Post on 10-Apr-2018
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G
IN
A
G
IN
A
lobal
itiative for
sthma
lobal
itiative for
sthma
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What is ASTHMA ?
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Definition of AsthmaDefinition of Asthma
A chronic inflammatory disorder of the airways
Many cells and cellular elements play a role
Chronic inflammation is associated with airwayhyperresponsiveness that leads to recurrentepisodes of wheezing, breathlessness, chest
tightness, and coughing Widespread, variable, and often reversible
airflow limitation
A chronic inflammatory disorder of the airways
Many cells and cellular elements play a role
Chronic inflammation is associated with airwayhyperresponsiveness that leads to recurrentepisodes of wheezing, breathlessness, chest
tightness, and coughing Widespread, variable, and often reversible
airflow limitation
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Source: Peter J. Barnes, MDSource: Peter J. Barnes, MD
Asthma Inflammation: Cells andMediators
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Source: Peter J. Barnes, MDSource: Peter J. Barnes, MD
Mechanisms: AsthmaInflammation
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Factors that Exacerbate AsthmaFactors that Exacerbate Asthma
Allergens
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide Food, additives, drugs
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Risk Factors for
Asthma
Host factors: predispose individuals to,or protect them from, developing
asthma
Environmental factors: influencesusceptibility to development of asthma
in predisposed individuals, precipitateasthma exacerbations, and/or causesymptoms to persist
Host factors: predispose individuals to,or protect them from, developing
asthma Environmental factors: influence
susceptibility to development of asthma
in predisposed individuals, precipitateasthma exacerbations, and/or causesymptoms to persist
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Factors that Influence Asthma
Development and Expression
Host Factors
Genetic
- Atopy- Airway
hyperresponsiveness
Gender
Obesity
Host Factors
Genetic
- Atopy- Airway
hyperresponsiveness
Gender
Obesity
Environmental FactorsIndoor allergens
Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution
Respiratory Infections Diet
Environmental FactorsIndoor allergens
Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution
Respiratory Infections Diet
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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 than10 days to clear
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Asthma Diagnosis
History and patterns of symptoms
Measurements of lung function
- Spirometry- Peak expiratory flow
Measurement of airway responsiveness
Measurements of allergic status to identifyrisk factors
Extra measures may be required todiagnose asthma in children 5 years andyounger and the elderly
History and patterns of symptoms
Measurements of lung function
- Spirometry
- Peak expiratory flow
Measurement of airway responsiveness
Measurements of allergic status to identifyrisk factors
Extra measures may be required todiagnose asthma in children 5 years andyounger and the elderly
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Typical Spirometric (FEV1)
Tracings
Typical Spirometric (FEV1)
Tracings
11Time (sec)Time (sec)
22 33 44 55
FEV1FEV1
VolumeVolume
Normal SubjectNormal Subject
Asthmatic (After Bronchodilator)Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)Asthmatic (Before Bronchodilator)
Note: Each FEV1 curve represents the highest of three repeat measurements
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TRIGGERS of ASTHMA ?
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Asthma Management and Prevention Program
Component 2: Identify and ReduceExposure to Risk Factors
Asthma Management and Prevention Program
Component 2: Identify and ReduceExposure 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.
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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
Component 2: Identify and ReduceExposure to Risk Factors
Asthma Management and Prevention Program
Component 2: Identify and ReduceExposure to Risk Factors
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REDUCE EXPOSURE TO
INDOOR ALLERGENS
Mites
Furred Animals
Cockroaches
Fungi
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REDUCE EXPOSURE TO
INDOOR ALLERGENS
Mites
Keep humidity below 50% (aircon)
Remove carpets
Encase mattress & pillows
Wash beddings weekly
Vacuum weekly
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REDUCE EXPOSURE TO
INDOOR ALLERGENS
Furred animals
The most effective way to combat symptomsof animal allergy is to REMOVE THE PET
from the home to avoid any contact.
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REDUCE EXPOSURE TO
INDOOR ALLERGENS
Cockroaches
Block areas where cockroaches can enter thehome.
