2. Guidelines for management of
asthma
GlobalINitiative for
Asthma (updated
Dec 2008)

3. Guidelines for management of
asthma
The British Thoracic
Society/Scottish
Intercollegiate
Guidelines Network
British Guideline on
the Management of
Asthma (updated
May 2008)

4. About asthma…
One of the most chronic diseases, with
an estimated 300 million individuals
affected worldwide
Prevalence is increasing especially among
children

5.  Asthma is a chronic inflammatory
disorder of the airways
 Chronically inflamed airways are
hyperresponsive, they become
obstructed and airflow is limited by
 Bronchoconstriction
 Mucus plug
 Increased inflammation
 when airways are exposed to various risk
factors

6. A stepwise approach to pharmacologic
treatment to achieve and maintain
control of asthma should take into
account the safety of treatment, potential
for adverse effects and the cost of
treatment
Controller medication must be taken
daily and reliever medication may
occasionally be used to treat acute
symptoms

7. Diagnosis
GINA 2008

8. Diagnosis
Spirometry
preferred method of measuring airflow
limitation and its reversibility to establish
a diagnosis of asthma.
An increase in FEV of >12% and 200 ml
1
after administration of a bronchodilator
indicates reversible airflow limitation
consistent with asthma.
GINA 2008

9. Diagnosis of asthma in children
 Initial clinical assessment
 Clinical features that increase the probability
of asthma:
 >1 of these symptoms: wheeze, cough,
difficulty breathing, chest tightness
 Personal history of atopy
 FH of atopy
 Widespread wheeze on auscultation
 History of improvement in symptoms or lung
function in response to adequate therapy
BTS guideline 2008

10. Diagnosis of asthma in children
 Initial clinical assessment:
 Clinical features that lower the probability of asthma
 Symptoms with colds only with no interval symptoms
 Isolated cough in the absence of wheeze/difficulty
breathing
 History of moist cough
 Prominent dizziness, light-headedness, peripheral
tingling
 Repeatedly normal physical exam of chest when
symptomatic
 Normal PEF or spirometry when symptomatic
 No response to trial of asthma therapy
 Clinical features pointing to alternative diagnosis
BTS guideline 2008

11.  The child can be classified into
 High probability of asthma  start a trial of
treatment
 Low probability of asthma  consider more
detailed investigation and specialist referral
 Intermediate probability of asthma
 perform spirometry and assess the change in
FEV1 or PFR in response to an inhaled
bronchodilator (reversibility)
If the child cannot perform spirometry,
consider treat as asthma and review, consider
other condition +/- refer to specialist
BTS guideline 2008

12. Remember…
The diagnosis of asthma in children is a
clinical one.
Based on recognizing a characteristic
pattern of episodic symptoms in the
absence of an alternative explanation
BTS guideline 2008

13. BTS guideline 2008

14. Classification of asthma control
GINA 2008

15. 4 components of asthma care
1. develop doctor/patient relationship
2. identify and reduce exposure to risk
factors
3. Assess, treat and monitor asthma
4. Manage asthma exacerbations
GINA 2008

16. Component 1: develop doctor-
patient relationship
 Patients should learn to:
 Avoid risk factors
 Take drugs regularly
 Understand the difference between
“controller” and “reliever” medications
 Monitor the status using symptoms and if
relevant, PFR
 recognize signs that asthma is worsening and
take action
 Seek medical help as appropriate

17. Component 2: identify and reduce
exposure to risk factors
Exercise may lead to asthmatic symptoms
but patients should not avoid exercise
but use beta agonist as prophylaxis
instead
Advice patient with moderate to severe
asthma to have influenza vaccine every
year

18. Component 2: identify and reduce
exposure to risk factors
 Avoidance that improve the control of
asthma:
 Tobacco smoke
 Drugs, food and addictives
 Occupational sensitizers
 Reasonable avoidance measures can be
recommended but have not been shown to
have clinical benefit:
 House dust mites, animals with fur, cockroaches,
outdoor pollens and mild, indoor mold

