1. Dr. Md. Khairul Hassan Jessy
Associate Professor
Respiratory Medicine
NIDCH,Mohakhali,Dhaka
Self Management of Asthma

9. Introduction
To define the self management plan
To highlight the importance
To discuss the detailed procedure
Conclusion

10. In the last few years there have been
remarkable progress and
outstanding improvement
in the management of Asthma

11. But sadly, many patients of
developing countries are getting
unplanned
&
unscientific management

12. With
education, caution &
medication most cases of
asthma can be effectively managed

13. History
 Asthma was first recognized in
ancient Egypt
&
treatment was
inhalation of frankincense
Source : Wikipedia

15. History…..
 It was first
recognized as a
specific respiratory
problem &
named by
Hippocrates

16. History…..

17. History…
 The most recent advancement
is
Combination of ICS & LABA with
Adjustable Maintenance Dose (AMD)
or
Single Maintenance And Reliever Therapy
(SMART)

19. Asthma is a
chronic inflammatory disease affecting
the airways with typical symptoms of
cough, wheezing, breathlessness
& chest tightness

20. Unified definition
 Asthma is a chronic inflammatory disorder
 causing hyper-responsiveness of the airways to certain
stimuli
 resulting in recurrent variable airflow limitation
 at least partially reversible with treatment or spontaneously
 manifested as shortness of breath, wheeze, cough and
chest tightness

21. It is not a curable disease
But to a large extent
It is
controllable like Diabetes & Hypertension

22. It is not a curable disease
But to a large extent
It is
controllable like Diabetes & Hypertension

23. Use of
anti- inflammatory preventive drugs
for 2-5 years may lead to
Complete Remission in
60 – 80 % of Childhood asthma
20 – 30 % of Adult asthma

24. But many serious episodes can
be avoided by
proper education and
care at home

25. Pharmacological management
& Medicines of Asthma

27. Pharmacological management of Asthma…
The mainstay of asthma therapy is the
use of inhaled drugs
the advantages of this method are that drugs are
delivered direct to the airways and
avoid passage to the liver

28. Pharmacological management of Asthma…
thus lower doses are necessary and systemic
unwanted effect are minimized
The drugs used in asthma should be given in a
stepwise fashion according to the severity and
frequency of the attacks

29. Medicines of Asthma:
Medicine used to treat asthma are basically three
types
A) Relievers
B) Preventers
C) Protectors

30. A) Relievers
These medicines relax smooth muscles that
have tightened around the airways.
They relieve asthma symptoms.

31. A) Relievers (Bronchodilators)…
1. Short acting β2-
agonists (SABA)
Salbutamol
Terbutaline
2. Short acting
Xanthenes' derivatives
Theophylline
Aminophylline
3. Anticholinergics Ipratropium bromide
Oxitropium bromide
Tiotropium

32. B) Protectors
These medicines are long acting bronchodilator
medicines
 which prevent the recurrence of attacks
particularly nocturnal symptoms.

33. B) Protectors (Symptom controllers)
1) Long acting β2 agonist
(LABA)
Salmeterol
Formoterol
2) Long acting Xanthene
derivatives
Theophylline
Aminophylline
3) Sustained released
Salbutamol

34. C) Preventers
medicines reduce or reverse the swelling in the
airways
These medicines also prevent the initiation of
inflammation after exposure to trigger factors
Thereby they prevent asthma episodes

35. C) Preventers (Anti-inflammatory medicines)
I)Corticosteroids •Inhaled
•Oral
II) Cromones •Nedocromil sodium
•Sodium Cromoglycate
III) Xanthene derivatives •Aminophylline and
•Theophylline
IV) Antileukotrienes •CysLT-1 receptor inhibitor:
•Montelukast and
•Zafirlukast
•Enzyme inhibitor: Zileuton

36. Newer and Disease modifying Drugs
Newer Drugs
Omalizumab (Xoliar)
Magnesium Sulfate
Frusemide
Ciclesonide

37. Newer and Disease modifying Drugs…
Disease modifying agents
Methotraxte,
Cyclosporin-A &
Gold-salts

38. OMALIZUMAB (XOLIAR)
Considerations for IgE blocker Therapy
Monoclonal anti-IgE ab preparation
Inhibit binding of IgE to mast cell – does not
provoke mast cell degranulation

