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Latest Guidelines for Asthma Management. Global Initiative for Asthma By: Dr. Mahmoud Taheri. Strategies for Asthma Management and Prevention. Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and Prevention Program

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latest guidelines for asthma management
Latest Guidelines for Asthma Management

Global Initiative for Asthma

By: Dr. MahmoudTaheri

strategies for asthma management and prevention
Strategies for Asthma Management and Prevention
  • Definition and Overview
  • Diagnosis and Classification
  • Asthma Medications
  • Asthma Management and Prevention Program
  • Implementation of Asthma Guidelines in Health Systems
definition of asthma
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 reversibleairflow limitation
factors that exacerbate asthma
Factors that Exacerbate Asthma
  • Allergens
  • Respiratory infections
  • Exercise and hyperventilation
  • Weather changes
  • Sulfur dioxide
  • Food, additives, drugs
factors that influence asthma development and expression
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
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
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
slide10

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

slide13

Asthma Management and Prevention Program

Goals of Long-term Management

  • Achieve and maintaincontrol 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
slide14

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

5. Special Considerations

slide15
.

Asthma Management and Prevention Program

  • Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstrictionand 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 part 1 educate patients to develop a partnership
Asthma Management and Prevention ProgramPart 1: Educate Patients to Develop a 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
Asthma Management and Prevention ProgramComponent 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 partnership1
Asthma Management and Prevention ProgramComponent 1: Develop Patient/Doctor Partnership

Key factors to facilitate communication:

  • Friendly demeanor
  • Interactive dialogue
  • Encouragement and praise
  • Provide appropriate information
  • Feedback and review
asthma management and prevention program factors involved in non adherence
Asthma Management and Prevention ProgramFactors Involved in Non-Adherence
  • Non-Medication Factors
  • Misunderstanding/lack of information
  • Inappropriate expectations
  • Underestimation of severity
  • Attitudes toward ill health
  • Cultural factors
  • Poor communication

Medication Usage

  • Difficulties associated with inhalers
  • Complicated regimens
  • Fears about, or actual side effects
  • Cost
  • Distance to pharmacies
slide20

Asthma Management and Prevention Program

Component 2: Identify and Reduce Exposure to Risk Factors

  • Measures to help reducing exposure to risk factors should be implemented wherever possible.
  • Asthma exacerbations are caused by a variety of risk factors – allergens, viral infections, pollutants and drugs.
  • Reducing exposure to some risk factors improves the control of asthma and reduces medications needs.
slide21

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
slide22

Asthma Management and Prevention Program

Influenza Vaccination

  • Routineinfluenza 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
Asthma Management and Prevention ProgramComponent 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

global strategy for asthma management and prevention clinical control of asthma
Global Strategy for Asthma Management and PreventionClinical Control of Asthma

The focus on asthma control is

important because:

  • the attainment of control correlates with a better quality of life, and
  • reduction in health care use
global strategy for asthma management and prevention clinical control of asthma1
Global Strategy for Asthma Management and PreventionClinical Control of Asthma
  • Determine the initial level of control to implement treatment
  • (assess patient impairment)
  • Maintain control once treatment has been implemented
  • (assess patient risk)
levels of asthma control assess patient impairment
Levels of Asthma Control(Assess patient impairment)

Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)

slide29

Assess Patient Risk

  • Features that are associated with increased risk of adverse events in the future include:
  • Poor clinical control
  • Frequent exacerbations in past year
  • Ever admission to critical care for asthma
  • Low FEV1, exposure to cigarette smoke, high dose medications
slide30

*IMPORTANT*

Any exacerbation should prompt review of maintenance treatment

slide31

Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma

  • Depending on level of asthma control, the patient is assigned to one of five treatment steps
  • Step 2 is the initial treatment for most patients. If the patient is severely uncontrolled, we start from step 3.
  • Our approach includes:

- Assessing Asthma Control

-Treating to Achieve Control

-Monitoring to Maintain Control

slide32

Controller Medications

  • Inhaled glucocorticosteroids
  • Leukotriene modifiers
  • Long-acting inhaled β2-agonists in combination with inhaled glucocorticosteroids
  • Systemic glucocorticosteroids
  • Theophylline
  • Cromones
  • Anti-IgE
slide34

Salbutamol (Albuterol)

  • Availability: Aerosol 90 mcg/inh.
  • Brand Names: Ventolin
  • Onset: 5-15 min
  • Peak: 1 Hour
  • Duration: 3-6 hrs.
slide35

Salmeterol

  • Availability: Aerosol 25 mcg/inh.
  • Brand Names: Serevent
  • Onset: 10-25 min
  • Peak: 3-4 hrs.
  • Duration: 12 hrs.
slide36

Beclomethasone

  • Availability: Aerosol 40 mcg/inh.
  • Aerosol 80 mcg/inh.
  • Brand Names: Becotide, Beclazone, Qvar
  • Onset: Within 24 hrs.
  • Peak: 1-4 Weeks
  • Duration: Unknown
slide37

Fluticasone

  • Availability: Aerosol 44 mcg/inh.
  • Aerosol 110 mcg/inh.
  • Aerosol 220 mcg/inh.
  • Brand Names: Flovent
  • Onset: Within 24 hrs.
  • Peak: 1-4 Weeks
  • Duration: Days after DC.
slide38

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)

slide39

Reliever Medications

  • Rapid-acting inhaled β2-agonists
  • Systemicglucocorticosteroids
  • Anticholinergics
  • Theophylline
  • Short-acting oral β2-agonists
slide40

Component 4: Asthma Management and PreventionProgramAllergen-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 environmentalavoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma
slide41

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

slide42

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

Shaded green - preferred controller options

slide43

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

Shaded green - preferred controller options

slide44

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)
slide45

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

Shaded green - preferred controller options

slide46

Treating to Achieve Asthma Control

  • Step 2 – Reliever medication plus a single controller
  • A low-dose inhaled glucocorticosteroidis 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.
slide47

TO STEP 4 TREATMENT, ADD EITHER

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

Shaded green - preferred controller options

slide48

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-actingβ2-agonist either in a combination inhaler device or as separate components (Evidence A)
  • Inhaled long-acting β2-agonist must not be used as monotherapy
slide49

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)
slide50

TO STEP 4 TREATMENT, ADD EITHER

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

Shaded green - preferred controller options

slide51

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 3treatments should be referred to a health professional with expertise in the management of asthma
slide52

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-dosesustained-releasetheophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence B)
slide53

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

Shaded green - preferred controller options

slide54

Treating to Achieve Asthma Control

  • Step 5 – Reliever medication plus additional controller options
  • Addition of oralglucocorticosteroids 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)
slide55

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
slide56

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)
slide57

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 low-dose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D)
slide58

Treating to Maintain Asthma Control

Stepping up treatment in response to loss of control

  • Rapid-onset, short-acting or long-acting 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
slide59

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 management and prevention program component 4 manage asthma exacerbations
Asthma Management and Prevention ProgramComponent 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 life-threatening and treatment requires close supervision
asthma management and prevention program component 4 manage asthma exacerbations1
Asthma Management and Prevention ProgramComponent 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
Asthma Management and Prevention ProgramSpecial 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