AsthmaCamp GINA

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    G

    IN

    A

    G

    IN

    A

    lobal

    itiative for

    sthma

    lobal

    itiative for

    sthma

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    What is ASTHMA ?

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    Definition of AsthmaDefinition of Asthma

    A chronic inflammatory disorder of the airways

    Many cells and cellular elements play a role

    Chronic inflammation is associated with airwayhyperresponsiveness that leads to recurrentepisodes of wheezing, breathlessness, chest

    tightness, and coughing Widespread, variable, and often reversible

    airflow limitation

    A chronic inflammatory disorder of the airways

    Many cells and cellular elements play a role

    Chronic inflammation is associated with airwayhyperresponsiveness that leads to recurrentepisodes of wheezing, breathlessness, chest

    tightness, and coughing Widespread, variable, and often reversible

    airflow limitation

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    Source: Peter J. Barnes, MDSource: Peter J. Barnes, MD

    Asthma Inflammation: Cells andMediators

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    Source: Peter J. Barnes, MDSource: Peter J. Barnes, MD

    Mechanisms: AsthmaInflammation

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    Factors that Exacerbate AsthmaFactors that Exacerbate Asthma

    Allergens

    Respiratory infections

    Exercise and hyperventilation

    Weather changes

    Sulfur dioxide Food, additives, drugs

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    Risk Factors for

    Asthma

    Host factors: predispose individuals to,or protect them from, developing

    asthma

    Environmental factors: influencesusceptibility to development of asthma

    in predisposed individuals, precipitateasthma exacerbations, and/or causesymptoms to persist

    Host factors: predispose individuals to,or protect them from, developing

    asthma Environmental factors: influence

    susceptibility to development of asthma

    in predisposed individuals, precipitateasthma exacerbations, and/or causesymptoms to persist

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    Factors that Influence Asthma

    Development and Expression

    Host Factors

    Genetic

    - Atopy- Airway

    hyperresponsiveness

    Gender

    Obesity

    Host Factors

    Genetic

    - Atopy- Airway

    hyperresponsiveness

    Gender

    Obesity

    Environmental FactorsIndoor allergens

    Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution

    Respiratory Infections Diet

    Environmental FactorsIndoor allergens

    Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution

    Respiratory Infections Diet

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    Is it Asthma?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 than10 days to clear

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    Asthma Diagnosis

    History and patterns of symptoms

    Measurements of lung function

    - Spirometry- Peak expiratory flow

    Measurement of airway responsiveness

    Measurements of allergic status to identifyrisk factors

    Extra measures may be required todiagnose asthma in children 5 years andyounger and the elderly

    History and patterns of symptoms

    Measurements of lung function

    - Spirometry

    - Peak expiratory flow

    Measurement of airway responsiveness

    Measurements of allergic status to identifyrisk factors

    Extra measures may be required todiagnose asthma in children 5 years andyounger and the elderly

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    Typical Spirometric (FEV1)

    Tracings

    Typical Spirometric (FEV1)

    Tracings

    11Time (sec)Time (sec)

    22 33 44 55

    FEV1FEV1

    VolumeVolume

    Normal SubjectNormal Subject

    Asthmatic (After Bronchodilator)Asthmatic (After Bronchodilator)

    Asthmatic (Before Bronchodilator)Asthmatic (Before Bronchodilator)

    Note: Each FEV1 curve represents the highest of three repeat measurements

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    TRIGGERS of ASTHMA ?

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    Asthma Management and Prevention Program

    Component 2: Identify and ReduceExposure to Risk Factors

    Asthma Management and Prevention Program

    Component 2: Identify and ReduceExposure to Risk Factors

    Measures to prevent the development of asthma,

    and asthma exacerbations by avoiding or reducing

    exposure to risk factors should be implemented

    wherever possible.

    Asthma exacerbations may be caused by a variety

    of risk factors allergens, viral infections,

    pollutants and drugs.

    Reducing exposure to some categories of risk

    factors improves the control of asthma and

    reduces medications needs.