39. OMALIZUMAB (XOLIAR)
Considerations for IgE blocker Therapy…
 Patient at least 12 years of age
 Evidence of reversible disease (such as 12% or
greater improvement in FEV1 with at least a 200-
ml increase
 or 20% or greater improvement in PEF)
 IgE level ≥ 30 IU/ml

40. OMALIZUMAB (XOLIAR)
Considerations for IgE blocker Therapy…
 Systemic corticosteroids or high-dose inhaled
corticosteroids required to maintain adequate control
 As directly observable therapy in patients who are not
adherent to prescribed therapy

41. OMALIZUMAB (XOLIAR)
Considerations for IgE blocker Therapy…

43. An overview of asthma triggers

50. Asthma Triggers…
 A trigger is anything that irritates the airways
and causes the symptoms of asthma
 Normal healthy person is not bothered by those
triggers

51. Asthma Triggers…
Everyone's asthma is different and you may have
several triggers
An important aspect of controlling your asthma is
avoiding your triggers
It may be impossible to avoid all of your triggers

52. Asthma Triggers…
 but once you've identified them
 there are things you can do to help you to reduce
unnecessary symptoms and
better control of your asthma

53. Unhealthy indoor environment for
asthma patient

54. Asthma Triggers…
Why To identify asthma triggers?
To prevent some asthma attacks
To reduce the frequency and severity of some
attacks

55. The patient is trying to control
his asthma without removing
trigger factor

56. Asthma Triggers…
Detection of trigger by monitoring the lung
function

58. To control asthma, PEP (Positive Expiratory
Pressure) is so important that if they are
educated properly, then-
73% of hospital admission from acute attack
of asthma can be reduced and
80% of death from asthma can be prevented

60. Effortless easy breathing
- is our goal
24 hours a day
30 days a month
12 months a year
-with an intention for full remission

62. Non- Pharmacological
- Education
- Caution
Pharmacological
- Medications used in management

63. We should educate our people
in their own language
Based on
- our scientific knowledge
- less scientific terminology
- less comprehensive patho-physiology

64. GINA aims
GINA guidelines
published
Implementation
GINA guidelines
How are we
doing?

65. Patients? Physicians?
Healthcare
system?
Asthma control
Who is responsible for asthma
control?
Researchers?

66. 41.1
14.5
35.4
Asia PacificEuropeUSA
% of patients
100
0
80
60
20
40
Rabe et al. Eur Respir J 2000;
www.asthmainamerica.com;
Lai et al. J Allergy Clin Immunol 2003
Patients with persistent asthma receiving controller therapy

68. Asthma control in practice was poor
Doctors didn't follow
 guidelines,
 underestimate severity and
 may confuse severity with control

69. Patients underestimate
the severity of their own disease
Guidelines were complex and can be difficult
to follow
Only 5% of patients achieved GINA-defined
control

70. Control of asthma means, patient-
is almost asymtomatic
can perform normal daily activities
requires reliever bronchodilator(sulbutamol
inhalation)<1 time a day

71. is free of nocturnal symptoms; if occurs , less
than two times per month
has PEFR reading >80% of personal best result
has <10% diurnal variability in Peak Flow Chart,
if available

72.  has no history of emergency visit to doctors
or hospitals
 has no or minimal side effects of medication

73. If we educate our patient properly
Then patient will cautiously avoid allergens
to control bronchial asthma
They will use their medications with an
intension to get remission

74. Includes –
Home Management
- of stable asthma
Emergency Management
-Loss of control of asthma
-Difficult to treat asthma

75. Asthma is a chronic disease and it should be
managed at home, except severe acute asthma
 If home management plan is applied intelligently
and skillfully most asthmatics can lead a
symptom-free near-normal life
 They may avoid hospitalization thereby
decreasing the financial expenditure significantly

76. There are two types of plans
 without self-management plan
 with guided self-management plan

77.  The patient is educated
 Appropriate precautionary measures
are advised
 “Step care management’’ is employed

78.  The prescription is quite inflexible
whatever be the condition
 patient will not increase the drugs
except β 2 agonist ( salbutamol )
inhaler
 Salbutamol inhaler may be taken as per
need upto 4-6 times / day

81. Development of a guide on the basis of
best Peak Flow is known as guided self
management plan.
Patient will measure his lung function with
the help of a peak flow meter and on the
basis of best peak flow results, patients will
modify their treatment.