Fix leaks & seal leaky faucets
Keep home clean and dry & keep food in tightlid containers
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REDUCE EXPOSURE TO
INDOOR ALLERGENS
Molds
Repair leaks
Clean with Zonrox regularly
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CLASSIFICATION
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Asthma Classification Based on
Severity
IntermittentMild
PersistentModeratePersistent
SeverePersistent
DaytimeSymptoms
1x / weekbut < daily
Daily
Affects dailyactivities
Daily Limitsdaily
activities
Nighttime
Symptoms < 2x / month > 2x / month > 1x / week > 1x / week
PEFR
> 80%
predicted
> 80%
predicted 60 79% < 60%
PEFR
Variability
< 20% 20 30 % > 30% > 30%
FEV 1> 80%
predicted> 80%
predicted 60 79% < 60%
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Levels of AsthmaControl
Characteristic Controlled
(All of the following)
Partly controlled(Any present in any week)
Uncontrolled
Daytime symptoms None (2 or less /week)
More thantwice / week
3 or morefeatures of partlycontrolled
asthma presentin any 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 1 in any week
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Long Term Asthma
Management( Based on Level of Control )
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Global Strategy for Asthma
Management and Prevention
Global Strategy for Asthma
Management and Prevention
Evidence Category Sources of Evidence
A Randomized clinical trialsRich body of data
B Randomized clinical trialsLimited body of data
C Non-randomized trialsObservational studies
D Panel judgment consensus
Evidence Category Sources of Evidence
A Randomized clinical trialsRich body of data
B Randomized clinical trialsLimited body of data
C Non-randomized trialsObservational studies
D Panel judgment consensus
Asthma Management and Prevention Program
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Asthma Management and Prevention Program
Goals of Long-term
Management
Achieve and maintain control ofsymptoms
Maintain normal activity levels,including exercise
Maintain pulmonary function as closeto normal levels as possible
Prevent asthma exacerbations
Avoid adverse effects from asthmamedications
Prevent asthma mortalit
Achieve and maintain control ofsymptoms
Maintain normal activity levels,including exercise
Maintain pulmonary function as closeto normal levels as possible
Prevent asthma exacerbations
Avoid adverse effects from asthmamedications
Prevent asthma mortalit
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Component 3: Assess,Treat and Monitor
Asthma
Component 3: Assess,Treat and Monitor
Asthma The goal of asthma treatment, to
achieve and maintain clinical
control, can be achieved in amajority of patients with apharmacologic intervention strategy
developed in partnership betweenthe patient/family and the healthcare professional
The goal of asthma treatment, toachieve and maintain clinical
control, can be achieved in amajority of patients with apharmacologic intervention strategy
developed in partnership betweenthe patient/family and the healthcare professional
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Asthma Classification Based on
Severity
IntermittentMild
PersistentModeratePersistent
SeverePersistent
DaytimeSymptoms
1x / weekbut < daily
Daily
Affects dailyactivities
Daily Limitsdaily
activities
Nighttime
Symptoms < 2x / month > 2x / month > 1x / week > 1x / week
PEFR
> 80%
predicted
> 80%
predicted 60 79% < 60%
PEFR
Variability
< 20% 20 30 % > 30% > 30%
FEV 1> 80%
predicted> 80%
predicted 60 79% < 60%
L l f A h
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Levels of AsthmaControl
Characteristic
Daytime symptoms
Limitations of activities
Nocturnal symptoms /awakening
Need for rescue /
reliever treatment
Lung function(PEF or FEV1)
Exacerbation
L l f A th
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Levels of AsthmaControl
Characteristic Controlled
(All of the following)
Daytime symptoms None (2 or less /week)
Limitations of activities None
Nocturnal symptoms /awakening
None
Need for rescue /
reliever treatment
None (2 or less /
week)
Lung function(PEF or FEV1)
Normal
Exacerbation None
L l f A th
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Levels of AsthmaControl
Characteristic Controlled
(All of the following)
Partly controlled(Any present in any week)
Daytime symptoms None (2 or less /week)
More thantwice / 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
Characte- Controlled Partly Uncontrolled
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Characte
ristics
Controlled Partly
Controlled
Uncontrolled
Daytime Sx None (2x /wk Three or morfeatures ofpartlycontrolledasthma presin any wk
Nocturnal Sx None Any
Need forrescue Rx
None(2x/ wk
Lung Fx Normal 1 / yr One in any w
Asthma Management and Prevention ProgramAsthma Management and Prevention Program
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Asthma Management and Prevention Program