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    Reduce exposure to indoor allergens

    Avoid tobacco smoke

    Avoid vehicle emission

    Identify irritants in the workplace

    Explore role of infections on asthma

    development, especially in children and

    young infants

    Asthma Management and Prevention Program

    Component 2: Identify and ReduceExposure to Risk Factors

    Asthma Management and Prevention Program

    Component 2: Identify and ReduceExposure to Risk Factors

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    REDUCE EXPOSURE TO

    INDOOR ALLERGENS

    Mites

    Furred Animals

    Cockroaches

    Fungi

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    REDUCE EXPOSURE TO

    INDOOR ALLERGENS

    Mites

    Keep humidity below 50% (aircon)

    Remove carpets

    Encase mattress & pillows

    Wash beddings weekly

    Vacuum weekly

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    REDUCE EXPOSURE TO

    INDOOR ALLERGENS

    Furred animals

    The most effective way to combat symptomsof animal allergy is to REMOVE THE PET

    from the home to avoid any contact.

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    REDUCE EXPOSURE TO

    INDOOR ALLERGENS

    Cockroaches

    Block areas where cockroaches can enter thehome.

    Fix leaks & seal leaky faucets

    Keep home clean and dry & keep food in tightlid containers

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    REDUCE EXPOSURE TO

    INDOOR ALLERGENS

    Molds

    Repair leaks

    Clean with Zonrox regularly

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    CLASSIFICATION

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    Asthma Classification Based on

    Severity

    IntermittentMild

    PersistentModeratePersistent

    SeverePersistent

    DaytimeSymptoms

    1x / weekbut < daily

    Daily

    Affects dailyactivities

    Daily Limitsdaily

    activities

    Nighttime

    Symptoms < 2x / month > 2x / month > 1x / week > 1x / week

    PEFR

    > 80%

    predicted

    > 80%

    predicted 60 79% < 60%

    PEFR

    Variability

    < 20% 20 30 % > 30% > 30%

    FEV 1> 80%

    predicted> 80%

    predicted 60 79% < 60%

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    Levels of AsthmaControl

    Characteristic Controlled

    (All of the following)

    Partly controlled(Any present in any week)

    Uncontrolled

    Daytime symptoms None (2 or less /week)

    More thantwice / week

    3 or morefeatures of partlycontrolled

    asthma presentin any week

    Limitations of activities None Any

    Nocturnal symptoms /awakening

    None Any

    Need for rescue /

    reliever treatment

    None (2 or less /

    week)

    More than

    twice / week

    Lung function(PEF or FEV1)

    Normal < 80% predicted or personal best (if known)

    on any day

    Exacerbation None One or more / year 1 in any week

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    Long Term Asthma

    Management( Based on Level of Control )

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    Global Strategy for Asthma

    Management and Prevention

    Global Strategy for Asthma

    Management and Prevention

    Evidence Category Sources of Evidence

    A Randomized clinical trialsRich body of data

    B Randomized clinical trialsLimited body of data

    C Non-randomized trialsObservational studies

    D Panel judgment consensus

    Evidence Category Sources of Evidence

    A Randomized clinical trialsRich body of data

    B Randomized clinical trialsLimited body of data

    C Non-randomized trialsObservational studies

    D Panel judgment consensus

    Asthma Management and Prevention Program

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    Asthma Management and Prevention Program

    Goals of Long-term

    Management

    Achieve and maintain control ofsymptoms

    Maintain normal activity levels,including exercise

    Maintain pulmonary function as closeto normal levels as possible

    Prevent asthma exacerbations

    Avoid adverse effects from asthmamedications

    Prevent asthma mortalit

    Achieve and maintain control ofsymptoms

    Maintain normal activity levels,including exercise

    Maintain pulmonary function as closeto normal levels as possible

    Prevent asthma exacerbations

    Avoid adverse effects from asthmamedications

    Prevent asthma mortalit

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    Component 3: Assess,Treat and Monitor

    Asthma

    Component 3: Assess,Treat and Monitor

    Asthma The goal of asthma treatment, to

    achieve and maintain clinical

    control, can be achieved in amajority of patients with apharmacologic intervention strategy

    developed in partnership betweenthe patient/family and the healthcare professional

    The goal of asthma treatment, toachieve and maintain clinical

    control, can be achieved in amajority of patients with apharmacologic intervention strategy

    developed in partnership betweenthe patient/family and the healthcare professional

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    Asthma Classification Based on

