Asthma

1. Asthma What is Asthma ?

2. Asthma What is Asthma? “The presence of widespread narrowing of the airways which alters in severity either spontaneously or as a result of treatment” 1952 Definition:

3. Asthma What is Asthma? • Chronic inflammatory disorder of the airways • Inflammation associated with • Airways hyperresponsiveness • Airflow limitation (at least partially reversible) • Respiratory symptoms (wheeze, cough, tight chest) • Airway inflammation can be present even in mild disease National Asthma Education and Prevention Panel, Expert Panel Report II “NAEPP Guidelines”, National Institutes of Health, 1997

4. TITANIC Symptoms Airflow obstruction Bronchial hyperresponsiveness Airway inflammation Asthma The “Tip” of the Iceberg

5. Asthma Symptoms of Asthma • Wheeze, cough, chest tightness (“dyspnea”) • Nocturnal awakenings • Recurrent attacks related to specific triggers

6. Asthma Special Aspects of Asthma • Allergic (or extrinsic) asthma • Nocturnal asthma • Exercise-induced bronchoconstriction (EIB) • Aspirin-sensitive • Cough-variant • Occupational

7. Asthma Asthma Prevalence by Age 37% 40% 30% 35% 10% 15-19y 30% 21% 25% Percentage of Asthmatic Population 20% 12% 19% 6-14y 15% 10% 5% 8% < 6y 0% 0-19y 20-39y 40-59y 60+y AGE (years)

8. Asthma Burden of Asthma …on society

9. Asthma Asthma in the United States -- a growing problem • 17.4 million Americans have asthma • Prevalence rose 75% 1980-1994 • Prevalence rose more in children (160% in 0–4 y.o.’s) • 1.9 million ER visits (in 1995) and466,000 hospitalizations (in 1993) • Office Visits doubled (from 1975 to 1995) • 3 per 10,000 asthmatic patients die (1994) • Deaths doubled (for 5–24 y.o.’s from 1980 to 1993) from National Center for Health Statistics

10. Asthma Asthma is the Most Common Chronic Illness of Childhood • 13 million physician visits/year • 87% of asthmatic children had unscheduled physician visits in the prior year • Third-ranking cause of hospitalization in children <15 andthe highest-ranking cause among chronic conditions • 200,000 hospitalizations/year • Most common chronic illness resulting in school absences • 10.1 million lost school days a year • On average: 1 week absent per asthmatic child

11. Asthma Asthma Mortality • Higher risk of death from asthma • African Americans • Males Rate of Asthma Deaths (per 1,000,000)

12. Asthma Pediatric Asthma Mortality • Asthma deaths have more than doubled for 0- to 14-year-olds from 1979 to 19951 Number of Asthma Deaths • Most patients who died – not seen as “high risk”2 • Some patients who died had mild disease

13. Asthma Burden of Asthma …on the patient

14. Asthma Asthma’s Impact • The highest-ranking chronic condition causing hospitalization in children • The most common chronic illness of childhood • Children with asthma have 3x the school absences of children without asthma • 40% of children with asthma have sleep disturbances, 1 to 2 nights/week • even if the child is not absent from school, he or she may have reduced school performance due to sleep disturbances

15. Asthma Asthma’s Impact • 23% of adults with asthma missed work during the prior year due to asthma • 36% of parents of asthmatics missed work in the prior year • 50% of parents and 49% of patients say asthma limits the range of activities a family can do together • 78% of parents of asthmatics report that asthma has a negative impact on the family

16. Asthma Diagnosis

17. Asthma Diagnosis of AsthmaSymptoms • Wheeze, cough, chest tightness (“dyspnea”) • Nocturnal awakenings • Recurrent attacks related to specific triggers • Response to asthma-specific therapy

18. Asthma Diagnosis of AsthmaLung Function Measurements • Changes in lung function over time(Spontaneously or in response to therapy) - Spirometry (FEV1) - Peak expiratory flow rate (PEFR or “peak flow”) • Airway hyperresponsiveness to stimuli - Methacholine challenge test - Exercise challenge test

