Global Initiative for Asthma (GINA). Michael P. Pietila, MD Pulmonary, Critical Care and Internal Medicine Yankton Medical Clinic, P.C.

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Michael P. Pietila, MD Pulmonary, Critical Care and Internal Medicine Yankton Medical Clinic, P.C. Assistant Professor S' - fiona

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

Asthma Control: Guideline BasedAmerican Thoracic Society (ATS), National Asthma Education and Prevention Program (NAEPP), and Global Initiative for Asthma (GINA)

Michael P. Pietila, MD

Pulmonary, Critical Care and Internal Medicine Yankton Medical Clinic, P.C.

Assistant Professor Sanford School of Medicine at USD

Professional relationships
Professional Relationships

  • I am a contracted speaker for:

    • Merck Pharmaceuticals

    • Dey Pharma L.P. Bureau of COPD Research and Education to Advance Therapeutic Excellence (BREATHE)

  • I will not be speaking specifically about any of these companies products today.

Asthma epidemiology
Asthma Epidemiology

  • Estimated > 23 million Americans

    • Prevalence 5-25% of population

  • Increasing prevalence and severity

    • USA and worldwide

    • Socioeconomics > genetics

  • $14 Billion direct annual costs in USA


  • More common in males (equal after age 20).

  • Atopy – Skin test reactivity, elevated IgE levels, blood eosinophilia.

  • Indoor allergens – dust mites, animal dander.

  • Environmental pollution, occupational exposure.

  • Respiratory infections.


Increasing asthma mortality
Increasing Asthma Mortality

  • 500,000 hospitalizations per year in U.S.

  • 5-6,000 deaths per year

  • 1978 - beginning of increasing mortality

  • Role of poverty (vs. race)

    • Access to health care, medications, education

    • Greater environmental exposure

    • Importance of identifying persons with high risk of death

Definition of asthma
Definition of Asthma

  • Obstructive lung disease with characteristics of:

    • Airway obstruction;reversible in most patients

    • Chronic airwayinflammation (eosinophils)

    • Increased airwayresponsiveness

  • Onset of symptoms can occur at any age

    NAEP - Guidelines for the Diagnosis and Management of Asthma 1991

Guidelines for the diagnosis and management of asthma
Guidelines for the Diagnosis and Management of Asthma

Key Messages

  • Asthma is an inflammatory disease

  • Environmental factors are important

  • Objective measures are needed

  • Health education is crucial

  • Emphasis on recognition and avoidance of triggers

    Buist & Vollmer. NEJM 331:1584-5;1996

    Asthma Guidelines 2007

Asthma guidelines 2007
Asthma Guidelines 2007

  • Components of severity:

    • Symptoms and objective testing.

    • FEV1 and FEV1/FVC measurement.

    • Need for short-acting beta-agonist (SABA).

    • Nighttime awakenings.

    • Interference with normal activity.

Diagnosing asthma
Diagnosing Asthma

  • Symptoms and Medical History

    • Wheezing, cough, difficult breathing and chest tightness

  • Symptoms worse at night/on awakening

  • Seasonal pattern

  • Eczema, hay fever, family history

  • Triggers – animal fur, chemicals, temperature change, dust mites, drugs, exercise, pollen, URI, smoke

  • Symptoms respond to anti-asthma therapy

  • Colds “go to the chest” or last > 10 days.

Pocket Guide for Asthma Management and Prevention 2011

Asthma phenotypes
Asthma Phenotypes

  • Intermittent/Persistent

    • Mild/Moderate/Severe

  • Adult onset wheezing

    • Primary asthma and secondary causes

    • Tends to me more severe

  • Occupational asthma

  • Neutrophilic inflammation

Diagnostic tests
Diagnostic Tests

  • No single test can secure a diagnosis of asthma

  • Spirometry is the most helpful, preferred method for establishing diagnosis.

    • Increase in FEV1 of > 12% and 200 ml after inhaled bronchodilator.

    • Many asthma patients are negative and repeat testing is advised.

Diagnostic testing
Diagnostic Testing

  • Peak expiratory flow (PEF) – aid in diagnosis and management.

    • Compare to patient's previous best effort

    • 60 L/min improvement after BD or diurnal variation in PEF of more than 20%

  • Bronchoprovaction testing.

    • Methacholine, histamine or inhaled mannitol

  • Skin testing or specific IgE testing for allergens.

Diagnostic challenges
Diagnostic Challenges

  • Cough variant asthma

    • Chronic cough, often at night

  • Exercise induced bronchospasm

    • Exercise challenge

  • Asthma in the elderly

    • COPD vs asthma

  • Occupational asthma

    • Must correlate symptoms with occupation

Goals of therapy
Goals of Therapy

  • Avoid troublesome symptoms night and day

  • Use little or no reliever meds

  • Have productive and physically active life

  • Have (near) normal lung function

  • Avoid serious attacks

Initiating therapy
Initiating Therapy

  • Determine level of severity.