    Severity

    IntermittentMild

    PersistentModeratePersistent

    SeverePersistent

    DaytimeSymptoms

    1x / weekbut < daily

    Daily

    Affects dailyactivities

    Daily Limitsdaily

    activities

    Nighttime

    Symptoms < 2x / month > 2x / month > 1x / week > 1x / week

    PEFR

    > 80%

    predicted

    > 80%

    predicted 60 79% < 60%

    PEFR

    Variability

    < 20% 20 30 % > 30% > 30%

    FEV 1> 80%

    predicted> 80%

    predicted 60 79% < 60%

    L l f A h

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    Levels of AsthmaControl

    Characteristic

    Daytime symptoms

    Limitations of activities

    Nocturnal symptoms /awakening

    Need for rescue /

    reliever treatment

    Lung function(PEF or FEV1)

    Exacerbation

    L l f A th

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    Levels of AsthmaControl

    Characteristic Controlled

    (All of the following)

    Daytime symptoms None (2 or less /week)

    Limitations of activities None

    Nocturnal symptoms /awakening

    None

    Need for rescue /

    reliever treatment

    None (2 or less /

    week)

    Lung function(PEF or FEV1)

    Normal

    Exacerbation None

    L l f A th

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    Levels of AsthmaControl

    Characteristic Controlled

    (All of the following)

    Partly controlled(Any present in any week)

    Daytime symptoms None (2 or less /week)

    More thantwice / week

    Limitations of activities None Any

    Nocturnal symptoms /awakening

    None Any

    Need for rescue /

    reliever treatment

    None (2 or less /

    week)

    More than

    twice / week

    Lung function(PEF or FEV1)

    Normal < 80% predicted or personal best (if known)

    on any day

    Exacerbation None One or more / year

    Characte- Controlled Partly Uncontrolled

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    Characte

    ristics

    Controlled Partly

    Controlled

    Uncontrolled

    Daytime Sx None (2x /wk Three or morfeatures ofpartlycontrolledasthma presin any wk

    Nocturnal Sx None Any

    Need forrescue Rx

    None(2x/ wk

    Lung Fx Normal 1 / yr One in any w

    Asthma Management and Prevention ProgramAsthma Management and Prevention Program

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    Asthma Management and Prevention Program

    Component 3: Assess,Treat and Monitor Asthma

    Asthma Management and Prevention Program

    Component 3: Assess,Treat and Monitor Asthma

    Depending on level of asthma control,the patient is assigned to one of fivetreatment steps

    Treatment is adjusted in a continuouscycle driven by changes in asthmacontrol status. The cycle involves:

    - Assessing Asthma Control

    - Treating to Achieve Control

    - Monitoring to Maintain Control

    Asthma Management and Prevention ProgramAsthma Management and Prevention Program

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    A stepwise approach to pharmacologicaltherapy is recommended

    The aim is to accomplish the goals oftherapy with the least possible medication

    Although in many countries traditionalmethods of healing are used, their efficacyhas not yet been established and their usecan therefore not be recommended

    A stepwise approach to pharmacologicaltherapy is recommended

    The aim is to accomplish the goals oftherapy with the least possible medication

    Although in many countries traditionalmethods of healing are used, their efficacyhas not yet been established and their usecan therefore not be recommended

    Asthma Management and Prevention Program

    Component 3: Assess,Treat and Monitor Asthma

    Asthma Management and Prevention Program

    Component 3: Assess,Treat and Monitor Asthma

    Asthma Management and Prevention ProgramAsthma Management and Prevention Program

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    The choice of treatment should be guided by:

    Level of asthma control

    Current treatment Pharmacological properties and availability

    of the various forms of asthma treatment

    Economic considerations

    Cultural preferences and differing health caresystems need to be considered

    The choice of treatment should be guided by:

    Level of asthma control

    Current treatment Pharmacological properties and availability

    of the various forms of asthma treatment

    Economic considerations

    Cultural preferences and differing health caresystems need to be considered

    g g

    Component 3: Assess,Treat and Monitor Asthma

    g g

    Component 3: Assess,Treat and Monitor Asthma

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    Component 4: Asthma Management and Prevention Program

    Controller Medications

    Component 4: Asthma Management and Prevention Program

    Controller Medications

    Inhaled glucocorticosteroids

    Leukotriene modifiers

    Long-acting inhaled 2-agonists

    Systemic glucocorticosteroids

    Theophylline

    Cromones

    Long-acting oral 2-agonists

    Anti-IgE

    Inhaled glucocorticosteroids

    Leukotriene modifiers

    Long-acting inhaled 2

    -agonists

    Systemic glucocorticosteroids

    Theophylline

    Cromones

    Long-acting oral 2-agonists

    Anti-IgE

    E ti t C ti D il D fE ti t C ti D il D f

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    Estimate Comparative Daily Dosages for