Component 3: Assess,Treat and Monitor Asthma
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 fivetreatment steps
Treatment is adjusted in a continuouscycle driven by changes in asthmacontrol status. The cycle involves:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control
Asthma Management and Prevention ProgramAsthma Management and Prevention Program
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A stepwise approach to pharmacologicaltherapy is recommended
The aim is to accomplish the goals oftherapy with the least possible medication
Although in many countries traditionalmethods of healing are used, their efficacyhas not yet been established and their usecan therefore not be recommended
A stepwise approach to pharmacologicaltherapy is recommended
The aim is to accomplish the goals oftherapy with the least possible medication
Although in many countries traditionalmethods of healing are used, their efficacyhas not yet been established and their usecan therefore not be recommended
Asthma Management and Prevention Program
Component 3: Assess,Treat and Monitor Asthma
Asthma Management and Prevention Program
Component 3: Assess,Treat and Monitor Asthma
Asthma Management and Prevention ProgramAsthma Management and Prevention Program
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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 caresystems need to be considered
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 caresystems need to be considered
g g
Component 3: Assess,Treat and Monitor Asthma
g g
Component 3: Assess,Treat and Monitor Asthma
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Component 4: Asthma Management and Prevention Program
Controller Medications
Component 4: Asthma Management and Prevention Program
Controller Medications
Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled 2-agonists
Systemic glucocorticosteroids
Theophylline
Cromones
Long-acting oral 2-agonists
Anti-IgE
Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled 2
-agonists
Systemic glucocorticosteroids
Theophylline
Cromones
Long-acting oral 2-agonists
Anti-IgE
E ti t C ti D il D fE ti t C ti D il D f
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Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
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
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
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400
Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400
Budesonide-Neb InhalationSuspension
250-500 >500-1000 >1000
Ciclesonide 80 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250
Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500
Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400
Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200
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Component 4: Asthma Management and Prevention Program
Reliever Medications
Component 4: Asthma Management and Prevention Program
Reliever Medications
Rapid-acting inhaled 2-agonists
Anticholinergics
Theophylline
Short-acting oral 2-agonists
Rapid-acting inhaled 2-agonists
Anticholinergics
Theophylline
Short-acting oral 2-agonists
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controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROLLEVEL OF CONTROL
maintain and find lowest
controlling step
consider stepping up to
gain control
step up until controlled
treat as exacerbation
TREATMENT OF ACTIONTREATMENT OF ACTION
TREATMENT STEPSREDUCE INCREASE
STEP
1
STEP
2
STEP
3
STEP
4
STEP
5
REDUCE
INCRE
AS
E
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Step 1 As-needed reliever medication
Patients with occasional daytime symptoms of
short duration A rapid-acting inhaled 2-agonist is the
recommended reliever treatment ( Evidence A )
When symptoms are more frequent, and/or
worsen periodically, patients require regular
controller treatment (step 2or higher)
Treating to Achieve AsthmaControl
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Step 2 Reliever medication plus a singlecontroller
Initial controller Rx: low-dose inhaled
glucocorticosteroid for patients of all ages(Evidence A )
Alternative controller medications :
leukotriene modifiers ( Evidence A )
Treating to Achieve AsthmaControl
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Step 3 Reliever medication plus one or twocontrollers
Adults and adolescents: combine a low-dose
inhaled glucocorticosteroid with an inhaled long-acting 2-agonist ( Evidence A )
Inhaled long-acting 2-agonist must not be used
as monotherapy
For children, increase to a medium-dose inhaled
glucocorticosteroid ( Evidence A )
Treating to Achieve AsthmaControl
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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 inhaled glucocorticosteroid pluslow-dose sustained-release theophylline( Evidence B )
Treating to Achieve AsthmaControl
