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BRONCHIAL ASTHMA
Introduction to Primary Care:
a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
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Objectives
 To describe how to make the diagnosis of
asthma utilizing the Saudi Asthma Guidelines.
 To discuss the efficacy of nebulizers versus
metered dose inhalers and other medications
in the treatment of asthma
 To describe the following methods for
monitoring disease severity and any evidence
supporting one method over the other
 Symptoms based (i.e. medication frequency and dose
based upon symptoms)
 Daily peak flow meter monitoring (i.e. red,
yellow, green zones)
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DEFINITION OF ASTHMA
• CHRONIC INFLAMATORY DISORDER OF THE
AIRWAY ASSOCIATED WITH WIDESPREAD BUT
VARIABLE AIRFLOW LIMITATION (PARTLY
REVERSIBLE WITH OR WITHOUT TREATMENT )
• AND WITH INCREASED AIRWAY
HYPERRESPONSIVENESS TO VARIETY OF
STIMULI
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WHAT IS THE PREVALENCE IN SAUDI
ARABIA ?
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The prevalence of asthma among
school children in KSA
• Range
4%-23%
• Riyadh
10%
• Jeddah
12%
( AL Frayh, et al, 2001 )
Diagnosis
history
• Required a full detailed medical history and
clinical exam. Including peak expiratory flow
(PEF)rate.
• 1-Symptoms:
– Cough
– Wheezing
– Shortness of breath
• How frequent, how severe, what intervention
needed.
• Interfere with sport or normal physical activity
• Trouble some cough between attacks
• Symptoms improve by asthma medication
• 2- atopy :skin eczema ,itchy eye,frequent nasal
blockage,discharge or sneezing especialy in
the morning
• 3- family history of atopic diseases.
• 4- environmental history
• 5- exclusion of other medical conditions
Physical examination
• Hight and weight(growth in childern)
• Nose,throat, sinusis(polyps,deviated nasal
septum,post nasal drip,pale-pink or congested
nasal turbinate.
• Feature of atopy
• Examination of the respiratory system
– May be normal between attacks
– wheeze brochi,tachypnea,chest deformity suggest
asthma
– Stridor,clubbing,heart murmers ----other than
bronchial astha
• Peak expiratory flow rate (PEF):
• Should be performed in every patient>5 yrs
• In certain patient measuring PEF prior to and
after a bronchodilator may help in confirming
the diagnosis.
• Measuring PEF variability comparing the
morning and evening PEF over a period of 2
weeks
• Variability over 15% conferms but not
essential for diagnosis
• PEF may be normal between attacks
Investigation
• Usually not necessary
• CXR Usually not necessary except in
• Severe cases
• Foreign body
• Infection
• Arterial blood gases in severe cases
Differential diagnosis
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In children < 5 yrs :
Upper airway allergies,rhinitis, sinusitis
GERD
Foreign body aspiration
Recurrent viral LRTI
Cystic fibrosis
Congenital heart disease
Differential diagnosis
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In older children and adults:
Upper airway allergies, rhinitis, sinusitis
GERD
Heart disease
COPD
Vocal cord dysfunction
Inhalation of foreign body
Hyperventilation and panic attack
Cough secondary to drugs(β-blockers and ACE inhibtors)
Bronchiachtiasis
Laryngeal dysfunction
classification
classification
• Etiology:
– Allergic and non allergic asthma
– Help in determining prognosis and in determining
allergen to be avoided
• Severity:
– Intermittent, mild persistent, moderate persistent,
severe persistent.
– Management at the initial assessment of a patient
• Control:
– Useful for ongoing therapy
Classification: asthma Severity:
classification
Minor
symptoms
intermittent
<1/week
Mild
persistent
Moderate
persistent
Severe
persistent
1-3/week
4-5/week
continuous
Exacerbations/ <1/month
nocturnal
1/month
2-3/month
>4/month
PEF between
attacks
>80%
>80%
60-80%
<60%
Pharmacological
therapy
step1
step2
step3
step4
Classification: asthma control
charachtarstic
controlled(all the
following)
Partly controlled
(any in any week)
uncontrolled
Day time symptoms None(twice or
less/week)
More than
twice/week
Limitation of
activity
None
Any
Three or more
Feature of partly
controlled asthma
present in any week
Nocturnal
None
symptoms /awaking
Any
Need for reliever
/rescue treatment
None (twice or
less/week)
More than
twice/week
Lung function (PEF
or FEV1)
Normal
<80 % predicted or
Personal best
Management
Goals of successful management
• Achieve and maintain control of symptoms
• Maintain normal activity level ,including
exercise
• Maintain (near) "normal" pulmonary
function.