  • Consider interval since last exacerbation.

    • Fluctuations in severity and frequency may occur.

  • Risk assessment:

    • Exacerbations requiring oral corticosteroids:

      • 0-1 per year in intermittent (low risk) patient.

      • > or equal to 2 per year in persistent (higher risk) patient.

  • Keep in mind the patients baseline FEV1.

  • Initiate treatment in a stepwise fashion.

    • Reevaluate level of control in 2-6 weeks.

Asthma care
Asthma Care

  • Patient/doctor relationship

    • Avoid triggers, understand and take meds, recognize symptoms and seek advice in timely fashion

  • Identify and reduce exposure to risk

    • Smoke, drugs, dust, fur, pollens, mold

  • Assess, treat and monitor

    • Stepwise approach, Ongoing monitoring q 3 monthly when stable, within 2 weeks after exacerbation.

  • Manage exacerbations

Stepwise approach
Stepwise Approach

  • If disease is poorly controlled

    • First evaluate for adherence to treatments and avoidance of triggers

    • Consider a step up treatments

  • If disease is well controlled

    • Step down treatments

  • Medications must be adjusted based on response to treatment and control of underlying disease, not on a fixed timetable.

    • If a medicine is not effective after 3 months, it should be stopped

Moderate to severe persistent asthma
Moderate to Severe Persistent Asthma

  • Daytime symptoms daily and nighttime symptoms at least weekly.

  • Using their rescue inhaler at least once daily.

  • FEV1 < 80% of predicted.

  • FEV1/FVC ratio reduced by 5% from baseline.

Moderate to severe persistent asthma1
Moderate to Severe Persistent Asthma

  • Moderate to High dose Inhaled Corticosteroids (ICS) are the cornerstone of treatment.

    • Higher potency preparations require fewer puffs and encourage compliance

    • Under dosing of ICS will result in poorer control

Managing disease
Managing Disease

  • Add in a Long Acting Beta Agonist (LABA)

    • Most pts in the severe category require at least 2 controller agents

    • Should NEVER be used as monotherapy

  • Leukotriene antagonists are also an option:

    • Limited evidence in literature

    • Montelukast, Zafirlukast, Zilueton

  • Theophylline

    • Limited role, controller agent only, not as efficacious as LABA’s

  • If symptoms are severe add oral corticosteroids.

    • 5-7 days if normal FEV1, 14-21 days if reduced FEV1

  • Consider treatment with IgE antibody.

Oral glucocorticoids
Oral Glucocorticoids

  • Most potent and effective controller agent.

    • Reserve for severe disease and those with reduced FEV1, use lowest dose possible

    • Should see an improvement in FEV1 of 15% after 2-3 weeks

    • If requiring oral GC’s every 2-3 months consider daily low dose (5-10 mg)

Follow up

  • 4 to 8 week intervals.

    • Use a questionnaire to evaluate control

      • Asthma Control Test (ACT)

    • Consider spirometry if worsening symptoms or a step down in care

Xolair what is that
Xolair: What is That?

  • Xolair (Omalizumab): Is an recombinant monoclonal anti-IgE antibody designed to treat moderate to severe allergy associated asthma.

    • Must demonstrate sensitization to an allergen.

    • Inadequate control with inhaled steroids.

Asthma guidelines 20071
Asthma Guidelines 2007

  • Xolair therapy:

    • Reduce the need for systemic and inhaled glucocorticoids.

    • Reduce the number of exacerbations, especially severe exacerbations.

    • No effect on FEV1 values.

    • Given via SubQ route q 2 to 4 weeks.

    • 850 patients radomized

      • 25% reduction in rate of exacerbation

      • Overall response rate 30-50%

      • 12 week trial should be offered

Hanania, et al;Ann Intern Med 2011;154:573

Co morbid illness
Co-Morbid Illness

  • Allergic rhinitis – treat with nasal GC’s if surgical disease refer to ENT

  • GERD – treat with PPI if patient is symptomatic from GERD

  • Vocal cord dysfunction (VCD)- referral to qualified speech therapist

  • OSA – study in sleep lab and treat as indicated

Special considerations


Variable, safe


Weight loss helps


PFT’s, if < 80% FEV1 steroids help

Chronic sinus/rhinitis

Treating these will improve asthma




More common in asthma but treatment doesn’t reduce morbidity

ASA induced



Special Considerations


  • Accurate and complete history and physical is crucial.

  • Objective testing – spirometry, methacholine challenge, peak flows, serum studies.

  • Classify the patient.

  • Step care.

  • Reevaluation/follow-up.


  • Written action plan

  • Proper inhaler technique

  • Trigger avoidance

  • Inhaled GC’s are cornerstone of therapy

  • LABA’s should be added next

  • LTA’s or theophylline follow

  • Consider IgE antibody in proper subset

  • Treat comorbid illnesses