19. Component 3: assess, treat and
monitor asthma
Assess:

20. Component 3: assess, treat and
monitor asthma
Treatment: GINA 2008

21. Stepwise treatment
Step 1:
No need for controller
Reliever: rapid acting beta 2 agonist

22. Step 2:
Controller:
◦ low dose inhaled corticosteroid
◦ Leukotriene modifier
Reliever:
◦ Rapid acting beta 2 agonist

23.  Step 3:
 Controller:
 low dose inhaled corticosteroid + long acting
beta 2 agonist
 Medium or high dose ICS
 Low dose ICS + leukotriene modifier
 Low dose ICS plus SR theophylline
 Reliever:
 Rapid acting beta 2 agonist

24.  Step 4:
 Controller:
 Medium/high dose inhaled corticosteroid +
long acting beta 2 agonist
 Add one or more:
 leukotriene modifier
 SR theophylline
 Reliever:
 Rapid acting beta 2 agonist

25. Step 5:
Controller:
◦ Controller as in step 4, add one or more:
◦ Oral glucocorticosteriod (lowest dose)
◦ Anti-IgE treatment
Reliever:
◦ Rapid acting beta 2 agonist

26. Component 3: assess, treat and
monitor asthma
Monitoring:
Typicallypatients should be seen 1-3
months after the initial visit, and every 3
months thereafter
After an exacerbation, FU within 2-4
weeks

27. Adjusting medication
 If asthma is not well controlled: step up
treatment and improvement should be seen
within 1 month
 Review the patient’s medication technique,
compliance and avoidance of risk factors
 Partly controlled: consider stepping up
treatment considering the safety, cost,
effectiveness of treatment and the patient’s
satisfaction
 If control is maintained for 3 months, step
down with gradual stepwise approach

28. GINA 2008

29. BTS guideline: Stepwise management in adults

30. BTS guideline: Stepwise management in children 5-12 year old

31. BTS guideline:Stepwise management in children<5 year old

32. Relievers
Short acting beta 2 agonists
Anticholinergics
Short acting theophylline

33. Reliever
Short acting beta 2 agonists
Salbutamol (Ventolin)
Terbutaline (Bricanyl) – tablet/injection
SE:
◦ Tachycardia, tremor, headache, irritability
◦ At very high dose hyperglycaemia,
hypokalemia
◦ Systemic administration increase risk of SE

34. Reliever
Anticholinergics:
Ipratropium bromide (Atrovent)
SE: minimal dry mouth or bad taste in the
mouth
May provide addictive effect to beta
agonist but slower onset

35. Reliever
Short acting theophylline
Aminophylline (7mg/kg loading over
20min then 0.4mg/kg/hr infusion)
SE:
◦ Nausea, vomiting, headache
◦ Higher serum concentration: seizure,
tachycardia, arrhythmia
◦ Require level monitoring

36. Controllers
Inhaled corticosteroid (ICS)
Oral steroid
Sodium cromoglycate
Long acting beta 2 agonist
Combination ICS/LABA
SR theophylline
Antileukotriene
Immunomodulators

37. Inhaled corticosteroid
 Beclotide (beclomethasone dipropionate
50mcg/dose)
 Becloforte (beclomethasone dipropionate
250mcg/dose)
 Beclazone (beclomethasone easi-breathe
100mcg/dose or 250mcg/dose)
 Pulmicort (budesonide 100mcg/dose or
200mcg/dose)
 Flixotide (fluticasone propionate)
 In accuhaler or inhaler

38. Inhaled corticosteroid
SE:
High daily doses may be associated with
skin thinning, bruises, and adrenal
suppression
Hoarseness, oral candidasis
Growth delay or supression in children
(average 1cm)

39. Inhaled corticosteriod

40. LABA
Salmeterol (serevent)
Should not use as monotherapy for
controller therapy, always use as adjunct
to ICS
Not used in acute attack

