G lobal

INitiative for
A sthma
 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 reversible
airflow limitation
Asthma Inflammation: Cells and
Mediators

Source: Peter J. Barnes, MD

Mechanisms: Asthma
Inflammation

Source: Peter J. Barnes,

MD
Asthma Inflammation: Cells and
Mediators

Source: Peter J. Barnes,

MD
 Burden of Asthma

 Asthma is one of the most common chronic

diseases worldwide with an estimated 300
million affected individuals
 Prevalence increasing in many countries,
especially in children
 A major cause of school/work absence
 Burden of Asthma

 Health care expenditures very high

 Developed economies might expect to
spend 1-2 percent of total health care
expenditures on asthma. Developing
economies likely to face increased demand
 Poorly controlled asthma is expensive;
investment in prevention medication likely
to yield cost savings in emergency care
Asthma Prevalence and Mortality

Source: Masoli M et al. Allergy 2004

Countries should enter their
own data on burden of
asthma.
 Risk Factors for Asthma

 Host factors: predispose individuals to,

or protect them from, developing
asthma
 Environmental factors: influence
susceptibility to development of asthma
in predisposed individuals, precipitate
asthma exacerbations, and/or cause
symptoms to persist
 Factors that Exacerbate Asthma

 Allergens
 Respiratory infections
 Exercise and hyperventilation
 Weather changes
 Sulfur dioxide
 Food, additives, drugs
 Factors that Influence Asthma
Development and Expression

Host Factors Environmental Factors

 Indoor allergens
 Genetic
 Outdoor allergens
- Atopy
 Occupational sensitizers
- Airway
 Tobacco smoke
hyperresponsiveness
 Air Pollution
 Gender
 Respiratory Infections
 Obesity  Diet
 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
 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
 Extra measures may be required to
diagnose asthma in children 5 years and
younger and the elderly
 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
Measuring Variability of
Peak Expiratory Flow
Measuring Airway
Responsiveness
 Clinical Control of Asthma

 No (or minimal)* daytime symptoms

 No limitations of activity
 No nocturnal symptoms
 No (or minimal) need for rescue
medication
 Normal lung function
 No exacerbations
_________
 Levels of Asthma Control
Controlled Partly controlled
Characteristic Uncontrolled
(All of the following) (Any present in any week)

None (2 or less / More than

Daytime symptoms
week) twice / week
Limitations of 3 or more
None Any
activities features of
Nocturnal partly
symptoms / None Any controlled
awakening asthma
present in
Need for rescue / None (2 or less / More than
any week
“reliever” treatment week) twice / week
< 80% predicted or
Lung function
Normal personal best (if
(PEF or FEV1)
known) on any day

Exacerbation None One or more / year 1 in any week

Asthma Management and Prevention
Program: Five Components

1. Develop Patient/Doctor
Partnership
2. Identify and Reduce
Exposure to Risk Factors
3. Assess, Treat and Monitor
Asthma
4. Manage Asthma
Exacerbations
Revised
2006

5. Special Considerations
 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
 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
 Asthma Management and
Prevention Program
.
 Asthma can be effectively controlled in
most patients by intervening to suppress
and reverse inflammation as well as
treating bronchoconstriction and 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.
 Asthma Management and
Prevention Program

 Although there is no cure for

asthma, appropriate management
that includes a partnership
between the physician and the
patient/family most often results
in the achievement of control
 Asthma Management and Prevention Program
Component 1: Develop
Patient/Doctor 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
 Asthma Management and Prevention Program
Component 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
 Asthma Management and Prevention Program
Component 1: Develop
Patient/Doctor Partnership

Key factors to facilitate communication:

 Friendly demeanor
 Interactive dialogue
 Encouragement and praise
 Provide appropriate information
 Feedback and review
 Example Of Contents Of An Action Plan To Maintain Asthma Control
Your Regular Treatment:
1. Each day take ___________________________
2. Before exercise, take _____________________

WHEN TO INCREASE TREATMENT

Assess your level of Asthma Control
In the past week have you had:
Daytime asthma symptoms more than 2 times ? No Yes
Activity or exercise limited by asthma? No Yes
Waking at night because of asthma? No Yes
The need to use your [rescue medication] more than 2 times? No Yes
If you are monitoring peak flow, peak flow less than________? No Yes
If you answered YES to three or more of these questions, your asthma is uncontrolled and you may need
to step up your treatment.

HOW TO INCREASE TREATMENT

STEP-UP your treatment as follows and assess improvement every day:
____________________________________________ [Write in next treatment step here]
Maintain this treatment for _____________ days [specify number]

WHEN TO CALL THE DOCTOR/CLINIC.

