Transcript Asthma Management and Prevention Program

Asthma
Fan Huizhen
Pulmonary Medicine
Zhujiang Hospital
Southern medical university
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 reversible
airflow limitation
Asthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, MD
Mechanisms: Asthma Inflammation
Source: Peter J. Barnes, MD
Asthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, MD
哮喘病理生理学
• 支气管高反应性
• 平滑肌增生/
体积增大
• 炎症介质释放增多
平滑肌
功能障碍
气道
炎症
气道重塑
•
•
•
•
细胞增生 （平滑肌细胞、黏液腺）
基质蛋白沉积增加
基底膜增厚
血管新生
•
•
•
•
•
炎症细胞数增加
黏膜水肿
支气管高反应
气道分泌物增加
上皮损伤
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
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
Asthma Prevalence and Mortality
Source: Masoli M et al. Allergy 2004
中国是哮喘病死率最高的国家之一
5~34岁年龄组患者哮喘病死率（case-fatality rates )
36.7/10万
( >10.0/10万，
处于高水平)
在中国，每100,000位哮喘患者中有36.7位哮喘患者会因哮喘死亡。 GINA2004
Masoli M (2004). The global burden of asthma GINA report.
Risk Factors for Asthma

Host factors: predispose individuals to,
or protect them from, developing
asthma

Environmental factors: influence
susceptibility to development of asthma
in predisposed individuals, precipitate
asthma exacerbations, and/or cause
symptoms to persist
Factors that Exacerbate Asthma






Allergens
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs
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?

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


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

Extra measures may be required to diagnose
asthma in children 5 years and younger and the
elderly
Typical Spirometric (FEV1)
Tracings
Volume
FEV1
Normal Subject
Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)
1
2
3
4
Time (sec)
5
Note: Each FEV1 curve represents the highest of three repeat measurements
FEV1 increased ≥12% and ≥200ml
Measuring Airway Responsiveness
FEV1 decreased ≥20%
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
_________
* Minimal = twice or less per week
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
Asthma Management and Prevention
Program: Five Components
1. Develop Patient/Doctor
Partnership
2. Identify and Reduce Exposure
to Risk Factors
3. Assess, Treat and Monitor
Asthma
4. Manage Asthma Exacerbations
Revised 2006
5. Special Considerations
Asthma Management and Prevention Program
Goals of Long-term Management
Achieve and maintain control 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

Asthma Management and Prevention Program
Component 1: Develop
Patient/Doctor 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

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 Partnership
Key factors to facilitate communication:
 Friendly demeanor
 Interactive dialogue
 Encouragement and praise
 Provide appropriate information
 Feedback and review
Example Of Contents Of An Action Plan To Maintain Asthma Control
Your Regular Treatment:
1. Each day take ___________________________
2. Before exercise, take _____________________
WHEN TO INCREASE TREATMENT
Assess your level of Asthma Control
In the past week have you had:
Daytime asthma symptoms more than 2 times ?
No
Yes
Activity or exercise limited by asthma?
No
Yes
Waking at night because of asthma?
No
Yes
The need to use your [rescue medication] more than 2 times?
No
Yes
If you are monitoring peak flow, peak flow less than________? No
Yes
If you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to
step up your treatment.
HOW TO INCREASE TREATMENT
STEP-UP your treatment as follows and assess improvement every day:
____________________________________________ [Write in next treatment step here]
Maintain this treatment for _____________ days [specify number]
WHEN TO CALL THE DOCTOR/CLINIC.
Call your doctor/clinic: _______________ [provide phone numbers]
If you don’t respond in _________ days [specify number]
______________________________ [optional lines for additional instruction]
EMERGENCY/SEVERE LOSS OF CONTROL
If you have severe shortness of breath, and can only speak in short sentences,
If you are having a severe attack of asthma and are frightened,
If you need your reliever medication more than every 4 hours and are not improving.
1. Take 2 to 4 puffs ___________ [reliever medication]
2. Take ____mg of ____________ [oral glucocorticosteroid]
3. Seek medical help: Go to _____________________; Address___________________
Phone: _______________________
4. Continue to use your _________[reliever medication] until you are able to get medical help.
Asthma Management and Prevention Program
Component 2: Identify and Reduce
Exposure 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.
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, especially in children and
young infants
Asthma Management and Prevention Program
Component 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
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 five
treatment steps
 Treatment is adjusted in a continuous
cycle driven by changes in asthma
control status. The cycle involves:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control
基于哮喘临床控制的哮喘管理
哮喘管理
模式
评估哮喘控
制水平
治疗并达到
哮喘控制
监测并维持
哮喘控制
2006 GINA
Asthma Management and Prevention Program
Component 3: Assess,
Treat and Monitor Asthma

A stepwise approach to pharmacological
therapy is recommended

The aim is to accomplish the goals of
therapy with the least possible medication
Asthma Management and Prevention Program
Component 3: Assess,
Treat and Monitor Asthma
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 care
systems need to be considered
Component 4: Asthma Management and Prevention Program
Controller Medications








Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled β2-agonists
Systemic glucocorticosteroids
Theophylline
Hormones
Long-acting oral β2-agonists
Anti-IgE
Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
Drug
Low Daily Dose (g)
> 5 y Age < 5 y
Medium Daily Dose (g)
> 5 y Age < 5 y
倍氯米松
200-500
100-200
>500-1000
>200-400
布地奈德
200-600
100-200
600-1000
>200-400
布地奈德混悬液
250-500
环索奈德
80 – 160
氟尼缩松
High Daily Dose (g)
> 5 y Age < 5 y
>1000
>1000
>500-1000
>400
>400
>1000
80-160
>160-320
>160-320
>320-1280
>320
500-1000
500-750
>1000-2000
>750-1250
>2000
>1250
氟替卡松
100-250
100-200
>250-500
>200-500
>500
>500
糠酸莫米松
200-400
100-200
> 400-800
>200-400
>800-1200
曲安奈德
400-1000
400-800
>1000-2000
>800-1200
>2000
>400
>1200
Component 4: Asthma Management and Prevention Program
Reliever Medications
 Rapid-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Anticholinergics
 Theophylline
 Short-acting oral β2-agonists
Component 4: Asthma Management and Prevention Program
Allergen-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 environmental avoidance and
pharmacologic intervention, including inhaled
glucocorticosteroids, have failed to control
asthma

Perform only by trained physician
REDUCE
LEVEL OF CONTROL
TREATMENT OF ACTION
maintain and find lowest
controlling step
partly controlled
consider stepping up to
gain control
INCREASE
controlled
uncontrolled
exacerbation
step up until controlled
treat as exacerbation
REDUCE
INCREASE
TREATMENT STEPS
STEP
STEP
STEP
STEP
STEP
1
2
3
4
5
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)
Treating to Achieve Asthma Control
Step 2 – Reliever medication plus a single
controller
 A low-dose inhaled glucocorticosteroid is
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
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 longacting β2-agonist either in a combination inhaler
device or as separate components (Evidence A)
 Inhaled long-acting β2-agonist must not be used
as monotherapy
 For children, increase to a medium-dose inhaled
glucocorticosteroid (Evidence A)
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)
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-dose sustained-release theophylline added
to medium- or high-dose inhaled
glucocorticosteroid combined with a long-acting
inhaled β2-agonist (Evidence B)
Treating to Achieve Asthma Control
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 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)
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
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)
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 lowdose inhaled glucocorticosteroids and
stop long-acting β2-agonist (Evidence D)
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of
control
 Rapid-onset, short-acting or longacting 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
MDI使用方法
MDI使用方法
贮雾罐使用方法
贮雾罐使用方法
雾化吸入方法
雾化吸入方法
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 effecting in maintaining a high level
of asthma control and reduces exacerbations
(Evidence A)
 Doubling the dose of inhaled glucocorticosteroids is not effective, and is not
recommended (Evidence A)
大多数哮喘患者可以达到哮喘控制
(~20%)
(~40%)
(~40%)
哮喘控制
控制改善
良好控制
完全控制
Bateman ED et al. AJRCCM 2004
基于哮喘临床控制的哮喘管理
使用哮喘管理工具评估哮喘控制
哮喘控制测试 (ACT) 、哮喘控制问卷 (ACQ) 、哮喘
治疗评估问卷（ATAQ）是：



经验证的、用于评估哮喘控制的工具，通过提供具体
数值区分哮喘控制的不同水平
不仅被推广用于研究，也用于基层医疗单位中患者哮
喘控制评估
可改善对哮喘控制的评估，并提供可反复使用的客观
指标，有助于改善医生和患者间的交流
2006 GINA
基于哮喘临床控制的哮喘管理
ACT 评分的使用
25分：哮喘完全控制
20－24分：哮喘良好控制
<20分：哮喘未得到控制
需要改变治疗方案，以达到哮喘控制
Schatz et al. 2004.
基于哮喘临床控制的哮喘管理
为达到哮喘控制的治疗方案
控制：
确定维持哮喘控制
所需最低治疗级别
部分控制：
考虑升级治疗
以达到哮喘控制
未控制：
升级治疗直至
达到哮喘控制
2006 GINA
Asthma Management and Prevention Program
Component 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 lifethreatening and treatment requires close
supervision
Asthma Management and Prevention Program
Component 4: Manage Asthma
Exacerbations
Treatment of exacerbations depends on:
 The patient
 Experience of the health care professional
 Availability of medications
 Emergency facilities
Asthma Management and Prevention Program
Component 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
Emergency Department Management
Acute Asthma
Initial Assessment
History, Physical Examination, PEF or FEV1
Initial Therapy
Bronchodilators; O2 if needed
Good
Response
Observe for
at least 1
hour
If Stable,
Discharge to
Home
Incomplete/Poor Response
Respiratory Failure
Add Systemic Glucocorticosteroids
Good Response
Poor Response
Discharge
Admit to Hospital
Admit to ICU
Asthma Management and Prevention Program
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
Asthma Management and
Prevention Program: Summary

Asthma can be effectively controlled in most
patients by intervening to suppress and
reverse inflammation as well as treating
bronchoconstriction and related symptoms

Although there is no cure for asthma,
appropriate management that includes a
partnership between the physician and the
patient/family most often results in the
achievement of control
Asthma Management and
Prevention Program: Summary
 A stepwise approach to pharmacologic
therapy is recommended. The aim is to
accomplish the goals of therapy with the
least possible medication
 The availability of varying forms of
treatment, cultural preferences, and
differing health care systems need to be
considered