Transcript Slide 1

How Do We Achieve Optimal
Asthma Control?
Role of Nebulised steroids in
Management of Asthma
BY
MAYSA SHARAF ELDIN
PROFESSOR OF PULMONARY
MEDICINE
CAIRO UNIVERISITY
• Why do we care about asthma
control?
• What do we mean by asthma
control?
• Inhalation Therapy
Prof. Maysa Sharaf El Din
Why do we care about
asthma control?
Prof. Maysa Sharaf El Din
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
GINA 2010
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
GINA 2011
What do we mean by
asthma control?
Prof. Maysa Sharaf El Din
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
No emergency visits
No treatment-related adverse events
All of the above sustained for at least
7 out of 8 weeks
* Minimal = twice or less per week
GINA 2011
Clinical Control of Asthma
How many of
our patients
actually
achieve this?
 No (or minimal)* daytime symptoms
 No limitations of activity
 No nocturnal symptoms
 No (or minimal) need for rescue medication
 Normal lung function
 No exacerbations
No emergency visits
No treatment-related adverse events
All of the above sustained for at least
7 out of 8 weeks
* Minimal = twice or less per week
GINA 2011
Factors Affecting Inhaled Drug
Delivery and Deposition
- Geometry of the
respiratory tract
- Inspiratory flow
- Time in the airway
(breath hold)
- Particle diameter and
density
Prof. Maysa Sharaf El Din
What we know: Particle Size
Particle size
(microns)
Regional
deposition
Efficacy
Safety
All inhaled methods ( MDI & DPI )
Absorption from
Mouth /
GIT if swallowed
• Compliance, adequate
technique
No clinical
>5
oesophageal
effect
• 75% - 93% of patients
on traditional
region
press-and-breathe inhalers use
Subsequent
Upper / central
Clinical
2 –technique
5
absorption
improper
airways
effect
from lung
• Even after retraining, up to 50%
High
Some local
Peripheral
revert to< incorrect
techniques
systemic
2
clinical
airways / alveoli
effect
absorption
Prof. Maysa Sharaf El Din
Factors affecting drug delivery
with nebulised therapy
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1. Device-related factors
Airflow
Droplet size
Nebulisation time and volume
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2. Drug-related factors
The shape and size of drug particles
water solubility
The viscosity and surface tension of the formulation
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3. Patient-related factors
Breathing patterns
inspiratory flow rate
Prof. Maysa Sharaf El Din
Clinical Profile: Who Are the Ideal
Patients for Nebulized Therapy?
• Patients inadequately controlled and
unable to achieve symptomatic relief with
MDI/DPI therapy
• Patients with cognitive impairment
• Patients unable to use MDI/DPI devices
appropriately (eg, patients with arthritis,
peripheral neuropathy)
• Home health care patients
Prof. Maysa Sharaf El Din
Advantages of Nebulizers
•
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Any age
Easy to teach and use
Patient coordination not required
preferred inhalation device in infants
and for acute Rx in ERs and hospital
• High drug doses possible
• Can be used with supplemental oxygen
• No propellant required
Prof. Maysa Sharaf El Din
Types of nebulizers
1. Jet nebulizer
Driven by compressed air. The smaller droplets leave the
nebuliser as a fine mist.The larger droplets fall by gravity
and returned to the reservoir
2. Ultrasonic nebulizer
The aerosol is created by a rapid vibrations.
Ultrasonic nebulisers should not be used to deliver
suspensions
3. Mesh nebulizer
Liquid or drug suspension is pushed through a fine static
mesh. There is no recycling into the reservoir of
inappropriately sized droplets
Prof. Maysa Sharaf El Din
Jet and Ultrasonic Nebulizers
JET
• Cools during operation
• Small aerosol particle size
• Less expensive
• More noise
ULTRASONIC
• Heats up during operation
• Larger aerosol particle
• More expensive
• Less noise
Prof. Maysa Sharaf El Din
New Generation Nebulizers:
Vibrating Mesh or Plate Nebulizers
MicroAIR U22
Pari e-flow
www.aerogen.com/theproducts.htm
www.omron-healthcare.com
www.eflow.pari.de/200/index.html
Advantages of New Vibrating
Mesh or Plate Nebulizers
• Simple, compact, silent
• Do not require propellants or a compressor system
• Portable, battery operated, designed for use by
ambulatory patients
• High fine particle fraction
– Highly efficient delivery of aerosols to lower
respiratory tract
• Only negligible volume of drug solution left in
device
• Low aerosol velocity   throat deposition
Prof. Maysa Sharaf El Din
Limitations of Vibrating
Plate/Mesh Devices
• Cost higher than jet nebulizers
• Need for regular cleaning to prevent blockage of
minute apertures with drug particles (especially
with suspensions)
• Batteries need to be replaced periodically
• Need to reduce drug dose/volume of solution
because of higher efficiency of drug delivery in
order to prevent “overdosing”
Prof. Maysa Sharaf El Din
Adaptive Aerosol Delivery (AAD)
“Smart nebulizers”
• Principle: delivery of precise
and reproducible amounts of
drug
– adapted to the breathing
pattern
– during part of inspiration
• Benefit
- improvement of efficacy
and compliance
Prodose AAD System
Hoda is 45 years old female patient.
