Transcript Rapid-acting inhaled β 2

Charo Angeles
Definition of Asthma

Asthma is a chronic inflammatory disorder of the
airways in which many cells and cellular elements play
a role

Chronic inflammation causes an associated increase in
airway hyperresponsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest tightness,
and coughing, particularly at night or in the early
morning

These episodes are usually associated with
widespread but variable airflow obstruction that is often
reversible either spontaneously or with treatment
Risk Factors that Lead to
Asthma Development
Host Factors
Environmental Factors
 Genetic predisposition
 Atopy
 Airway hyperresponsiveness
 Gender
 Race/Ethnicity

Indoor allergens
 Outdoor allergens
 Occupational sensitizers
 Tobacco smoke
 Air Pollution
 Respiratory Infections
 Parasitic infections
 Socioeconomic factors
 Family size
 Diet and drugs
 Obesity
Factors that Exacerbate Asthma

Allergens

Air Pollutants

Respiratory
infections

Exercise and
hyperventilation

Weather changes

Food, additives,
drugs
Mechanisms Underlying the
Definition of Asthma
Mechanisms Underlying the
Definition of Asthma
Mechanisms Underlying the
Definition of Asthma
Risk Factors
(for development of asthma)
INFLAMMATION
Airway
Hyperresponsiveness
Risk Factors
(for exacerbations)
Airflow Obstruction
Symptoms
Asthma Diagnosis

History and patterns of symptoms

Physical examination

Measurements of lung function

Measurements of allergic status to
identify risk factors
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
Measurement of Lung Function

provide assessment of the severity,
reversibility and variability of airflow
limitation and confirm diagnosis of asthma
Measurement of Lung Function

Spirometry
-increase in FEV1 of > 12 % and 200 ml after administration of a
bronchodilator indicates reversible airflow limitation

Peak Expiratory flow
- PEF measurements are ideally compared to the patient’s
own previous best measurement using his/her own peak
flow meter.
-Improvement of 60L/min (>20 % of the prebronchodilator PEF) after inhalation of bronchodilator, or
diurnal variation in PEF of >20% suggest asthma
Additional diagnostics:
• Measurements of airway responsiveness to
methacholine, histamine, direct airway challenges
such as inhaled mannitol, or exercise challenge
may help establish diagnosis
• Skin test with allergens or measurement of
specific IgE in serum presence of allergies
increases the probability of a diagnosis of asthma
Classification of Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment
Symptoms
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent
Nocturnal
Symptoms
Continuous
Limited physical
activity
Frequent
Daily
Attacks affect activity
> 1 time week
> 1 time a week
but < 1 time a day
 60% predicted
Asymptomatic
and normal PEF
between attacks
Variability > 30%
60 - 80% predicted
> 2 times a month
Variability > 30%
 80% predicted
Variability 20 - 30%
< 1 time a week
STEP 1
Intermittent
FEV1 or PEF
 2 times a month
 80% predicted
Variability < 20%
The presence of one feature of severity is sufficient to place patient in that category.
Classification by level of control
Six-Part Asthma Management
Program
1. Educate Patients
2. Assess and Monitor Severity
3. Avoid Exposure to Risk Factors
4. Establish Medication Plans for
Chronic Management:
5. Establish Plans for Managing
Exacerbations
6. Provide Regular Follow-up Care
Medication Plans for Long-Term Asthma
Management in Infants and Children
 At present, inhaled glucocorticosteroids
are the most effective controller
medications and are recommended for
persistent asthma at any step of severity
 Long-term treatment with inhaled
glucocorticosteroids markedly reduces the
frequency and severity of exacerbations
Pharmacologic Therapy
Controller Medications:
Inhaled glucocorticosteroids
 Systemic glucocorticosteroids
 Cromones
 Methylxanthines
 Long-acting inhaled β2-agonists
 Long-acting oral β2-agonists
 Leukotriene modifiers
 Anti-IgE

Pharmacologic Therapy
Reliever Medications:

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids

Anticholinergics

Methylxanthines

Short-acting oral β2-agonists
Stepwise Approach to Asthma Therapy
Adults/Children Older Than 5 yrs
Outcome: Best
Possible Results
Outcome: Asthma Control
Controller:

Controller:
Controller:
None
Controller:

Low-dose
inhaled
corticosteroid

High-dose
inhaled
corticosteroid
plus long –
acting inhaled
β2-agonist
plus (if needed)
Low to mediumdose inhaled
corticosteroid

plus long-acting -Theophylline-SR
inhaled β2-Leukotriene
agonist
-Long-acting inhaled
β2- agonist
-Oral corticosteroid