    Inhaled Glucocorticosteroids by Age

    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

    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

    Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

    Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400

    Budesonide-Neb InhalationSuspension

    250-500 >500-1000 >1000

    Ciclesonide 80 160 80-160 >160-320 >160-320 >320-1280 >320

    Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250

    Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500

    Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400

    Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200

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    Component 4: Asthma Management and Prevention Program

    Reliever Medications

    Component 4: Asthma Management and Prevention Program

    Reliever Medications

    Rapid-acting inhaled 2-agonists

    Anticholinergics

    Theophylline

    Short-acting oral 2-agonists

    Rapid-acting inhaled 2-agonists

    Anticholinergics

    Theophylline

    Short-acting oral 2-agonists

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    controlled

    partly controlled

    uncontrolled

    exacerbation

    LEVEL OF CONTROLLEVEL OF CONTROL

    maintain and find lowest

    controlling step

    consider stepping up to

    gain control

    step up until controlled

    treat as exacerbation

    TREATMENT OF ACTIONTREATMENT OF ACTION

    TREATMENT STEPSREDUCE INCREASE

    STEP

    1

    STEP

    2

    STEP

    3

    STEP

    4

    STEP

    5

    REDUCE

    INCRE

    AS

    E

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    Step 1 As-needed reliever medication

    Patients with occasional daytime symptoms of

    short duration A rapid-acting inhaled 2-agonist is the

    recommended reliever treatment ( Evidence A )

    When symptoms are more frequent, and/or

    worsen periodically, patients require regular

    controller treatment (step 2or higher)

    Treating to Achieve AsthmaControl

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    Step 2 Reliever medication plus a singlecontroller

    Initial controller Rx: low-dose inhaled

    glucocorticosteroid for patients of all ages(Evidence A )

    Alternative controller medications :

    leukotriene modifiers ( Evidence A )

    Treating to Achieve AsthmaControl

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    Step 3 Reliever medication plus one or twocontrollers

    Adults and adolescents: combine a low-dose

    inhaled glucocorticosteroid with an inhaled long-acting 2-agonist ( Evidence A )

    Inhaled long-acting 2-agonist must not be used

    as monotherapy

    For children, increase to a medium-dose inhaled

    glucocorticosteroid ( Evidence A )

    Treating to Achieve AsthmaControl

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    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 inhaled glucocorticosteroid pluslow-dose sustained-release theophylline( Evidence B )

    Treating to Achieve AsthmaControl

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    Step 4 Reliever medication plus two or morecontrollers

    Selection of treatment at Step 4 depends

    on prior selections at Steps 2 and 3

    Where possible, patients not controlled on

    Step 3 treatments should be referred to a

    health professional with expertise in the

    management of asthma

    Treating to Achieve AsthmaControl

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    Step 4 Reliever medication plus two or more controllers

    Medium- or high-dose inhaled glucocorticosteroid

    combined with a long-acting inhaled 2-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 2-agonist (

    Evidence B )

    Treating to Achieve AsthmaControl

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    i hi h

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    Treating to Achieve AsthmaControl

    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 severeside-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 )

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    Treating to Maintain AsthmaControl

    When control as been achieved,ongoing monitoring is essential to:

    - maintain control

    - establish lowest step/dose treatment

    Asthma control should be monitoredby the health care professional andby the patient

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    Treating to Maintain AsthmaControl

    Stepping down treatment when asthma is controlled

    When controlled on medium- to high-dose

    inhaled glucocorticosteroids: 50% dosereduction at 3 month intervals( Evidence B )

    When controlled on low-dose inhaled

    glucocorticosteroids: switch to once-daily

    dosing ( Evidence A )

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    Treating to Maintain AsthmaControl

    Stepping down treatment when asthma is controlled

    When controlled on combination inhaledglucocorticosteroids and long-actinginhaled 2-agonist, reduce dose of inhaled

    glucocorticosteroid by 50% whilecontinuing the long-acting 2-agonist

    ( Evidence B )

    If control is maintained, reduce to low-dose inhaled glucocorticosteroids and

    stop long-acting 2-agonist ( Evidence D )

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    Treating to Maintain AsthmaControl

    Stepping up treatment in response to loss of control

    Rapid-onset, short-acting or long-

    acting inhaled 2-agonistbronchodilators provide temporaryrelief.