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Step 4 Reliever medication plus two or morecontrollers
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 AsthmaControl
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Step 4 Reliever medication plus two or more controllers
Medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled 2-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 2-agonist (
Evidence B )
Treating to Achieve AsthmaControl
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i hi h
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Treating to Achieve AsthmaControl
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 severeside-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 )
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Treating to Maintain AsthmaControl
When control as been achieved,ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
Asthma control should be monitoredby the health care professional andby the patient
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Treating to Maintain AsthmaControl
Stepping down treatment when asthma is controlled
When controlled on medium- to high-dose
inhaled glucocorticosteroids: 50% dosereduction at 3 month intervals( Evidence B )
When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily
dosing ( Evidence A )
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Treating to Maintain AsthmaControl
Stepping down treatment when asthma is controlled
When controlled on combination inhaledglucocorticosteroids and long-actinginhaled 2-agonist, reduce dose of inhaled
glucocorticosteroid by 50% whilecontinuing the long-acting 2-agonist
( Evidence B )
If control is maintained, reduce to low-dose inhaled glucocorticosteroids and
stop long-acting 2-agonist ( Evidence D )
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Treating to Maintain AsthmaControl
Stepping up treatment in response to loss of control
Rapid-onset, short-acting or long-
acting inhaled 2-agonistbronchodilators provide temporaryrelief.
Need for repeated dosing over morethan one/two days signals need forpossible increase in controller therapy
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Treating to Maintain AsthmaControl
Stepping up treatment in response to loss of control
Use of a combination rapid and long-actinginhaled 2-agonist (e.g., formoterol) and an
inhaled glucocorticosteroid (e.g., budesonide)in a single inhaler both as a controller andreliever 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
C t 3 A T t dAsthma Management and Prevention Program
C t 3 A T t d
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Childhood and adult asthma share the
same underlying mechanisms.However, because of processes of
growth and development, effects of
asthma treatments in children differfrom those in adults.
Childhood and adult asthma share the
same underlying mechanisms.However, because of processes of
growth and development, effects of
asthma treatments in children differfrom those in adults.
Component 3: Assess, Treat andMonitor Asthma Children 5
Years and Younger
Component 3: Assess, Treat andMonitor Asthma Children 5
Years and Younger
Asthma Management and Prevention Program
C t 3 A T t dAsthma Management and Prevention Program
Component 3 Assess Treat and
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Many asthma medications (e.g.
glucocorticosteroids, 2- agonists,theophylline) are metabolized faster in
children than in adults, and younger
children tend to metabolize medicationsfaster than older children
Many asthma medications (e.g.
glucocorticosteroids, 2- agonists,theophylline) are metabolized faster in
children than in adults, and younger
children tend to metabolize medicationsfaster than older children
Component 3: Assess, Treat andMonitor Asthma Children 5
Years and Younger
Component 3: Assess, Treat andMonitor Asthma Children 5
Years and Younger
Asthma Management and Prevention Program
C t 3 A T t dAsthma Management and Prevention Program
Component 3: Assess Treat and
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Glucocorticosteroids has not been shown
to be associated with any increase in
osteoporosis in long-term treatment withinhaled or bone fracture
Studies including a total of over 3,500
children treated for periods of 1 13 yearshave found no sustained adverse effect of
inhaled glucocorticosteroids on growth
Glucocorticosteroids has not been shown
to be associated with any increase in
osteoporosis in long-term treatment withinhaled or bone fracture
Studies including a total of over 3,500
children treated for periods of 1 13 yearshave found no sustained adverse effect of
inhaled glucocorticosteroids on growth
Component 3: Assess, Treat andMonitor Asthma Children 5
Years and Younger
Component 3: Assess, Treat andMonitor Asthma Children 5
Years and Younger
Asthma Management andAsthma Management and