When
asthma is
controlled,
reduce
therapy

Monitor
Reliever: Rapid-acting inhaled β2-agonist prn
STEP 1:
Intermittent
STEP 2:
Mild Persistent
STEP 3:
Moderate
Persistent
STEP 4:
Severe
Persistent
STEP Down
Alternative controller and reliever medications may be considered (see text).
Medication Plans for Long-Term Asthma
Management in Infants and Children
 Rapid-acting inhaled β2-agonists are the
most effective reliever therapy for
children
 These medications are the most
effective bronchodilators available and
are the treatment of choice for acute
asthma symptoms
Medication Plans for Long-Term Asthma
Management in Infants and Children
 Long-term treatment with inhaled
glucocorticosteroids has not been shown
to be associated with any increase in
osteoporosis or bone fracture
 Studies including a total of over 3,500
children treated for periods of 1 – 13 years
have found no sustained adverse effect of
inhaled glucocorticosteroids on growth
Stepwise Approach to Asthma Therapy
Children Younger Than 5 yrs
Outcome: Best
Possible Results
Outcome: Asthma Control
Controller:

Controller:
Controller:
None
Controller:

Low-dose
inhaled
corticosteroid

Medium-dose
inhaled
corticosteroid

High-dose
inhaled
corticosteroid
plus long –
acting inhaled
β2-agonist
plus (if needed)
-Theophylline-SR
-Leukotriene
-Long-acting inhaled
β2- agonist
-Oral corticosteroid

When
asthma is
controlled,
reduce
therapy

Monitor
Reliever: Rapid-acting inhaled β2-agonist prn
STEP 1:
Intermittent
STEP 2:
Mild Persistent
STEP 3:
Moderate
Persistent
STEP 4:
Severe
Persistent
STEP Down
Alternative controller and reliever medications may be considered (see text).
Establish Plans for Managing
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
Stepwise Approach to Asthma Therapy: Adults and Children >5 yr
Step 1: Intermittent Asthma
Daily Controller
Medications
None required
Reliever
Medications
Rapid-acting inhaled 2-agonist
for symptoms (but < once a week)
Rapid-acting inhaled 2-agonist,
or cromone before exercise or
exposure to allergen




Continuously review medication technique, compliance and environmental control
Review treatment every three months.
Step up if control is not achieved; step down if control is sustained for at least 3 months
Preferred treatments are in bold print
Stepwise Approach to Asthma Therapy: Adults and Children >5yr
Step 2: Mild Persistent Asthma
Daily Controller
Medications
Reliever
Medications
Low-dose inhaled
glucocorticosteroid
Rapid-acting inhaled 2-agonist
for symptoms (but < 3-4 times/day)
Other options (order by cost):
 sustained-release theophylline, or
 Cromone, or
 leukotriene modifier
Other options:
 inhaled anticholinergic, or
 short-acting oral 2-agonist, or
 short-acting theophylline




Continuously review medication technique, compliance and environmental control.
Review treatment every three months
Step up if control is not achieved; Step down if control is sustained for at least 3 months
Preferred treatments are in bold print
Stepwise Approach to Asthma Therapy: Adults and Children >5 yr
Step 3: Moderate Persistent Asthma
Daily Controller
Medications
Low- to medium-dose inhaled glucocorticosteroid, plus long-acting inhaled β2-agonist
Other options (order by cost):
 Medium-dose inhaled glucocorticosteroid plus
sustained-release theophylline, or
 Medium-dose inhaled glucocorticosteroid plus longacting inhaled β2- agonist, or
 High-dose inhaled glucocorticosteroid, or
 Medium-dose inhaled glucocorticosteroid plus
leukotriene modifier




Reliever
Medications
Rapid-acting inhaled
β2 -agonist for symptoms
(but < 3 - 4 times/day)
Other options:
 inhaled anticholinergic or
 short-acting oral
β2-agonist or
 short-acting theophylline
Continuously review medication technique, compliance and environmental control.
Review treatment every three months.
Step up if control is not achieved; Step down if control is sustained for at least 3 months.
Preferred treatments are in bold print.
Stepwise Approach to Asthma Therapy: Adults and Children >5 yr
Step 4: Severe Persistent Asthma
Daily Controller
Medications
High-dose inhaled glucocorticosteroid, plus long-acting inhaled
β2-agonist plus one or more of the
following, if needed (order by cost):
 sustained-release theophylline, or
 leukotriene modifier or
 oral glucocorticosteroid




Reliever
Medications
Rapid-acting inhaled
β2-agonist for symptoms
(but < 3-4 times/day)
Other options:
 inhaled anticholinergic or
 short-acting oral
β2-agonist or
 short-acting theophylline
Continuously review medication technique, compliance and environmental control.
Review treatment every three months.
Step up if control is not achieved; Step down if control is sustained for at least 3 months.
Preferred treatments are in bold print.