82. Peak Flow Meter

83.  lead a symptom free near normal life
 avoid many serious episodes of acute
asthma &
 Chances of mortality and morbidity is
reduced considerably

84.  Time consuming
 More laborious
 Needs patient compliance

85. Flow meters are devices to measure
the strength of airways (force of
inspiration and expiration)

86. Types of flow meters are
 Peak expiratory flow meter ( peak flow
meter)
 Incentive Spirometer
 Peak inspiratory flow meter ( PIF )

87.  The measurement of peak expiratory
flow was pioneered by Martin Wright
 who produced the first meter to
measure lung function

88.  The original design of instrument was
introduced in the late 1950s
 and the subsequent development of a more
portable, lower cost version is the "Mini-
Wright" peak flow meter

90. Who Should Use a Peak Flow Meter?
People with moderate-to-severe asthma should have a
peak flow meter at home.
Even Peak flow meters are very helpful if a child have
moderate to severe asthma and require daily asthma
medications.
Most children ages 6 and up may be able to use a
peak flow meter.

91. PEF(Peak expiratory flow):
It is the highest flow one can achieve
during forceful expiration

92. The peak flow meter
measures how fast air comes out of
the lungs when a person exhale
forcefully after inhaling fully

93. Inexpensive, portable & handy device.
Only measures the amount of airflow out of the large
airways of the lungs.
Small airways (which also occur with asthma) will not
be detected by a peak flow meter.
Depends on a patient's sex, age and height.

95.  Move the marker to the bottom of the
numbered scale.
 Stand up if you're able.
 Take a deep breath, filling your lungs
completely.
 Place your lips tightly around the mouthpiece.

96.  Blow as hard and as fast as you can with a single
breath.
 Note the final position of the marker. This is
your peak flow rate.
 Follow the steps above then blow into the peak
flow meter two more times.
 Best of 3 blows is recorded.

99. To recognize early changes that may be signs of
worsening asthma and thus preventing asthma attack.
During an asthma attack, the muscles in the airways
tighten and cause the airways to narrow.
The peak flow meter alerts you to the tightening of
the airways often hours or even days before the
development of asthma symptoms.

100. By following the steps in asthma action plan,
patient may be able to
stop the narrowing of the airways
quickly and
avoid a severe asthma emergency

101. Mainly Used to find out
 early asthma attack (long before the
onset of symptoms) &
 by doubling the medicine a
serious episode can be avoided
 Used as a short term monitoring tool at
Doctor’s chamber & emergency room
during exacerbations

102. Long term monitoring of asthma
at patient’s home
by maintaining peak flow chart
essential for constructing self
management plan

103. Can also be used to see
whether the management plan is
working or not
 to decide when to add or stop
medicine
 to decide when the patient seeks
emergency care
 to identify triggers

104. By using own PEF with his/her asthma action
plan, he/she will know when to take his/her
rescue asthma inhaler or other asthma
medicine.

105. Diurnal variability =
(highest PEF – lowest PEF)X100
highest PEF

106. How to take care of Peak Flow
Meter?
Most peak flow meters require
weekly cleaning with warm water
and a mild detergent.

107. PEF varies throughout the day.
In a person who does not have asthma, it may
vary between 10% and 15%.
 In a person who has poorly controlled asthma,
it may vary more than 20%.

108. Peak Flow Chart

109. Peak Flow Chart

111. The highest peak flow measurement of a patient
achieved over a two week period when patient’s
asthma is totally/ well controlled
“Self management plan” needs to be constructed
depending on his own personal best peak flow value
A person's personal best is his or her highest peak flow.

112. Determine by taking readings over 2 weeks
when the asthma is under control.
Should be recorded at least twice daily.
Best is usually reached in the evening.
Never measured during an asthma attack.

113. Patient will-
Record his personal best peak flow result in the
prescribed peak flow diary or chart
3 zones will be demarcated in the diary
Take peak flow reading every morning on
waking up and night at bedtime
Peak flow readings should be taken at the same
time each day
They will also write down if they were exposed
to any trigger factor’s initiating an attack.