• Prevent recurrent exacerbations of asthma
• Avoid adverse effects from asthma medication
• Prevent asthma medication
Component of asthma therapy
1) Develop patient /doctor partenership asthma
education
2) Identify and reduce exposure to risk factors
3) Assess treat and monitor asthma
4) Manage asthma exacerbation emergencies
5) Special consideration coexisting and related
condition
Component 1:Develop patient /doctor
partnership asthma education
• Asthma education
• Asthma follow up and referal
Component 1:Develop patient /doctor
partnership asthma education
Asthma education
Objectives:
1- improving knowledge of
asthma
2-changing attitude and
behavior
3-Improving management
skills
4- improving satisfaction and
overall quality of life
Component 1:Develop patient /doctor
partnership asthma education
Elements of patient education :
1- basic facts about asthma:
Disease, medication and goal of therapy
2- socio-cultural misconception:
Asthma as infectious disease,asthma medication
are addictive,
3- medication
Advantage of inhaled over systemic medications
The need for more than one inhaler
Component 1:Develop patient /doctor
partnership asthma education
• 4- management skills
Technique:
• Inhalation devices,spacer, PEF
Asthma self management:
• Name and dose of the medication
• Monitoring of asthma
• Sign suggest worsening of asthma
• Action in exacerbation
• How and when adjust medication
• How and when to seek medical attention
Component 1:Develop patient /doctor
partnership asthma education
Follow up
Initial phase:
• Last until asthma control is
optimum
• The diagnnosis is
established
• Patient need to be seen at
least every 3-6 weeks
during this phase
Component 1:Develop patient /doctor
partnership asthma education
• Second phase:
• The asthma is well controlled
• Interval history, examination ,medication
• Special attention include:
1-need for emergency care
2-loss of time in work or school
3-freq. of β2 agonist usage
4-wheezing interfere with normal physical activity
Component 1:Develop patient /doctor
partnership asthma education
5-use of oral steroid
6-Perform spirometry or PEF in clinic
7-go over PEF chart with the patient
8- observe inhalation technique
9- step up or down anti-inflammatory therapy
10-provide written instruction to certain patients
Patient need to be seen every 3-6 months
Or earlier if patient deteriorate
Component 1:Develop patient /doctor
partnership asthma education
Referral
Primary health care centers:
Manage asthma whose
diagnosis is striaght
forward and are easily
controlled
If asthma is partialy
controlled or
uncontrolled --refer to
secondary care
Component 2: Identify and reduce
exposure to risk factors
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Domestic dust mites
Air pollution
Tobacco smoke
Occupational irritants
Cockroach
Animal with fur
Pollen
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Respiratory (viral) infections
Chemical irritants
Strong emotional expressions
Drugs ( aspirin, beta blockers)
Component 3:Assess treat and monitor asthma
• asthma Severity
• asthma control
Asthma control test
step1
step2
step3
step4
step5
As needed rapid –acting β2 agonist
Low dose
ICS
Low dose ICS+LABA
Medium to high
dose ICS +LABA
Step 4
+steriods
Leukotriene
modifier
Low –dose ICS +
Leukotriene
modifier
Medium to high
dose ICS+
Leukotriene
modifier
STEP 4+anti
IgE
Medium to high
dose ICS
Medium to high
dose ICS +LABA+
Leukotriene
modifier
Addition of
sustained release
theophylline may
be considered
LEVEL OF CONTROL
controlled
TREATMENT OPTION
Step down therapy
Maintain therapy
Partly controlled
Maintain therapy
Step up therapy
Uncontrolled
Step up therapy
Look up for reasons
Component 4:Manage asthma exacerbation
emergencies
• Home management:
• Frequent β2 agonist
preferaply via spacer
device q 4h
• Dose of ICS to be
increased 4 folds
• Action plan
Management of severe attack
Peak Flow Meter Zones
 Green Zone (80 to 100 percent of your personal best) signals
good control. Take your usual daily long-term-control
medicines, if you take any. Keep taking these medicines even
when you are in the yellow or red zones.
 Yellow Zone (50 to 79 percent of your personal best) signals
caution: your asthma is getting worse. Add quick-relief
medicines. You might need to increase other asthma medicines
as directed by your doctor.
 Red Zone (below 50 percent of your personal best) signals
medical alert! Add or increase quick-relief medicines and call
your doctor now.
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Component 5:special consideration
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Rhinitis
Sinusitis
Nasal polyps
Respiratory infection
GERD
Asprin induced asthma(AIA)
Pregnancy
surgery
• B. This patient has mild persistent asthma,
which is defined as having asthma symptoms
more than two times a week but less than one
time a day. These patients also have nocturnal
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Is the asthma of the patient in the previous question controlled
or not? What recommendations might you give her
regarding her therapy?
• A. Controlled, do not change her therapy
• B. Controlled, educate regarding triggers
• C. Not controlled, give a short burst of oral prednisone
• D. Not controlled, add a long-acting bronchodilator such as
salmeterol
• E. Not controlled, add a low-dose inhaled corticosteroid or
leukotriene antagonist
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• E. This patient is not well controlled since she
is using her inhaler more than twice a week
and experiencing symptoms so frequently.
Addition of a low-dose inhaled corticosteroid
or a leukotriene antagonist are appropriate
options for mild persistent asthma.
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The same 23-year-old patient comes in to your office 2 months
later after having a kitchen fire at home and is complaining
of shortness of breath. What factor on your history and
physical might make you consider admitting her to the
hospital?
• A. Wheezing on lung exam
• B. Pulse oximetry less than 93%
• C. Respiratory rate of 30 breaths per minute
• D. No response to one treatment with an albuterol nebulizer
• E. PaCO2 of 25
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• C. A respiratory rate of greater than 28 or pulse of
greater than 110 beats per minute would both
indicate a severe episode. Wheezing is an
unreliable indicator of the severity of attack. A
pulse oximetry measurement of 90% is the goal
unless the patient is pregnant or has cardiac
disease. A PaCO2 of 25 is expected in a patient
who is hyperventilating. A PaCO2 that is normal or
elevated may be a sign of impending respiratory
failure and such patients should be monitored
closely in the intensive care unit
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Thanks
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