Call your doctor/clinic: _______________ [provide phone numbers]
If you don’t respond in _________ days [specify number]
______________________________ [optional lines for additional instruction]

EMERGENCY/SEVERE LOSS OF CONTROL

If you have severe shortness of breath, and can only speak in short sentences,
If you are having a severe attack of asthma and are frightened,
If you need your reliever medication more than every 4 hours and are not improving.
1. Take 2 to 4 puffs ___________ [reliever medication]
2. Take ____mg of ____________ [oral glucocorticosteroid]
3. Seek medical help: Go to _____________________; Address___________________
Phone: _______________________
4. Continue to use your _________[reliever medication] until you are able to get medical help.
 Asthma Management and Prevention Program
Factors Involved in Non-Adherence

Medication Usage Non-Medication Factors

 Difficulties associated
with inhalers
 Complicated regimens
 Fears about, or actual
side effects
 Cost
 Distance to pharmacies
 Misunderstanding/lack of
information
 Fears about side-effects
 Inappropriate expectations
 Underestimation of severity
 Attitudes toward ill health
 Cultural factors
 Poor communication
 Asthma Management and Prevention Program
Component 2: Identify and Reduce
Exposure 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.
 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, especially in children and
young infants
 Asthma Management and Prevention Program
Influenza Vaccination

 Influenza vaccination should be

provided to patients with asthma when
vaccination of the general population is
advised
 However, routine influenza vaccination
of children and adults with asthma
does not appear to protect them from
asthma exacerbations or improve
asthma control
 Asthma Management and Prevention Program

Component 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
 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 five
treatment steps
 Treatment is adjusted in a continuous
cycle driven by changes in asthma
control status. The cycle involves:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control
 Asthma Management and Prevention Program

Component 3: Assess,
Treat and Monitor Asthma
 A stepwise approach to pharmacological
therapy is recommended
 The aim is to accomplish the goals of
therapy with the least possible medication
 Although in many countries traditional
methods of healing are used, their efficacy
has not yet been established and their use
can therefore not be recommended
 Asthma Management and Prevention Program

Component 3: Assess,
Treat and Monitor Asthma
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 care
systems need to be considered
 Levels of Asthma Control

Characteristic Controlled Partly controlled Uncontrolled

(Any present in any week)

None (2 or less / More than

Daytime symptoms
week) twice / week
Limitations of 3 or more
None Any
activities features of
Nocturnal partly
symptoms / None Any controlled
awakening asthma
present in
Need for rescue / None (2 or less / More than
any week
“reliever” treatment week) twice / week
< 80% predicted or
Lung function
Normal personal best (if
(PEF or FEV1)
known) on any day

Exacerbation None One or more / year 1 in any week

 Asthma Management and Prevention Program

Component 3: Assess,
Treat and Monitor Asthma
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 care
systems need to be considered
 Component 4: Asthma Management and Prevention Program

Controller Medications
 Inhaled glucocorticosteroids
 Leukotriene modifiers
 Long-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Theophylline
 Cromones
 Long-acting oral β2-agonists
 Anti-IgE
 Systemic glucocorticosteroids
 Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose (µg) Medium Daily Dose (µg) High Daily Dose (µg)
> 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- 600-1000 >200-400 >1000 >400

200

Budesonide-Neb 250- >500- >1000

Inhalation Suspension 500 1000

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

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

750
Fluticasone 100-250 100- >250-500 >200-500 >500 >500
200
Mometasone furoate 200-400 100- > 400-800 >200-400 >800-1200 >400
200

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

800
 Component 4: Asthma Management and Prevention Program

Reliever Medications

 Rapid-acting inhaled β2-agonists

 Systemic glucocorticosteroids
 Anticholinergics
 Theophylline
 Short-acting oral β2-agonists
 Component 4: Asthma Management and Prevention Program
Allergen-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 environmental avoidance and
pharmacologic intervention, including inhaled
glucocorticosteroids, have failed to control
asthma
 Perform only by trained physician
 REDUCE
LEVEL OF CONTROL TREATMENT OF ACTION

maintain and find lowest

controlled
controlling step
consider stepping up to
partly controlled gain control

INCREASE
uncontrolled step up until controlled

exacerbation treat as exacerbation

REDUCE INCREASE
TREATMENT STEPS
STEP STEP STEP STEP STEP
1 2 3 4 5
 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)
 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
 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)
 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)
 Treating to Achieve Asthma
Control
Step 4 – Reliever medication plus two or more
controllers
 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 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)
 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)
 Treating to Maintain Asthma
Control

 When control as been achieved,

ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
 Asthma control should be monitored
by the health care professional and
by the patient
 Treating to Maintain Asthma
Control
Stepping down treatment when asthma is controlled

 When controlled on medium- to high-

dose inhaled glucocorticosteroids: 50%
dose reduction at 3 month intervals
(Evidence B)
 When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily
dosing (Evidence A)
 Treating to Maintain Asthma
Control
Stepping down treatment when asthma is controlled
 When controlled on combination inhaled
glucocorticosteroids and long-acting
inhaled β2-agonist, reduce dose of inhaled
glucocorticosteroid by 50% while
continuing the long-acting β2-agonist
(Evidence B)
 If control is maintained, reduce to low-
dose inhaled glucocorticosteroids and
stop long-acting β2-agonist (Evidence D)
 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
 Treating to Maintain Asthma
Control
Stepping up treatment in response to loss of control
 Use of a combination rapid and long-acting
inhaled β2-agonist (e.g., formoterol) and an
inhaled glucocorticosteroid (e.g., budesonide)
in a single inhaler both as a controller and
reliever is effecting 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
Component 3: Assess, Treat and
Monitor Asthma – Children 5 Years
and Younger

