ASTHMA

COMPENDIUM OF PHILIPPINE MEDICINE. 12th edition

National Asthma Education and Prevention Panel, Expert Panel Report II

WHAT IS ASTHMA?
Chronic inflammatory disorder of the airway

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

Asthma
National Asthma Education and Prevention Panel, Expert Panel Report II NAEPP Guidelines, National Institutes of Health, 1997

CLASSIFICATION OF ASTHMA BASED ON SEVERITY

Persistent
Intermittent Daytime Symptoms Nighttime symptoms PEFR PEFR Variability FEV1 <1x/week Mild >1x/week but less than daily >2x/month <2x/month >80% predicted >80% predicted <20% > 80% predicted >80% predicted 60-79% <60% 20-30% 60-79% >30% <60% >30% Moderate Affects DAILY activities >1x/week Severe Limits DAILY activity >1x/week

SEVERITY OF ASTHMA EXACERBATIONS

Mild Breathless Walking Can lie down Moderate Talking Infant: softer shorter cry Prefers sitting Severe At rest Infant: stops feeding Respiratory Arrest Imminent

Talks in
Alertness Respiratory rate

Sentences
May be agitated Increased

Phrases
Usually agitated Increased

Words
Usually agitated Often >30/min Bradypnea

Accessory muscles and suprasternal retractions

Wheeze

None

Present

Present

Present thoracoabdominal movement

Absence of wheeze with decreased to absent breath sounds

Audible with stethoscope

Audible with stethoscope

Audible without stethoscope

Pulse/min

<100

100-120

>120

Bradycardia

ALGORITHM FOR ASTHMA MGT

ALGORITHM FOR ASTHMA MGT

Diagnosis
Objective Measure Indicator of significant airflow limitation

Spirometry

> 12% improvement in FEV1 from the baseline after inhaled bronchodilator use > 20% improvement in FEV1 after 10-14 days corticosteroid therapy >20% change after using a bronchodilator over time

Serial measures of PEFR

Pre- and Post>15% change afterusing inhaled bronchodilator PEFR bronchodilator in the clinic Methacoline challenge 20% fall in FEV1 from the baseline (PC20) <8mg/mL

NAEPP and GINA Guidelines Asthma severity: Classified the same

Classified by:
Severe Persistent Moderate Persistent Mild Persistent

Symptoms Activity levels

Exacerbations
FEV1/PEFR

2
1

Mild Intermittent

PEFR variability

Severity is classified before therapy begins

Asthma

Asthma Guidelines Severity: 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

Mild Intermittent

PEF variability < 20%

Asthma

Asthma Guidelines Severity: 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%

2
Mild Persistent

Asthma

Asthma Guidelines Severity: Moderate Persistent

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

Asthma

Asthma Guidelines Severity: Severe Persistent

Severe Persistent
Continuous symptoms
Frequent exacerbations Frequent nighttime symptoms Limited activity FEV1 and PEF < 60% predicted PEF variability > 30%

Clinical features before treatmen

Asthma

PCCP Classification
Parameter Intermittent Mild-Moderate Persistent Severe Persistent

Daytime Symptoms
Nocturnal Awakening Rescue 2agonists Use PEFR or FEV1 Treatment

Monthly
Less than monthly Less than weekly >80% pred Occasional prn 2-agonists

Weekly
Monthly to weekly Weekly to daily 60-80% pred Regular ICS + LABA

Daily
Nightly Several times a day <60% pred Combination ICS + LABA+ OCS

Home Treatment
Assess Severity Cough, breathlessness, wheeze, chest tightness, use of accessory muscles, suprasternal retractions, and sleep disturbance. PEF less than 80 percent of personal best or predicted. Initial Treatment Inhaled rapid-acting 2-agonist up to three treatments in 1 hour. Patients at high risk of asthma-related death should contact physician promptly after initial treatment

Home Treatment
Response to Initial Treatment Is... Good if... Symptoms subside after initial 2-agonist and relief is sustained for 4 hours. PEF is greater than 80% predicted or personal best. ACTIONS: May continue 2-agonist every 3-4 hours for 1-2 days. Contact physician or nurse for follow-up instructions.

Home Treatment
Poor if Symptoms persist or worsen despite initial 2-agonist treatment. PEF is less than 60% predicted or personal best. ACTIONS: Add oral glucocorticosteroid. Repeat 2-agonist immediately. Add inhaled anticholinergic. Immediately transport to hospital emergency department.

Home Treatment
Incomplete if Symptoms decrease but return in less than 3 hours after initial 2-agonist treatment. PEF is 60-80% predicted or personal best. ACTIONS: Add oral glucocorticosteroid. Add inhaled anticholinergic. Continue 2-agonist. Consult clinician urgently for instructions.

Hospital-Based Treatment
Initial Assessment History, physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate, PEF or FEV1, oxygen saturation, arterial blood gas) Initial Treatment Inhaled rapid-acting 2-agonist, usually by nebulization, one dose every 20 minutes for 1 hour Oxygen to achieve O2 saturation = 90% Systemic glucocorticosteroids if no immediate response, or if patient recently took oral glucocorticosteroids, or if episode is severe Sedation is contraindicated in the treatment of attacks

Hospital-Based Treatment
Repeat Assessment Physical Exam, PEF or FEV1, O2 saturation, other tests as needed Moderate Episode PEF 60-80% predicted/ personal best Physical exam: moderate symptoms, accessory muscle use Inhaled 2-agonist and inhaled anticholinergic every 60 minutes Consider glucocorticosteroids Continue treatment 1-3 hours, provided there is improvement

Hospital-Based Treatment
Severe Episode PEF < 60% predicted/personal best Physical exam: severe symptoms at rest, chest retraction History: high-risk patient No improvement after initial treatment Inhaled 2-agonist and inhaled anticholinergic Oxygen Systemic glucocorticosteroid Consider subcutaneous, intramuscular, or intravenous 2agonist Consider intravenous methylxanthines Consider intravenous magnesium

Hospital-Based Treatment
Treatment Response
Good Response Response sustained 60 minutes after last treatment PEF >70%

Incomplete Response Within1-2 Hours PEF < 70%

Poor Response Within 1 Hour PEF < 30% PCO2 > 45 mmHg PO2 < 60 mmHg

Acute Asthma Care

What is the ideal first line therapy for asthma exacerbation? Inhaled 2-agonists, due to their rapid onset of action, are recommended as first line therapy (Grade A)

Acute Asthma Care

Is nebulization better than MDI in the delivery of short-acting 2-agonists during acute asthma exacerbations? NO, there is no difference between nebulized and MDI-administered

Acute Asthma Care

Does systemically administered 2-agonists have a role in acute asthma excerbations? NO. There is no evidence to support the use of IV 2-agonists.

Acute Asthma Care

Should IV aminophylline be used as first line drug for acute asthma? NO. IV aminophylline offers little benefit over 2-agonists and has a higher incidence of side effects.

Acute Asthma Care

Should systemic steroids be used in acute exacerbations of asthma? YES. The use of short course systemic steroids has been shown to shorten duration of attacks, prevent relapse, and reduce subsequent hospital admissions. The recommended dosage is 50mg IV q6 for 48 hours, followed by oral Prednisone.

Acute Asthma Care

In the treatment of acute exacerbations, are oral steroids as effective as parenteral steroids? YES. The recommended dose interval of oral steroids is every 12 hours.