41. Combines inhalers
 ICS + LABA
 Symbicort (budesonide + formoterol
turbuhaler 160/4.5mcg, 80/4.5mcg,
320/9mcg)
 Seretide (salmeterol + fluticasone 50/100mcg,
50/250mcg, 50/500mcg)
 Seretide lite (salmeterol + fluticasone
25/50mcg)
 Seretide medium (salmeterol + fluticasone
25/125mcg)
 Seretide forte (salmeterol + fluticasone
25/250mcg)

42. Controllers
SRtheophylline
Aminophylline
◦ Starting dose 10mg/kg/d with usual 800mg
max in 1-2 doses
◦ SE:
 nausea, vomiting,
 high serum concentration: seizure, tachycardia,
arrhythmia

43. Controllers
Antileukotrienes
Montelucast (Singulair)
Adult: 10mg daily
Children: 5mg daily
No specific SE to date

44. Controllers
Immunomodulators
AntiIgE
Omalizumab
Subcutaneous injection every 2-4 weeks

45. How to monitor asthma
control?
 Questions to ask the patient:
 Has your asthma awaken you at night?
 Have you needed more reliever medication
as usual?
 Have you needed any urgent medical care?
 Has your peak flow been below your
personal best?
 Are you participating in your usual physical
activities?

46. How to monitor asthma
control?
is the patient using the inhaler, spacer or
peak flow meters correctly?
Is the patient taking the medications and
avoiding risk factors according to the asthma
management risk factors according to the
asthma management plan?
Does the patient have any other concerns?

47. Component 4: manage
exacerbations
Signs and symptoms of severe attack:
◦ Breathless at rest,
◦ talks in words rather than sentences (infant
stops feeding),
◦ agitated, drowsy, or confuse
◦ Tachycardia (pulse>120) or Bradycardia
◦ Tachypnea
◦ PEF < 60% predicted
◦ Patient is exhausted

48. The response to the initial
bronchodilator treatment is not prompt
and sustained for at least 3 hours
There is no improvement within 2-6
hours after oral steroid
There is further deterioration

49. Treatment of acute attack
 Inhaled rapid-acting beta agonist
 begin with 2-4 puff q20min for the first hour, then mild
attack: 2-4 puff q3-4h
mod attack: 6-10 puff q1-2h
 Oral steroid 0.5-1mg prednisolone/kg/day
 Oxygen (keep SaO2>95%)
 combination of beta agonist/anticholinergic therapy is
associated with lower hospitalization rates and greater
improvement in PEF and FEV1
 Methylxanthines are not recommended together with
high doses of inhaled beta agonists. If patient is already
on theophylline daily, check level before adding short
acting theophylline

50. Therapies not recommended for
treating asthma attacks
 Sedatives
 Mucolytic drugs (may worsen cough)
 Chest physio (may increase patient discomfort)
 Hydration with large volume of fluid for adults
and older children (may be necessary for younger
children and infants)
 Antibiotics (do not treat attacks, only use when
pneumonia present)
 Epinephrine/adrenaline (may be indicated for
acute treatment of anaphylaxis and angioedema
but not indicated for asthma attacks)

52. Case 1
M/16, F.4 student
History of asthma on Becotide 2 puff BD
and prn Ventolin
How would you assess the control of
asthma?

53. He had more frequent cough and chest
tightness recently during the cold
weather and require to use Ventolin ~3
days per week
PE: occasional wheeze over bilateral
chest, AE fair
How would you manage him?

54. Case 2
3/M
Asthma on Becotide 400 mcg/d ( 2 puff
QID)
Persistently poor control with 2 attacks
in 3 months
Further management?

55. Case 3
M/5
Currently on Becotide (beclomethasone
dipronpionate) at 200mcg/d
Wheezing every morning when he wakes
up
Use Ventolin every morning
Further management?

56. Case 4
F/12
On Seretide 100 1 puff BD and prn
Ventolin
She has not been using Ventolin from last
FU 3 months ago
Further management?

57. Take home message…
Good asthma control:
Risk factor control
Compliance
Inhaler technique
Step up/down treatment as appropriate
Suitable treatment for acute exacerbation

58. Reference
GINA 2008
BTS guideline May 2008