Childhood and adult asthma share the

same underlying mechanisms.
However, because of processes of
growth and development, effects of
asthma treatments in children differ
from those in adults.
 Asthma Management and Prevention Program
Component 3: Assess, Treat and
Monitor Asthma – Children 5 Years
and Younger

Many asthma medications (e.g.

glucocorticosteroids, β2- agonists,
theophylline) are metabolized faster in
children than in adults, and younger
children tend to metabolize medications
faster than older children
 Asthma Management and Prevention Program
Component 3: Assess, Treat and
Monitor Asthma – Children 5 Years
and Younger

 Long-term treatment with inhaled

glucocorticosteroids has not been shown
to be associated with any increase in
osteoporosis or bone fracture
 Studies including a total of over 3,500
children treated for periods of 1 – 13 years
have found no sustained adverse effect of
inhaled glucocorticosteroids on growth
 Asthma Management and Prevention Program
Component 3: Assess, Treat and
Monitor Asthma – Children 5 Years
and Younger

 Rapid-acting inhaled β2-agonists are the

most effective reliever therapy for
children
 These medications are the most
effective bronchodilators available and
are the treatment of choice for acute
asthma symptoms
 Asthma Management and Prevention Program
Component 4: Manage Asthma
Exacerbations

 Exacerbations of asthma are episodes of

progressive increase in shortness of breath,
cough, wheezing, or chest tightness
 Exacerbations are characterized by decreases
in expiratory airflow that can be quantified and
monitored by measurement of lung function
(FEV1 or PEF)
 Severe exacerbations are potentially life-
threatening and treatment requires close
supervision
 Asthma Management and Prevention Program
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
 Asthma Management and Prevention Program
Component 4: Manage Asthma
Exacerbations

Primary therapies for exacerbations:

• Repetitive administration of rapid-acting inhaled
β2-agonist
• Early introduction of systemic
glucocorticosteroids
• Oxygen supplementation
Closely monitor response to treatment with serial
measures of lung function
 Asthma Management and Prevention Program
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
 Asthma Management and
Prevention Program: Summary

 Asthma can be effectively controlled in most

patients by intervening to suppress and reverse
inflammation as well as treating
bronchoconstriction and related symptoms
 Although there is no cure for asthma,
appropriate management that includes a
partnership between the physician and
the patient/family most often results in
the achievement of control
 Asthma Management and
Prevention Program: Summary

 A stepwise approach to pharmacologic

therapy is recommended. The aim is to
accomplish the goals of therapy with the
least possible medication

 The availability of varying forms of

treatment, cultural preferences, and
differing health care systems need to be
considered
Alternate Slides for
Asthma Treatment
 Levels of Asthma Control
Characteristic Controlled Partly Controlled Uncontrolled
(All of the (Any measure
following) present in any
week)
Daytime symptoms None (twice or More than twice/week
less/week)
Limitations of None Any
activities Three or more
features of
Nocturnal None Any partly
symptoms/awakeni controlled
ng asthma
Need for reliever/ None (twice or More than twice/week
less/week) present in any
rescue treatment
week
Lung function (PEF Normal < 80% predicted or
or FEV1) personal best (if known)

Exacerbations None One or more/year* One in any week†

* Any exacerbation should prompt review of maintenance treatment to ensure that it

is adequate.
† By definition, an exacerbation in any week makes that an uncontrolled asthma week.
Asthma Control: Treatment Steps
Children Older than Five Years, Adolescents, Adults
 Example Of Contents Of An Action Plan To Maintain Asthma Control
Your Regular Treatment:
1. Each day take ___________________________
2. Before exercise, take _____________________

WHEN TO INCREASE TREATMENT

Assess your level of Asthma Control
In the past week have you had:
Daytime asthma symptoms more than 2 times ? No Yes
Activity or exercise limited by asthma? No Yes
Waking at night because of asthma? No Yes
The need to use your [rescue medication] more than 2 times? No Yes
If you are monitoring peak flow, peak flow less than________? No Yes
If you answered YES to three or more of these questions, your asthma is uncontrolled and you may need
to step up your treatment.

HOW TO INCREASE TREATMENT

STEP-UP your treatment as follows and assess improvement every day:
____________________________________________ [Write in next treatment step here]
Maintain this treatment for _____________ days [specify number]

WHEN TO CALL THE DOCTOR/CLINIC.

Call your doctor/clinic: _______________ [provide phone numbers]
If you don’t respond in _________ days [specify number]
______________________________ [optional lines for additional instruction]

EMERGENCY/SEVERE LOSS OF CONTROL

If you have severe shortness of breath, and can only speak in short sentences,
If you are having a severe attack of asthma and are frightened,
If you need your reliever medication more than every 4 hours and are not improving.
1. Take 2 to 4 puffs ___________ [reliever medication]
2. Take ____mg of ____________ [oral glucocorticosteroid]
3. Seek medical help: Go to _____________________; Address___________________
Phone: _______________________
4. Continue to use your _________[reliever medication] until you are able to get medical help.