19. Asthma Bronchial Provocation 0 A 20 B FEV1 % fall from C baseline Low PD20 High PD20 High BHR Low BHR Increasing dose of methacholine

20. Asthma The Early and Late Asthmatic Response 100 LAR 75 FEV1 (% predicted) 50 AAR 25 AAR = Acute asthmatic response LAR = Late asthmatic response 1 2 3 4 5 6 7 8 9 10 11 12 Inhaled Time (hours) allergen

21. Asthma Spirometry FEV1 post-bronchodilator FEV1 pre-bronchodilator 4 3 Exhaledvolume (L) FVC 2 After bronchodilator 1 Before bronchodilator 1 2 3 4 5 6 Time (seconds)

22. Asthma Uses of Daily Peak Flow Monitoring Acutely: • Assess severity of exacerbations Short term: • Evaluate therapy • Establish temporal relationship to triggers Long-term: • Detect changes in disease status • Evaluate treatment • Provide patient with a written action plan

23. Asthma Circadian Changes in PEFR PEFR recorded twice-daily over 2 weeks Normal Asthma 100% 100% PEFR (%Predicted) 50% 50% Evening peak flow Morning peak flow

24. Asthma Diagnosis…per the guidelines

25. Asthma Asthma Guidelines: Recent evolution • NAEPP Guidelines1997 • National Asthma Education and Prevention Panel, Expert Panel Report II, National Institutes of Health (“NIH”), National Heart, Lung, and BloodInstitute (NHLBI)) • GINAGuidelines 1998 • Global INitiative for Asthma,Asthma Management and Prevention Report, NHLBI and World Health Organization (WHO) • Pediatric Asthma: Promoting Best Practices 1999 • American Academy of Allergy, Asthma & Immunology (AAAAI), American Academy of Pediatrics (AAP), National Heart, Lung, and Blood Institute (NHLBI), NAEPP, etc

26. 4 Severe Persistent 3 Moderate Persistent 2 Mild Persistent 1 Mild Intermittent Asthma NAEPP and GINA GuidelinesAsthma severity: Classified the same Classified by: • Symptoms • • Activity levels • • Exacerbations • • FEV1/PEFR • • PEFR variability Severity is classified before therapy begins Severity is classified before therapy begins

27. Asthma Asthma GuidelinesSeverity: Mild Intermittent • Clinical features before treatment • Symptoms < 2x per week • Brief exacerbations • Nighttime symptoms < 2x per • month • Asymptomatic with normal lung • function between exacerbations • FEV1 and PEF > 80% predicted • PEF variability < 20% 1 Mild Intermittent

28. 2 Asthma Asthma GuidelinesSeverity: Mild Persistent • Clinical features before treatment • Symptoms > 2x per week but <1x per day • Exacerbations may affect activity • Nighttime asthma symptoms > 2x per month • FEV1 and PEF > 80% predicted • PEF variability 20 - 30% Mild Persistent

29. 3 Asthma Asthma GuidelinesSeverity: Moderate Persistent • Clinical features before treatment • Daily symptoms • Exacerbations > 2x per week affect activity • Nighttime asthma symptoms > 1x per week • Daily use of short-acting ß agonist • FEV1 and PEF > 60% and < 80% predicted • PEF variability > 30% Moderate Persistent

30. 4 Asthma Asthma GuidelinesSeverity: Severe Persistent Severe Persistent • Clinical features before treatment • Continuous symptoms • Frequent exacerbations • Frequent nighttime symptoms • Limited activity • FEV1 and PEF < 60% predicted • PEF variability > 30%

31. Asthma Management of Asthma • Assessment and monitoring • Control of factors contributing to asthma severity • Pharmacotherapy • Education

32. Asthma Inflammatory Cell-DerivedMediators Mastcells Eosinophils Histamine Leukotrienes Mediators Prostaglandins Mast cell tryptase Eosinophil cationic protein Cytokines (IL-4, IL-5) manyothercells T lymphocytes

33. Asthma

34. Asthma