114. Patient will-
 Peak expiratory flow is lowest in the early
morning and highest in the afternoon.
 If patient wants to take the test only one time
during the day, they should take it first in the
morning, before using a bronchodilator
medicine.
 note how many times they took extra
reliever asthma medicine to stop their
symptoms every day

115. ( 3 basic steps )( 3 basic steps )
Step 1Step 1
Patient will measure the lung function
with peak flow meter & maintain a
peak flow chart

116. ( 3 basic steps )
Step 2
With this chart - patient’s personal
best peak flow result is
determined
On that basis readings are recorded in a
chart with 3 color zones :
Green,Yellow, Red

117. Peak Flow Chart

118. ( 3 basic steps )
Step 3
Physician will develop one
prescription for each zone
Patient is educated to modify drugs
up to a certain limit

119. Peak Flow Zone System

120. 3 traffic light colors are used to measure the
control of asthma
Green
Yellow
Red

122. Green zone indicates
well controlled asthma

123. Green zone ( safety zone )
peak flow 100 - 80 % of personal best
no/minimal symptoms
maintenance therapy continues
inhaled β 2 agonists may be used in some specific
situations
( before exercise / mild symptoms)

124. Yellow zone ( zone of alert )
- PEF is < 80 –> 60 % of personal best
o Asthma symptoms –
cough ( nocturnal )
breathlessness
wheezing may be present

125. Yellow zone ( zone of alert )…
suggestive of –
 Acute exacerbation or gradual deterioration of
severity of asthma
 Consultation with physician is needed .
 Patient will double his preventer drug and take one or
two oral protector drugs.

126.  Red zone ( zone of emergency )
This signals a medical alert
o PEF is < 60 % of personal best
o Asthma symptoms are present at rest and
interferes activity
o β 2 agonist should be taken immediately
o patient will start rescue oral steroid &
o should contact the physician ( may need
hospitalization )

127. Red Zone means
Along with prescription of yellow Zone
 patient will start rescue oral steroid and
 should contact a physician immediately

128. Scenario 1:
Mr. X , 45 years - known case of bronchial
Asthma & Allergic Rhinitis
 Personal best peak flow result
=500L/min
 Present PEFR = 420 l/min
Questions:
1.PEF Zone?
2.What treatment to be given?

129. Ans. 1. Green Zone
2.Rx
Inhaler Fluticasone/Salmaterol (125/25)
2 puffs 12 hourly (contd) (gargle after use)
Inhaler Salbutamol
2 puffs SOS
Tab. Montelukast 10 mg
0+0+1(contd)
Tab. Fexofenadine 120/Rupatidine 10
0+0+1 SOS
Fluticasone nasal spray
2 puffs once daily in the morning (sos)

130. Scenario 2:
Mr. X , 45 years - known case of bronchial
Asthma & Allergic Rhinitis
Personal best peak flow result=500L/min
Present PEFR = 350 l/min
Questions:
1.PEF Zone?
2.What treatment to be given?

131. Ans. 1.Yellow Zone
2.Rx:
Inhaler Fluticasone/Salmaterol(250/25)
2 puffs 12 hourly (contd)(gargle after use)
Inhaler Salbutamol
2 puffs sos
Tab. Montelukast 10 mg
0+0+1(contd)
Tab. Fexofenadine 120/Rupatidine 10
0+0+1 sos
Theophylline S.R.(200 mg)
0+0+1 (contd)
Fluticasone nasal spray
2 puffs once daily in the morning (contd)

132. Scenario 3:
Mr. X , 45 years - known case of bronchial
Asthma & Allergic Rhinitis
 Personal best peak flow result = 500 L/min
 Present PEFR = 150 l/min
Questions:
1.PEF Zone?
2.What treatment to be given?

133. Ans. 1.Red Zone
2.Rx
Tab. Prednisolone (20 mg)
2+0+0 (after meal) 7 days
Tab. Esomoprazole (20 mg)
1+0+1
+treatment of yellow zone
(to contact physician immediately)

134. Asthma is not a curable disease
But total/well control is possible in almost all
cases by
oproper Education
otaking Caution ( regarding
environmental control )&
oNeed for Medication.

135. Asthma is a chronic disease and it
should be managed at home except
severe acute asthma

138. THANKTHANK
YOU !YOU !