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A stepwise approach to pharmacologic therapyis recommended. The aim is to accomplish the
goals of therapy with the least possiblemedication
The availability of varying forms of treatment,
cultural preferences, and differing health caresystems need to be considered
A stepwise approach to pharmacologic therapyis recommended. The aim is to accomplish the
goals of therapy with the least possiblemedication
The availability of varying forms of treatment,
cultural preferences, and differing health caresystems need to be considered
Asthma Management and
Prevention Program: Summary
Asthma Management and
Prevention Program: Summary
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MANAGEMENT of
EXACERBATION
Asthma Management and Prevention ProgramAsthma Management and Prevention Program
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Exacerbations of asthma
Episodes of progressive in shortness ofbreath, cough, wheezing, or chest
tightness
Characterized by in expiratory airflow,can quantified and monitored by
measurements of lung function (FEV1or
PEF)
Exacerbations of asthma
Episodes of progressive in shortness ofbreath, cough, wheezing, or chest
tightness
Characterized by in expiratory airflow,can quantified and monitored by
measurements of lung function (FEV1 or
PEF)
Component 4: Manage Asthma
Exacerbations
Component 4: Manage Asthma
Exacerbations
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Aims of Treatment of AcuteAsthma Exacerbation
Relieve airway obstruction as quickly as possible
Relieve hypoxemia as quickly as possible
Plan the prevention of future relapses
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AbsentUsu ally loudLoudM od. often
en d-ex p irato ry
Wheeze
Paradoxical
breathing
UsuallyUsuallyUsu ally notUse of accessory
m uscles o f resp
Often > 30/m inIncreasedIncreasedResp. ra te
Drows y/ confused
or com atose
Usu ally agitatedUsually
agitated
M ay be
agitated
Alertness
WordsPhrasesSentencesTalks in
M ay be cyanotic,exhaustedAt restHunched forwardTalkingPre fers sitting
WalkingCan l ie dow n
Breathless w hen
RESP. ARRE S
IMMINENT
SEVEREM O D E R A T EMILD
Assessm ent of Severity of
Asthm a Exacerbations
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Asthma Management and Prevention ProgramAsthma Management and Prevention Program
C t 4 M A th
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Component 4: Manage Asthma
Exacerbations
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
Treatment of exacerbations depends on:
The patient
Experience of the health careprofessional
Therapies that are the most effective for
the particular patient Availability of medications
Emergency facilities
Management of asthma exacerbation in acute
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Management of asthma exacerbation in acutecare setting
Initial assessmentHistory, PE (auscultation, use of accessory
muscles, HR, RR, PEF or FEV1, O2 saturation, ABG
Initial Treatment-Oxygen to achieve saturation to >95% in children
-Inhaled acting beta-2 agonist continuously for 1H
-Systemic glucocorticosteroids if no immediateresponse
-Sedation contraindicated in the treatment of acuteexacerbation
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Criteria formoderate episode
PEF 60-80% predicted /personal best
PE: moderate symptoms,accessory muscle use
Treatment O2; Inhaled beta-2 agonist &
anticholinergic for 1 Hr
Oral glucocorticosteroids
Continue for 1-3H, providedwith improvement
Criteria forsevere episode RFs for near fatal asthma PEF
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Re-assess after 1-2 H
Good response within 1-2H
Response sustained 1H after treatment
PE Normal: No distressPEF >70%; O2 sat 95%
Improved: Criteria for Discharge Home
PEF >60% predicted/ personal best
Sustained on oral/inhaled medication
Home Treatment: Inhaled beta-2 agonist
and oral GC; consider combination inhaler
Patient education
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Re-assess after 1-2HIncomplete response
within 1-2H RFs for near fatal asthma PEF
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Re-assess at intervals
Incomplete to poor response Intensive Care
Incomplete response in 6-12H
Consider admission to Intensive Care
Improved
Consider discharge criteria
Asthma Management and Prevention Program
C t 4 M A th
Asthma Management and Prevention Program
C t 4 M A th
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Primary therapies for exacerbations:
Repetitive administration of rapid-acting inhaled 2-agonist
Early introduction of systemic glucocorticosteroids
Oxygen supplementation
Closely monitor response to treatment with serial
measures of lung function.
Primary therapies for exacerbations:
Repetitive administration of rapid-acting inhaled 2-agonist
Early introduction of systemic glucocorticosteroids
Oxygen supplementation
Closely monitor response to treatment with serial
measures of lung function.
