ASTHMA

1. ASTHMA CAPA 2012 Deborah Hellyer MD

2. Objectives • Review Asthma – what is it • Control is possible • What is new? CTS 2012 Guidelines • Special considerations • ASA Triad • Occupational Asthma • Asthma in Pregnancy • Emergency treatment

3. Asthma • An inflammatory disorder of the airways characterized by paroxysmal or persistent symptoms such as dyspnea, chest tightness, wheezing, sputum production and cough, associated with variable airflow limitation and a variable degree of hyperresponsiveness of airways to endogenous or exogenous stimuli

4. Asthma Prevalence and Mortality Source: Masoli M et al. Allergy 2004

5. Asthma Statistics • 2.7 million Canadians have asthma • 13% of Ontarians have asthma , 21% of Ontario children aged 0-14 have asthma • 39% of people with asthma report limitation in physical activity • Asthma is the # 1 reason for children being hospitalized

6. Pathology of Asthma Asthma involves inflammation of the airways Asthma Normal Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI, 1995

7. Mechanisms: Asthma Inflammation Inducers Allergens, chemical sensitizers Air pollution, viruses, occupational exposures Inflammation Airway Hyperresponsiveness Airflow Limitation Symptoms Cough, Wheeze, Chest tightness Dyspnea Triggers Allergens, exercise, cold air, SO2 particulates

8. Asthma Inflammation: Cells and Mediators Source: Peter J. Barnes, MD

9. Asthma Inflammation: Cells and Mediators Source: Peter J. Barnes, MD

10. Symptoms Suggestive of Asthma • Frequent episodes of breathlessness, chest tightness, wheezing or cough • Symptoms worse at night or the early morning • Symptoms develop with a viral respiratory tract infection, after exercise, or to exposure to alloallergens or irritants • Symptoms develop in young children after playing or laughing • Symptoms improve with bronchodilators or corticosteroids

11. Differential Diagnosis(Wheezing/Cough) • Post infectious Cough • Post Nasal Drip • COPD • Heart Failure • Angina • Lung Cancer • Hyperventilation Syndrome • Vocal Cord Dysfunction

12. Risk Factors Associated the Development of Asthma • Predisposing Factors • Atopy • Genetics • Gender • Causal Factors • Indoor Allergens • Occupational Sensitizers • Outdoor Allergens • Contributing Factors • Air Pollution • Diet • Low Birth Weight • Respiratory Infections • Smoking

13. How to Diagnose Asthma? • Supplement history with objective measures in lung function in children over six years of age • Reversible airway obstruction after bronchodilator or • Variable airflow limitation over time or • Airway hyperresponsiveness • Assessing Allergic Status

14. Breathing Tests • Spirometry Testing: lung volumes in/out, lung flow of air in/out • Peak Flow Monitoring: lung flow of air in/out

15. Diagnosis of Asthma Pulmonary Function Criteria

16. Typical Spirometric Tracing Volume FEV1 Normal Subject Asthmatic (After Bronchodilator) Asthmatic (Before Bronchodilator) 1 2 3 4 5 Time (sec) Note: Each FEV1 curve represents the highest of three repeat measurements

17. Measuring Airway Responsiveness

21. Approach to Management • Confirm diagnosis • Self management education including: environmental trigger avoidance, inhaler technique, adherence, action plan • Reliever therapy • Daily Controller therapy • Regular assessment of asthma control, including spirometry and PEF

22. 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

23. Reducing Exposure to Environmental Tobacco Smoke Evidence suggests an association between environmental tobacco smoke exposure and exacerbations of asthma among school-aged, older children, and adults. Evidence shows an association between environmental tobacco smoke exposure and asthma development among pre-school aged children.

24. Reducing Exposure to House Dust Mites Use bedding encasements Wash bed linens weekly Avoid down fillings Limit stuffed animals to those that can be washed Reduce humidity level (between 30% and 50% relative humidity per EPR-3) Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI, 1995

25. Reducing Exposure to Mold Eliminating mold and the moist conditions that permit mold growth may help prevent asthma exacerbations.

