BRONCHIAL ASTHMA

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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 [phone] 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 )
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Diagnosis
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history

• Required a full detailed medical history and
  clinical exam. Including peak expiratory flow
  (PEF)rate.
• 1-Symptoms
• Cough
• Wheezing
• Shortness of breath

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• How frequent, how severe, what intervention
  needed.
• Interfere with sport or normal physical activity
• Trouble some cough between attacks
• Symptoms improve by asthma medication

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• 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

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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

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• Peak expiratory flow rate (PEF)
• Should be performed in every patientgt5 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

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• Variability over 15 conferms but not essential
  for diagnosis
• PEF may be normal between attacks

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Investigation

• Usually not necessary
• CXR Usually not necessary except in
• Severe cases
• Foreign body
• Infection
• Arterial blood gases in severe cases

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Differential diagnosis

• In children lt 5 yrs
• Upper airway allergies,rhinitis, sinusitis
• GERD
• Foreign body aspiration
• Recurrent viral LRTI
• Cystic fibrosis
• Congenital heart disease

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Differential diagnosis

• 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(ß-blockers and ACE
  inhibtors)
• Bronchiachtiasis
• Laryngeal dysfunction

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classification
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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

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Classification asthma Severity
classification intermittent Mild persistent Moderate persistent Severe persistent
Minor symptoms lt1/week 1-3/week 4-5/week continuous
Exacerbations/nocturnal lt1/month 1/month 2-3/month gt4/month
PEF between attacks gt80 gt80 60-80 lt60
Pharmacological therapy step1 step2 step3 step4
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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 Three or more Feature of partly controlled asthma present in any week
Limitation of activity None Any Three or more Feature of partly controlled asthma present in any week
Nocturnal symptoms /awaking None Any Three or more Feature of partly controlled asthma present in any week
Need for reliever /rescue treatment None (twice or less/week) More than twice/week Three or more Feature of partly controlled asthma present in any week
Lung function (PEF or FEV1) Normal lt80 predicted or Personal best Three or more Feature of partly controlled asthma present in any week
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Management
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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

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Component of asthma therapy

• Develop patient /doctor partenership asthma
  education
• Identify and reduce exposure to risk factors
• Assess treat and monitor asthma
• Manage asthma exacerbation emergencies
• Special consideration coexisting and related
  condition

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Component 1Develop patient /doctor partnership
asthma education

• Asthma education
• Asthma follow up and referal

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Component 1Develop 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

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Component 1Develop 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

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Component 1Develop 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

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Component 1Develop 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

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Component 1Develop 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 ß2 agonist usage
• 4-wheezing interfere with normal physical
  activity

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Component 1Develop 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

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Component 1Develop 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

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Component 2 Identify and reduce exposure to risk
factors

• 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)

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Component 3Assess treat and monitor asthma

• asthma Severity
• asthma control

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Asthma control test
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step1 step2 step3 step4 step4 step5
As needed rapid acting ß2 agonist As needed rapid acting ß2 agonist As needed rapid acting ß2 agonist As needed rapid acting ß2 agonist As needed rapid acting ß2 agonist As needed rapid acting ß2 agonist
Low dose ICS Low dose ICSLABA Medium to high dose ICS LABA Step 4 steriods Step 4 steriods
Leukotriene modifier Low dose ICS Leukotriene modifier Medium to high dose ICS Leukotriene modifier STEP 4anti IgE STEP 4anti IgE
Medium to high dose ICS Medium to high dose ICS LABA Leukotriene modifier
Addition of sustained release theophylline may be considered
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LEVEL OF CONTROL TREATMENT OPTION
controlled Step down therapy
controlled Maintain therapy
Partly controlled Maintain therapy
Partly controlled Step up therapy
Uncontrolled Step up therapy
Uncontrolled Look up for reasons
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Component 4Manage asthma exacerbation
emergencies

• Home management
• Frequent ß2 agonist preferaply via spacer device
  q 4h
• Dose of ICS to be increased 4 folds
• Action plan

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Management of severe attack
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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 5special consideration

• Rhinitis
• Sinusitis
• Nasal polyps
• Respiratory infection
• GERD
• Asprin induced asthma(AIA)
• Pregnancy
• surgery

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• 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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