She has long-term asthma. She is known case of Diabetes. Her
current treatment is ICS+LABA plus SABA when needed. She has
symptoms which impair ability to sleep and perform daily
activities with persistent cough, wheezing and chest tightness
several days each week
Q: Is her asthma
1. Well controlled
2. Partially uncontrolled
3. Uncontrolled
Hoda is 45 years old female patient.
She has long-term asthma. She is known case of Diabetes. Her
current treatment is ICS+LABA plus SABA when needed. She has
symptoms which impair ability to sleep and perform daily
activities with persistent cough, wheezing and chest tightness
several days each week
Q: Is her asthma
1. Well controlled
2. Partially uncontrolled
3. Uncontrolled
Levels of Asthma Control
Characteristic
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
Uncontrolled
3 or more
features of
partly
controlled
asthma
present in
any week
1 in any week
GINA 2011
What is your further management?
1. Increase dose of ICS
2. Add Theophylline
3. Start Antibiotics
4. Oral steroids
What is your further management?
1. Increase dose of ICS
2. Add Theophylline
3. Start Antibiotics
4. Oral steroids
(Evidence A)
2009
She increased her inhaled steroid from 2 to 4 inhalations
twice daily, but noted no improvement. She found herself
needing to use her ventolin inhaler 4-5 times per day. After
a sleepless night of cough and chest congestion, she sought
help at her local hospital
In the ED she appeared in moderate distress. She had
laboured breathing at 28 breaths/min, with a markedly
prolonged expiratory phase. She was using her accessory
muscles of respiration. Her blood pressure was 120/70 mm
Hg with 20 mm Hg paradoxical pulse. Her heart rate was
112 beats/minute. Chest examination revealed musical
inspiratory and expiratory wheezes throughout all lung
fields.
What is the required treatment
for her in hospital?
1.
2.
3.
4.
5.
6.
Nebulised steroids
Oxygen therapy
IV Theophylline
Nebulized SAMA
All of above
None of the above
What is the required treatment
for her in hospital?
1.
2.
3.
4.
5.
6.
Nebulised steroids
Oxygen therapy
IV Theophylline
Nebulized SAMA
All of above
None of the above
Over the next 2-3 days she progressively
improved, and is now ready for home
discharge.
To prevent relapse after hospital or ER
discharge , would you recommend :
1. Oral steroids
2. Nebulized steroids
3. ICS
4. No steroids
Over the next 2-3 days she progressively
improved, and is now ready for discharge
home.
To prevent relapse after hospital or ER
discharge , would you recommend :
1. Oral steroids
2. Nebulized steroids
3. ICS
4. No steroids
How do you classify her acute
asthma?
1.
2.
3.
4.
5.
Near-fatal asthma
Life threatening asthma
Acute severe asthma
Moderate asthma exacerbation
Brittle asthma
How do you classify her acute
asthma?
1.
2.
3.
4.
5.
Near-fatal asthma
Life threatening asthma
Acute severe asthma
Moderate asthma exacerbation
Brittle asthma
Levels of severity of acute
asthma
• Life threatening asthma : altered conscious level, Exhaustion,
Arrhythmia Hypotension, Cyanosis, Silent chest, Poor
respiratory effort.
• Near-fatal asthma : Hypoxemia SpO2 <92%, PaO2<60 mmHg
and/or Raised PaCO2 requiring MV with raised inflation
pressures.
• Acute Severe Asthma : Any one of: unable to complete 1
sentences in 1 breath, respiratory rate ≥25/min, heart rate
≥110/min, PEF 33-50% best or predicted
• Moderate asthma exacerbation: Increasing symptoms, PEF
>50-75% best or predicted no features of acute severe asthma
• Brittle Asthma :
• Type 1: wide PEF variability despite intense therapy (>40%
diurnal variation for >50% of time over a period >150 days)
• Type 2: sudden severe attacks on a background of apparently
well controlled asthma
British Thoracic Society Guidelines (BTS) 2009
NOTES
Prof. Maysa Sharaf El Din
Instructions for correct use of Nebulizer:
1. Budisonide should be administered via Jet Nebulizer with a
mouthpiece or suitable facemask. Ultrasonic nebulizers are not
suitable & therefore dis-recommended.
Instructions for correct use of Nebulizer:
2.Nebulizer should be connected to an air compressor with an
adequate
airflowNebulising
(5 – 8 l/min).
4. Budisonide
Suspension can be mixed with 0.9%
Management
of Acute Asthma (Evidence-Based)
saline & nebulizer solutions of:
volume should
be 2 – 4 ml.
-Terbutaline
• 3.Fill
Regular
bronchodilators
including ipratropium
-Salbutamol
bromide. (Level A).
-Sodium Cromoglycate
• -Ipratropium
Oxygen (Controlled) (Level A).
• -Fenoterol
Corticosteroids (Level A).
-Acetylcysteine
• No role for routine antibiotics, rehydration
(Level A).
• Magnesium for more severe attacks (Level A).
Prof. Maysa Sharaf El Din
Reactivated Esterification of
budesonide
Cell
Nucleus
GC-receptor
Budesonide
Budesonide
esterification
Prolonged
duration of
action
lipolysis
Budesonide esters
INACTIVE!
Miller-Larsson et al. 1998 and Wieslander et al. 1997
Increased
airway
selectivity