26. Reducing Exposure to Cockroaches Remove as many water and food sources as possible to avoid cockroaches.

27. Exercise Exercise can cause asthma symptoms … BUT Asthma should not usually prevent you from exercising if you: • Keep your asthma under control • Warm-up before and cool-down after exercise • Take a “reliever” medicine 5–10 minutes before exercising, if needed

28. Irritants - Air Pollution • Air pollution comes from many sources, including vehicles and industry • Highest pollution levels tend to be during the hot humid days of summer • To reduce exposure to air pollution, the following may help: • Reduce outdoor activity when pollution levels are high • Keep windows and doors closed when there are high pollution levels (air conditioning may be needed when it gets hot)

29. Allergens - Mould • Moulds can be indoors in damp basements and bathrooms, and outdoors in damp weather • The following can help: • Clean mouldy areas well • Keep humidity around 35-45% • A de-humidifier can help, especially in damp basements • Get rid of clutter in the basement, to allow air to move freely • Ensure proper water drainage around your home • Keep bathroom dry and use fan to remove humidity • Seek professional help if indoor mould doesn’t go away or if there is a lot of mould • Limit outdoor activity when outdoor mould levels are high

30. Allergens - Pollen • Pollens are tiny particles that come off trees, grass and weeds • If you are allergic to pollens, the following may help: • Keep windows and doors closed in home and car during pollen seasons (air conditioner is often needed when it’s hot outside) • After being outside for a long time during pollen season, shower and change clothes • Person with allergies should not mow the lawn

31. Allergens - Pets • If a pet is making your asthma worse, the best option by far is to find it a new home • If it is not possible to find it a new home: • Keep pet out of bedroom always • Wash pet twice a week • Encase pillows and mattress in allergy-proof covers • Remove carpeting if possible • Use a large HEPA* filter air cleaner in bedroom • Vacuum furniture regularly with vacuum equipped with a HEPA* filter, or central vacuum system with exhaust outside the house *HEPA = High Efficiency Particulate Air

32. Worse Case Scenario

34. Reliever Medications • Rapid-acting inhaled β2-agonists • Systemic glucocorticosteroids • Anticholinergics • Theophylline • Short-acting oral β2-agonists

35. Controller Medications • Inhaled glucocorticosteroids • Leukotriene modifiers • Long-acting inhaled β2-agonists in combination with inhaled glucocorticosteroids • Systemic glucocorticosteroids • Theophylline • Cromones • Anti-IgE

36. Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g) > 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

37. Regularly Reassess • Control • Spirometry or PEF • Inhaler Technique • Adherence • Triggers and new exposures • Medications • Environment – home and work • Comorbidities • Sputum eosinophils

38. 60% of Canadians with asthma do not have it under control Why do so many people let asthma affect them so much?

39. Possible reasons … • Do not know what good asthma control is • Do not realize that you can get good control of asthma • May not think that their asthma is bad enough to need treatment (even mild asthma often needs daily medicines) • Worried about taking medicines every day, about side effects, and costs • It may be hard to avoid triggers (eg. pets, smoke, dust mites in the bed, carpets, moulds, pollen)

40. Asthma Management and Prevention ProgramFactors Involved in Non-Adherence Medication Usage • Difficulties associated with inhalers • Complicated regimens • Fears about, or actual side effects • Cost • Distance to pharmacies • Non-Medication Factors • Misunderstanding/lack of information • Fears about side-effects • Inappropriate expectations • Underestimation of severity • Attitudes toward ill health • Cultural factors • Poor communication

41. ASTHMA CONTROL

42. Asthma Diary - Sample

43. Asthma Action Plan - Sample

44. 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)

45. 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

46. 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 long-acting 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)

47. 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)

48. 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)

49. 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)

50. 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