Component 4: Manage Asthma
Exacerbations
Component 4: Manage Asthma
Exacerbations
Criteria for Discharge from the
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Emergency Department vs. Hospitalization
Patients with pre-treatment FEV1 or PEF 60%predicted
For patients discharged from the emergency
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For patients discharged from the emergency
department
Shorter course (3-5 days) should be prescribed +
continuation of bronchodilator therapy
Bronchodilator can be prn, based on symptomatic and
objective measurement Ipratropium bromide unlikely to provide additional
benefit beyond the acute phase
Continue inhaled glucocorticosteroids!
Review of patients inhaler technique and use of peak
flow meter
Review of action plan with written guidance
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SPECIAL CONSIDERATIONS
Asthma Management and Prevention ProgramAsthma Management and Prevention ProgramAsthma Management and Prevention ProgramAsthma Management and Prevention Program
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Special Considerationsg gg g
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
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
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Rhinitis
Allergic Rhinitis and its impact on asthma
(ARIA)
Classification: Intermittent or Persistent; Mild
or Moderate-Severe Treatment: H1- antagonists (oral and
intranasal), decongestant, steroids
(intranasal, oral), cromones, leukotrienemodifiers.
Allergen avoidance, Immunotherapy,
Education
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Sinusitis
A complication of URI, AR,
nasal polyps and other forms of
nasal obstruction
Antibiotic therapy for 10 days
Topical nasal decongestants,topical nasal steroids, systemic
glucocorticosteroids
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Respiratory Infections
RSV, most common cause of wheezing ininfancy
Rhinovirus, principal trigger of wheezing and
worsening of asthma in older children &adults Role of chronic infection with
Chlamydia/Mycoplasma pneumoniae in thepathogenesis or worsening of asthma isuncertain
Treatment of an infectious exacerbationfollows the same principles as treatment ofother asthma exacerbations
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Gastroesophageal Reflux
3x as prevalent in patients with asthma
compared o the general population
Advise smaller frequent meals, avoidfatty meals, alcohol, theophylline, oral 2
agonists
Use proton pump inhibitors or H2antagonists
Elevate the head of the head
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Anaphylaxis and Asthma
Anaphylaxis is a potentially life-threatening
condition that can both mimic and complicate
severe asthma Allergen Immunotherapy, Food intolerance,
Avian-based vaccines, insect stings and
bites, NSAIDS, ACE inhibitors, exercise Epinephrine should be the bronchodilator of
choice
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Case
R.J., a 7-year old male child, newly
diagnosed to have bronchial
asthma last March 2007, came in atthe emergency room for cough and
coryza the past 3 days. Few hours
prior to consult, child was noted tohave sudden onset of shortness of
breath.
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Case
At the ER, pertinent PE revealed a
wheezy chest with alar flaring. Vital
signs were: heart rate = 120 beats
per minute and respiratory rate = 30
breaths per minute. O2 saturation was93% and peak expiratory flow rate
(PEFR) was 75%.
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Case
Pertinent medical history revealed
poor compliance with the anti-asthmamaintenance medications (inhaled
long acting beta-2 agonist and
corticosteroid combination).
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BRONCHIAL ASTHMA UNCONTROLLEDin MODERATE EXACERBATION
Treatment
O2
Inhaled beta-2 agonist & anticholinergic for1 Hr
Oral glucocorticosteroids
Continue for 1-3H, provided withimprovement
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Case
After continuous nebulization for one
hour. He was drowsy. Vital signs
revealed: heart rate= 180 beats/min,respiratory rate= 50 breaths/min with
Oxygen saturation was 50% at
2L/minute O2 via nasal cannula.
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Case
P.E. :C/L findings revealed severe
retractions with use of accessorymuscles and absent breath sounds.
ABG showed Pc02 : 50 mm Hg and
P02 : 60 mm Hg
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Case
1. What is your assessment?
2. What will be your treatment?
Poor response within 1-2H
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Poor response within 1 2H
RFs for near fatal asthma
PEF 45 mm Hg
pO2