Transcript Asthma Control

ASTHMA
Asthma is…
• chronic inflammatory disorder of the
airways
• airway hyperresponsiveness
• recurrent episodes of wheezing,
breathlessness, chest tightness, and
coughing,
• night or in the early morning
• often reversible either spontaneously or
with treatment
Burden of disease
• estimated 300 million affected
individuals
• global prevalence of asthma ranges
from 1% to 18% of the population
in different countries
Hygiene
hypothesis
MECHANISMS
OF ASTHMA
Measurements
of lung function :
reversibility,
and its variability
Measurement and
monitoring
• Spirometry
FEV1/FVC ratio is normally
greater than 0.75 to 0.80
FEV1 ≥ 12% and ≥ 200 ml from the
pre-bronchodilator value
less reliable in young people (< age
20) and in the elderly (> age 70)
Peak expiratory flow
• important aid
• diurnal variation in PEF of more than
20%
• with twice daily readings, more than 10%
Classification of asthma
Asthma Severity
• level of
symptoms
• airflow
limitation,
• lung function
variability
Asthma Control
Medication
• Controller
medications taken daily on a longterm basis
• Reliever
medications used on an as-needed
basisthat act quickly to reverse
bronchoconstriction and relieveits
symptoms
CONTROLLER
MEDICATIONS
• inhaled and systemic glucocorticosteroids,
• leukotriene modifiers,
• long-acting inhaled B2-agonists in
combination with inhaled
glucocorticosteroids,
• sustained-release theophylline,
• cromones,
• anti-IgE,
• other systemic steroid-sparing therapies
• Inhaled
most effective
antiinflammatory
glucocorticosteroids medication
Side effects
Local adverse effects
• oropharyngeal candidiasis,
• dysphonia, and occasionally coughing from
upper airway
• irritation
Side effects
• Current evidence suggests that in adults,
systemic effects of inhaled
glucocorticosteroids are not a problem at
doses of 400 ug or less budesonide or
equivalent daily
Side effects
Systemic side effect
• easy bruising
• adrenal suppression
• decreased bone mineral density
• cataracts and glaucoma
Leukotriene modifiers
• small and variable bronchodilator effect,
• reduce symptoms : cough, improve lung function,
and reduce airway inflammation
• reduce asthma exacerbations
• add-on therapy may reduce the dose of inhaled
glucocorticosteroids
Side effects
• well tolerated, and few if any class-related
effects
Long-acting inhaled B2agonists.
• formoterol and salmeterol,
• should not be used as monotherapy
• most effective when combined with
inhaled glucocorticosteroids
• improves symptoms scores,
• decreases nocturnal asthma,
• improves lung function
• decreases the use of rapid-acting inhaled
B2-agonists
• reduces the number of exacerbations
• achieves clinical control
• lower dose of inhaled glucocorticosteroids
Side effects
• fewer systemic adverse effects
cardiovascular stimulation, skeletal
muscle tremor, and hypokalemia
• relative refractoriness to B2-agonists
Theophylline
• bronchodilator
• modest anti-inflammatory
• add-on therapy in patients who do not achieve
control on inhaled glucocorticosteroids alone
Side effect
• gastrointestinal symptoms, loose stools, cardiac
arrhythmias, seizures, and even death
Cromones: sodium cromoglycate
and nedocromil sodium
• Efficacy has been reported in patients
with mild persistent asthma and exerciseinduced bronchospasm
• Side effects - uncommon
• coughing upon inhalation and sore throat
Long-acting oral B2agonists.
• slow release formulations of salbutamol,
terbutaline, and bambuterol
• used only on rare occasions
• Side effect - tachycardia), anxiety and
skeletal muscle tremor
Anti-IgE
• option limited to patients with elevated
serum levels of IgE
• uncontrolled on inhaled
glucocorticosteroids
Systemic
glucocorticosteroids
• required for severely uncontrolled asthma
Side effects
• osteoporosis, arterial hypertension,
diabetes, hypothalamicpituitary-adrenal
axis suppression, obesity, cataracts,
glaucoma, skin thinning leading to
cutaneous striae and easy bruising, and
muscle weakness
Reliever Medications
•
•
•
•
•
Rapid-acting inhaled B2-agonists.
Systemic glucocorticosteroids.
Anticholinergics.
Theophylline.