    Need for repeated dosing over morethan one/two days signals need forpossible increase in controller therapy

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    Treating to Maintain AsthmaControl

    Stepping up treatment in response to loss of control

    Use of a combination rapid and long-actinginhaled 2-agonist (e.g., formoterol) and an

    inhaled glucocorticosteroid (e.g., budesonide)in a single inhaler both as a controller andreliever is effective in maintaining a high level

    of asthma control and reduces exacerbations( Evidence A )

    Doubling the dose of inhaled glucocortico-steroids is not effective, and is not

    recommended ( Evidence A )

    Asthma Management and Prevention Program

    C t 3 A T t dAsthma Management and Prevention Program

    C t 3 A T t d

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    Childhood and adult asthma share the

    same underlying mechanisms.However, because of processes of

    growth and development, effects of

    asthma treatments in children differfrom those in adults.

    Childhood and adult asthma share the

    same underlying mechanisms.However, because of processes of

    growth and development, effects of

    asthma treatments in children differfrom those in adults.

    Component 3: Assess, Treat andMonitor Asthma Children 5

    Years and Younger

    Component 3: Assess, Treat andMonitor Asthma Children 5

    Years and Younger

    Asthma Management and Prevention Program

    C t 3 A T t dAsthma Management and Prevention Program

    Component 3 Assess Treat and

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    Many asthma medications (e.g.

    glucocorticosteroids, 2- agonists,theophylline) are metabolized faster in

    children than in adults, and younger

    children tend to metabolize medicationsfaster than older children

    Many asthma medications (e.g.

    glucocorticosteroids, 2- agonists,theophylline) are metabolized faster in

    children than in adults, and younger

    children tend to metabolize medicationsfaster than older children

    Component 3: Assess, Treat andMonitor Asthma Children 5

    Years and Younger

    Component 3: Assess, Treat andMonitor Asthma Children 5

    Years and Younger

    Asthma Management and Prevention Program

    C t 3 A T t dAsthma Management and Prevention Program

    Component 3: Assess Treat and

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    Glucocorticosteroids has not been shown

    to be associated with any increase in

    osteoporosis in long-term treatment withinhaled or bone fracture

    Studies including a total of over 3,500

    children treated for periods of 1 13 yearshave found no sustained adverse effect of

    inhaled glucocorticosteroids on growth

    Glucocorticosteroids has not been shown

    to be associated with any increase in

    osteoporosis in long-term treatment withinhaled or bone fracture

    Studies including a total of over 3,500

    children treated for periods of 1 13 yearshave found no sustained adverse effect of

    inhaled glucocorticosteroids on growth

    Component 3: Assess, Treat andMonitor Asthma Children 5

    Years and Younger

    Component 3: Assess, Treat andMonitor Asthma Children 5

    Years and Younger

    Asthma Management andAsthma Management and

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    A stepwise approach to pharmacologic therapyis recommended. The aim is to accomplish the

    goals of therapy with the least possiblemedication

    The availability of varying forms of treatment,

    cultural preferences, and differing health caresystems need to be considered

    A stepwise approach to pharmacologic therapyis recommended. The aim is to accomplish the

    goals of therapy with the least possiblemedication

    The availability of varying forms of treatment,

    cultural preferences, and differing health caresystems need to be considered

    Asthma Management and

    Prevention Program: Summary

    Asthma Management and

    Prevention Program: Summary

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    MANAGEMENT of

    EXACERBATION

    Asthma Management and Prevention ProgramAsthma Management and Prevention Program

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    Exacerbations of asthma

    Episodes of progressive in shortness ofbreath, cough, wheezing, or chest

    tightness

    Characterized by in expiratory airflow,can quantified and monitored by

    measurements of lung function (FEV1or

    PEF)

    Exacerbations of asthma

    Episodes of progressive in shortness ofbreath, cough, wheezing, or chest

    tightness

    Characterized by in expiratory airflow,can quantified and monitored by

    measurements of lung function (FEV1 or

    PEF)

