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Latest Guidelines for Asthma Management

Latest Guidelines for Asthma Management. Global Initiative for Asthma By: Dr. Mahmoud Taheri. Strategies for Asthma Management and Prevention. Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and Prevention Program

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Latest Guidelines for Asthma Management

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  1. Latest Guidelines for Asthma Management Global Initiative for Asthma By: Dr. MahmoudTaheri

  2. Strategies for Asthma Management and Prevention • Definition and Overview • Diagnosis and Classification • Asthma Medications • Asthma Management and Prevention Program • Implementation of Asthma Guidelines in Health Systems

  3. 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 reversibleairflow limitation

  4. Asthma Inflammation: Cells and Mediators

  5. Factors that Exacerbate Asthma • Allergens • Respiratory infections • Exercise and hyperventilation • Weather changes • Sulfur dioxide • Food, additives, drugs

  6. 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

  7. 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

  8. 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

  9. Typical Spirometric (FEV1) Tracings 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

  10. Measuring Variability of Peak Expiratory Flow

  11. Measuring Airway Responsiveness

  12. Asthma Management and Prevention Program Goals of Long-term Management • Achieve and maintaincontrol 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

  13. 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

  14. . Asthma Management and Prevention Program • Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstrictionand 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.

  15. Asthma Management and Prevention ProgramPart 1: Educate Patients to Develop a 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

  16. Asthma Management and Prevention ProgramComponent 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

  17. Asthma Management and Prevention ProgramComponent 1: Develop Patient/Doctor Partnership Key factors to facilitate communication: • Friendly demeanor • Interactive dialogue • Encouragement and praise • Provide appropriate information • Feedback and review

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

  19. Asthma Management and Prevention Program Component 2: Identify and Reduce Exposure to Risk Factors • Measures to help reducing exposure to risk factors should be implemented wherever possible. • Asthma exacerbations are caused by a variety of risk factors – allergens, viral infections, pollutants and drugs. • Reducing exposure to some risk factors improves the control of asthma and reduces medications needs.

  20. 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

  21. Asthma Management and Prevention Program Influenza Vaccination • Routineinfluenza vaccination of children and adults with asthma does not appear to protect them from asthma exacerbations or improve asthma control

  22. Asthma Management and Prevention ProgramComponent 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

  23. Global Strategy for Asthma Management and PreventionClinical Control of Asthma The focus on asthma control is important because: • the attainment of control correlates with a better quality of life, and • reduction in health care use

  24. Global Strategy for Asthma Management and PreventionClinical Control of Asthma • Determine the initial level of control to implement treatment • (assess patient impairment) • Maintain control once treatment has been implemented • (assess patient risk)

  25. Levels of Asthma Control(Assess patient impairment) Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)

  26. Assess Patient Risk • Features that are associated with increased risk of adverse events in the future include: • Poor clinical control • Frequent exacerbations in past year • Ever admission to critical care for asthma • Low FEV1, exposure to cigarette smoke, high dose medications

  27. *IMPORTANT* Any exacerbation should prompt review of maintenance treatment

  28. Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma • Depending on level of asthma control, the patient is assigned to one of five treatment steps • Step 2 is the initial treatment for most patients. If the patient is severely uncontrolled, we start from step 3. • Our approach includes: - Assessing Asthma Control -Treating to Achieve Control -Monitoring to Maintain Control

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

  30. Salbutamol (Albuterol) • Availability: Aerosol 90 mcg/inh. • Brand Names: Ventolin • Onset: 5-15 min • Peak: 1 Hour • Duration: 3-6 hrs.

  31. Salmeterol • Availability: Aerosol 25 mcg/inh. • Brand Names: Serevent • Onset: 10-25 min • Peak: 3-4 hrs. • Duration: 12 hrs.

  32. Beclomethasone • Availability: Aerosol 40 mcg/inh. • Aerosol 80 mcg/inh. • Brand Names: Becotide, Beclazone, Qvar • Onset: Within 24 hrs. • Peak: 1-4 Weeks • Duration: Unknown

  33. Fluticasone • Availability: Aerosol 44 mcg/inh. • Aerosol 110 mcg/inh. • Aerosol 220 mcg/inh. • Brand Names: Flovent • Onset: Within 24 hrs. • Peak: 1-4 Weeks • Duration: Days after DC.

  34. Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)

  35. Reliever Medications • Rapid-acting inhaled β2-agonists • Systemicglucocorticosteroids • Anticholinergics • Theophylline • Short-acting oral β2-agonists

  36. Component 4: Asthma Management and PreventionProgramAllergen-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 environmentalavoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma

  37. LEVEL OF CONTROL TREATMENT OF ACTION REDUCE maintain and find lowest controlling step controlled consider stepping up to gain control partly controlled uncontrolled step up until controlled INCREASE exacerbation treat as exacerbation REDUCE INCREASE TREATMENT STEPS STEP 1 STEP 2 STEP 3 STEP 4 STEP 5

  38. TO STEP 3 TREATMENT, SELECT ONE OR MORE: TO STEP 4 TREATMENT, ADD EITHER Shaded green - preferred controller options

  39. TO STEP 3 TREATMENT, SELECT ONE OR MORE: TO STEP 4 TREATMENT, ADD EITHER Shaded green - preferred controller options

  40. 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)

  41. TO STEP 3 TREATMENT, SELECT ONE OR MORE: TO STEP 4 TREATMENT, ADD EITHER Shaded green - preferred controller options

  42. Treating to Achieve Asthma Control • Step 2 – Reliever medication plus a single controller • A low-dose inhaled glucocorticosteroidis 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.

  43. TO STEP 4 TREATMENT, ADD EITHER TO STEP 3 TREATMENT, SELECT ONE OR MORE: Shaded green - preferred controller options

  44. 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-actingβ2-agonist either in a combination inhaler device or as separate components (Evidence A) • Inhaled long-acting β2-agonist must not be used as monotherapy

  45. 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)

  46. TO STEP 4 TREATMENT, ADD EITHER TO STEP 3 TREATMENT, SELECT ONE OR MORE: Shaded green - preferred controller options

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