Short-acting oral B2-agonists.
Rapid-acting inhaled B2agonists.
• medications of choice for relief of
bronchospasm during acute exacerbation
• salbutamol, terbutaline, fenoterol,
reproterol, and pirbutero
• Increased use : deterioration of asthma
control
Side effects
• tremor and tachycardia
• Oral >> inhaler
Systemic
glucocorticosteroids.
• important in the treatment of severe
acute exacerbations
• main effects >> after 4-6 hrs
• 40-50 mg prednisolone given daily for 5 to
10 days depending on the severity of the
exacerbation
• Oral therapy is preferred
• effective as intravenous hydrocortisone
Side effects
• Adverse effects are uncommon
• increased appetite, fluid retention, weight
gain, hypertension, peptic ulcer
Anticholinergics
• ipratropium bromide and oxitropium
bromide
• Inhaled ipratropium bromide is a less
effective reliever medication in
asthma
Side effects
Theophylline.
• role of theophylline in treating
exacerbations remains controversial
Side effects
• potential for significant adverse effects
Alternative medicine
• Yoga
• Acupuncture
recommendations for
asthma management
• Develop Patient/Doctor Partnership
• Identify and Reduce Exposure to Risk
Factors
• Assess, Treat, and Monitor Asthma
• Manage Asthma Exacerbations
• Special Considerations.
ASSESSING ASTHMA
CONTROL
• establish :
– current treatment regimen,
– adherence to the current regimen
– level of asthma control
TREATING TO
ACHIEVE CONTROL
• not controlled on the current treatment
regimen, treatment should be stepped up
until control is achieved.
• When control is maintained for at least
three months, treatment can be stepped
down
MONITORING TO
MAINTAIN CONTROL
• Asthma control should be monitored in
regular intervals
• three months after the initial visit, and
every three months thereafter
• After an exacerbation, follow-up should be
offered within two weeks to one month
• improvement begins within days of
initiating treatment, but the full benefit
may only be evident after 3 or 4 months
Stepping Down
Treatment
• When inhaled glucocorticosteroids alone in
medium to high-doses are being used, a
50% reduction in dose should be
attempted at 3 month intervals (Evidence
B).
• Where control is achieved at a low-dose of
inhaled glucocorticosteroids alone, in most
patients treatment may be switched to
once-daily dosing (Evidence A).
• combination of inhaled glucocorticosteroid
and long-acting B2-agonist  reducing the
dose of inhaled glucocorticosteroid by
approximately 50% while continuing the
long-acting B2-agonist(Evidence B)
• Controller treatment may be stopped if
the patients asthma remains controlled on
the lowest dose of controller and no
recurrence of symptoms occurs for one
year (Evidence D)
MANAGE ASTHMA
EXACERBATIONS
1. Assess severity
2. primary therapies include
• the repetitive administration of rapidacting inhaled bronchodilators
• the early introduction of systemic
glucocorticosteroids
• oxygen supplementation
Treatment
•
Rapid-acting inhaled B2–agonists. Rapidacting inhaled B2-agonists should be
administered at regular intervals
(Evidence A)
Additional
bronchodilators
•
•
Ipratropium bromide may produce better
bronchodilation than either drug alone
(Evidence B)
Combination B2-agonist/anticholinergic
therapy is associated with lower
hospitalization rates (Evidence A) and
greater improvement in PEF and FEV1
(Evidence B)
•
•
Theophylline : minimal role in the
management of acute asthma
severe and potentially fatal side effects
Systemic
glucocorticosteroids
•
speed resolution of exacerbations and
should be utilized in the all but the
mildest exacerbation (Evidence A)
•
•
•
•
60-80 mg methylprednisolone as a single
dose
300-400 mg hydrocortisone in divided
doses, are adequate for hospitalized
patients
40 mg methylprednisolone
200 mg hydrocortisone adequate in most
cases (Evidence B)
•
7-day course in adults has been found to
be effective (Evidence B).
Inhaled
glucocorticosteroids
•
effective as part of therapy for asthma
exacerbations
Magnesium.
•
not recommended for routine use in
asthma exacerbations
Used in selected case
• adults with FEV1 25-30% predicted at
presentation,
• adults and children who fail to respond to
initial treatment (Evidence A).
Sedatives
•
strictly avoided during exacerbations