    Component 4: Manage Asthma

    Exacerbations

    Component 4: Manage Asthma

    Exacerbations

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    Aims of Treatment of AcuteAsthma Exacerbation

    Relieve airway obstruction as quickly as possible

    Relieve hypoxemia as quickly as possible

    Plan the prevention of future relapses

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    AbsentUsu ally loudLoudM od. often

    en d-ex p irato ry

    Wheeze

    Paradoxical

    breathing

    UsuallyUsuallyUsu ally notUse of accessory

    m uscles o f resp

    Often > 30/m inIncreasedIncreasedResp. ra te

    Drows y/ confused

    or com atose

    Usu ally agitatedUsually

    agitated

    M ay be

    agitated

    Alertness

    WordsPhrasesSentencesTalks in

    M ay be cyanotic,exhaustedAt restHunched forwardTalkingPre fers sitting

    WalkingCan l ie dow n

    Breathless w hen

    RESP. ARRE S

    IMMINENT

    SEVEREM O D E R A T EMILD

    Assessm ent of Severity of

    Asthm a Exacerbations

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    Asthma Management and Prevention ProgramAsthma Management and Prevention Program

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    Component 4: Manage Asthma

    Exacerbations

    Component 4: Manage Asthma

    Exacerbations

    Treatment of exacerbations depends on:

    The patient

    Experience of the health care

    professional

    Therapies that are the most effective for

    the particular patient

    Availability of medications

    Emergency facilities

    Treatment of exacerbations depends on:

    The patient

    Experience of the health careprofessional

    Therapies that are the most effective for

    the particular patient Availability of medications

    Emergency facilities

    Management of asthma exacerbation in acute

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    Management of asthma exacerbation in acutecare setting

    Initial assessmentHistory, PE (auscultation, use of accessory

    muscles, HR, RR, PEF or FEV1, O2 saturation, ABG

    Initial Treatment-Oxygen to achieve saturation to >95% in children

    -Inhaled acting beta-2 agonist continuously for 1H

    -Systemic glucocorticosteroids if no immediateresponse

    -Sedation contraindicated in the treatment of acuteexacerbation

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    Criteria formoderate episode

    PEF 60-80% predicted /personal best

    PE: moderate symptoms,accessory muscle use

    Treatment O2; Inhaled beta-2 agonist &

    anticholinergic for 1 Hr

    Oral glucocorticosteroids

    Continue for 1-3H, providedwith improvement

    Criteria forsevere episode RFs for near fatal asthma PEF

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    Re-assess after 1-2 H

    Good response within 1-2H

    Response sustained 1H after treatment

    PE Normal: No distressPEF >70%; O2 sat 95%

    Improved: Criteria for Discharge Home

    PEF >60% predicted/ personal best

    Sustained on oral/inhaled medication

    Home Treatment: Inhaled beta-2 agonist

    and oral GC; consider combination inhaler

    Patient education

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    Re-assess after 1-2HIncomplete response

    within 1-2H RFs for near fatal asthma PEF

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    Re-assess at intervals

    Incomplete to poor response Intensive Care

    Incomplete response in 6-12H

    Consider admission to Intensive Care

    Improved

    Consider discharge criteria

    Asthma Management and Prevention Program

    C t 4 M A th

    Asthma Management and Prevention Program

    C t 4 M A th

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    Primary therapies for exacerbations:

    Repetitive administration of rapid-acting inhaled 2-agonist

    Early introduction of systemic glucocorticosteroids

    Oxygen supplementation

    Closely monitor response to treatment with serial

    measures of lung function.

    Primary therapies for exacerbations:

    Repetitive administration of rapid-acting inhaled 2-agonist

    Early introduction of systemic glucocorticosteroids

    Oxygen supplementation

    Closely monitor response to treatment with serial

    measures of lung function.

    Component 4: Manage Asthma

    Exacerbations

    Component 4: Manage Asthma

    Exacerbations

    Criteria for Discharge from the

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    g

    Emergency Department vs. Hospitalization

    Patients with pre-treatment FEV1 or PEF 60%predicted

    For patients discharged from the emergency

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    For patients discharged from the emergency

    department

    Shorter course (3-5 days) should be prescribed +

    continuation of bronchodilator therapy

    Bronchodilator can be prn, based on symptomatic and

    objective measurement Ipratropium bromide unlikely to provide additional

    benefit beyond the acute phase

    Continue inhaled glucocorticosteroids!

