Download Levels of Asthma Control

BRONCHIAL ASTHMA
Department of Pediatrics
Soochow University Affiliated Children’s Hospital
由于哮喘和束手
无策的医生而死
于维也纳
Exhausted by asthma
and hopeless doctors
in Vienna
Ludwig Van Beethoven
1770-1827
哮喘名人录
Global Strategy for Asthma
Management and Prevention
Evidence Category
Sources of Evidence
A
Randomized clinical trials
Rich body of data
B
Randomized clinical trials
Limited body of data
C
Non-randomized trials
Observational studies
D
Panel judgment consensus
Outline of this lecture
Revised 2006

Definition and Overview

Diagnosis and Classification

Asthma Medications

Asthma Management and
Prevention Program
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
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
In China, there are 30,000,000
asthmatic patients.
Etiology
 Asthma is a multifactorial disorder,caused by a
combination of genetic predisposition and
environmental factors
 Asthma is one manifestation of atopy
 Asthma is belong to a multi-genetic inherited disorder
 In most asthmatic childhood characterized by
raised serum IgE levels
Eosinophilia
Eczema
Allergic rhinitis and conjunctivitis
hay fever
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 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
Factors that Exacerbate Asthma
 Allergens
 Respiratory infections
 Exercise and hyperventilation
 Weather changes
 Sulfur dioxide
 Food, additives, drugs
Pathophysiology
 The airway chronic inflammation is “three S”
 Spasm –smooth muscle spasm
 Swelling—mucosal oedema
 Secretion—mucosal hypersecretion
Pathophysiology
SPASMA
SWELLING
SECRETION
INFLAMMATORY CELL
BHR
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
Airway inflammation
Healthy person
Asthmatic patient
These lungs appear essentially normal, but are
normal-appearing because they are the hyperinflated
lungs of a patient who died with status asthmaticus
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
History
 Recurrent episodes of cough, wheeze and
breathlessness
 A diagnosis of asthma in infants(under 1 year or
2 years) may be particularly difficult
 In the some children, a nocturnal cough may be
the only symptom
 Asthma is a clinical diagnosis
Examination
 Auscultation of the chest is usually normal
 Wheezing
 Crackles
Differential diagnosis
 Acute bronchiolitis
 Pneumonia
 Foreign body aspiration
 Croup
 Cystic fibrosis
 Cardiac failure
 TB
Sometime, the diagnosis is more difficult, special in infant
Investigation
 X-ray
 PEFR(Peak Expiratory Flow Rate)
 Lung function
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
Measuring Variability of Peak
Expiratory Flow
Measuring Airway Responsiveness
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.
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
5. Special Considerations
Revised 2006
Asthma Management and Prevention
Program: Five Interrelated Components
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to
Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
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
 Asthma
can be effectively controlled in
most patients by intervening to suppress
and reverse inflammation as well as
treating bronchoconstriction and related
symptoms
 Early
intervention to stop exposure to the
risk factors that sensitized the airway may
help improve the control of asthma and
reduce medication needs.
Asthma Management and
Prevention Program

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
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
Factors Involved in Non-Adherence
Medication Usage
Non-Medication Factors

Difficulties associated
with inhalers
 Misunderstanding/lack

Complicated regimens
 Fears

Fears about, or actual
side effects
 Inappropriate

Cost

Distance to pharmacies
of
information
about side-effects
expectations
 Underestimation
 Attitudes
 Cultural
 Poor
of severity
toward ill health
factors
communication
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
Influenza Vaccination

Influenza vaccination should be provided to
patients with asthma when vaccination of
the general population is advised

However, routine influenza vaccination of
children and adults with asthma does not
appear to protect them from asthma
exacerbations or improve asthma control
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
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

Although in many countries traditional methods
of healing are used, their efficacy has not yet
been established and their use can therefore not
be recommended
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
Levels of Asthma Control
Partly controlled
Characteristic
Controlled
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
(Any present in any week)
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
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
 Cromones
 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
Beclomethasone
200-500
100-200
>500-1000
>200-400
Budesonide
200-600
100-200
600-1000
>200-400
Budesonide-Neb Inhalation
Suspension
Ciclesonide
250-500
80 – 160
High Daily Dose (g)
> 5 y Age < 5 y
>1000
>1000
>500-1000
>400
>400
>1000
80-160
>160-320
>160-320
>320-1280
>750-1250
>2000
>1250
>200-500
>500
>500
Flunisolide
500-1000
500-750
>1000-2000
Fluticasone
100-250
100-200
>250-500
Mometasone furoate
200-400
100-200
> 400-800
>200-400
>800-1200
Triamcinolone acetonide
400-1000
400-800
>1000-2000
>800-1200
>2000
>320
>400
>1200
Component 4: Asthma Management and Prevention Program
Reliever Medications
inhaled β2-agonists
Rapid-acting
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

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 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 β2agonist, reduce dose of inhaled
glucocorticosteroid by 50% while continuing the
long-acting β2-agonist (Evidence B)

If control is maintained, reduce to low-dose
inhaled glucocorticosteroids and stop longacting β2-agonist (Evidence D)
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control

Rapid-onset, short-acting or long-acting 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
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)
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor
Asthma – Children 5 Years and Younger
Childhood and adult asthma share the
same underlying mechanisms. However,
because of processes of growth and
development, effects of asthma
treatments in children differ from those in
adults.
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor
Asthma – Children 5 Years and Younger
Many asthma medications (e.g.
glucocorticosteroids, β2- agonists,
theophylline) are metabolized faster in
children than in adults, and younger
children tend to metabolize medications
faster than older children
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor
Asthma – Children 5 Years and Younger

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
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor
Asthma – Children 5 Years and Younger

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
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 life-threatening
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
 Therapies that are the most effective for the
particular patient
 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 β2agonist

Early introduction of systemic glucocorticosteroids

Oxygen supplementation
Closely monitor response to treatment with serial
measures of lung function
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
Acute severe asthma
 Respiratory rate over 50 breaths/min
 Pulse over 140 beats/min
 Use of accessory muscles
 Too breathless to talk
Life-threatening feature
 Cyanosis
 Silent chest(insufficient airflow to generate
wheeze)
 Exhaustion:poor respiratory effort
 Agitation, diminished consciousness
Peak
flow
meter
PARI
Spacer
Turbuhaler
思考题
 Write short notes on the following:
1. The management of a 5-year-old girl referred with
recurrent wheeze and nocturnal cough who has a
strong family history of atopy and allergy.
2. The important features of an asthma inhaler
device prior to prescribing such a device for an
8-year girl.
3. The management of the respiratory system in
12-year-old child with severe cystic fibrosis.
(answer in text P70)
Thank you
Scenes of Children’s Hospital of Soochow University