    Review of patients inhaler technique and use of peak

    flow meter

    Review of action plan with written guidance

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    SPECIAL CONSIDERATIONS

    Asthma Management and Prevention ProgramAsthma Management and Prevention ProgramAsthma Management and Prevention ProgramAsthma Management and Prevention Program

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    g gg g

    Special Considerationsg gg g

    Special Considerations

    Special considerations are required to

    manage asthma in relation to:

    Pregnancy

    Surgery Rhinitis, sinusitis, and nasal polyps

    Occupational asthma

    Respiratory infections

    Gastroesophageal reflux

    Aspirin-induced asthma

    Anaphylaxis and Asthma

    Special considerations are required to

    manage asthma in relation to:

    Pregnancy

    Surgery Rhinitis, sinusitis, and nasal polyps

    Occupational asthma

    Respiratory infections

    Gastroesophageal reflux

    Aspirin-induced asthma

    Anaphylaxis and Asthma

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    Rhinitis

    Allergic Rhinitis and its impact on asthma

    (ARIA)

    Classification: Intermittent or Persistent; Mild

    or Moderate-Severe Treatment: H1- antagonists (oral and

    intranasal), decongestant, steroids

    (intranasal, oral), cromones, leukotrienemodifiers.

    Allergen avoidance, Immunotherapy,

    Education

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    Sinusitis

    A complication of URI, AR,

    nasal polyps and other forms of

    nasal obstruction

    Antibiotic therapy for 10 days

    Topical nasal decongestants,topical nasal steroids, systemic

    glucocorticosteroids

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    Respiratory Infections

    RSV, most common cause of wheezing ininfancy

    Rhinovirus, principal trigger of wheezing and

    worsening of asthma in older children &adults Role of chronic infection with

    Chlamydia/Mycoplasma pneumoniae in thepathogenesis or worsening of asthma isuncertain

    Treatment of an infectious exacerbationfollows the same principles as treatment ofother asthma exacerbations

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    Gastroesophageal Reflux

    3x as prevalent in patients with asthma

    compared o the general population

    Advise smaller frequent meals, avoidfatty meals, alcohol, theophylline, oral 2

    agonists

    Use proton pump inhibitors or H2antagonists

    Elevate the head of the head

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    Anaphylaxis and Asthma

    Anaphylaxis is a potentially life-threatening

    condition that can both mimic and complicate

    severe asthma Allergen Immunotherapy, Food intolerance,

    Avian-based vaccines, insect stings and

    bites, NSAIDS, ACE inhibitors, exercise Epinephrine should be the bronchodilator of

    choice

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    Case

    R.J., a 7-year old male child, newly

    diagnosed to have bronchial

    asthma last March 2007, came in atthe emergency room for cough and

    coryza the past 3 days. Few hours

    prior to consult, child was noted tohave sudden onset of shortness of

    breath.

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    Case

    At the ER, pertinent PE revealed a

    wheezy chest with alar flaring. Vital

    signs were: heart rate = 120 beats

    per minute and respiratory rate = 30

    breaths per minute. O2 saturation was93% and peak expiratory flow rate

    (PEFR) was 75%.

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    Case

    Pertinent medical history revealed

    poor compliance with the anti-asthmamaintenance medications (inhaled

    long acting beta-2 agonist and

    corticosteroid combination).

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    BRONCHIAL ASTHMA UNCONTROLLEDin MODERATE EXACERBATION

    Treatment

    O2

    Inhaled beta-2 agonist & anticholinergic for1 Hr

    Oral glucocorticosteroids

    Continue for 1-3H, provided withimprovement

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    Case

    After continuous nebulization for one

    hour. He was drowsy. Vital signs

    revealed: heart rate= 180 beats/min,respiratory rate= 50 breaths/min with

    Oxygen saturation was 50% at

    2L/minute O2 via nasal cannula.

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    Case

    P.E. :C/L findings revealed severe

    retractions with use of accessorymuscles and absent breath sounds.

    ABG showed Pc02 : 50 mm Hg and

    P02 : 60 mm Hg

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    Case

    1. What is your assessment?

    2. What will be your treatment?

    Poor response within 1-2H

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    Poor response within 1 2H

    RFs for near fatal asthma

    PEF 45 mm Hg

    pO2