Talk given by me at K S Hegde Medical College, Mangalore; on World Asthma Day

1. Management of Stable
Bronchial Asthma
Dr Subin Ahmed MD, FCCP
Assistant Professor
Department of Pulmonary Medicine
Yenepoya Medical College Hospital, Mangalore

2. WORLD ASTHMA DAY
May 1st 2012
‘You can control your Asthma’

3. COMPONENTS OF ASTHMA
MANAGEMENT
4 essential components
• Routine monitoring of symptoms and lung
function
• Patient education to create a partnership
between clinician and patient
• Controlling environmental factors (trigger
factors) and comorbid conditions that
contribute to asthma severity
• Pharmacologic therapy

4. GOALS OF ASTHMA TREATMENT
• 2 domains: Reduction in impairment and Reduction of risk
i. Reduce impairment:
• Impairment refers to the intensity and frequency of asthma
symptoms and the degree of limitation
1. Freedom from frequent or troublesome symptoms of asthma
(cough, chest tightness, wheezing, or shortness of breath),
including symptoms that disturb sleep
2. Minimal need (≤2 times per week) of inhaled short acting beta
agonists (SABAs) to relieve symptoms
3. Optimization of lung function
4. Maintenance of normal daily activities, including work or school
attendance and participation in athletics and exercise
5. Satisfaction with asthma care on the part of patients and families

5. GOALS OF ASTHMA TREATMENT
ii. Reduce risk
1. Prevention of recurrent exacerbations
and need for emergency department or
hospital care
2. Prevention of reduced lung growth in
children, and loss of lung function in
adults
3. Optimization of pharmacotherapy with
minimal or no adverse effects

6. Classification of asthma control (youth ≥ 12
years of age and adults)
Components of control
Well-controlled Not-well Very poorly
controlled controlled
Symptoms ≤ 2 days/week > 2 days/week Throughout day
I
Nighttime awakenings ≤ 2x/month 1-3x/week ≥ 4x/week
m Interference with normal None Some Limitation Extremely
p activity limited
a SABA use for symptom control ≤2days/week >2days/week Several times
i (not prevention of EIB) per day
r FEV1 or peak flow >80% predicted/ 60-80 % predicted/ < 60 predicted/
m personal best personal best personal best
e Validated Questionnaires
ATAQ 0 1-2 3-4
n
ACQ ≤0.75 ≥1.5 N/A
t ACT >20 16-19 ≤15
Exacerbations 0-1/year ≥2/year
R Progressive Loss of lung Evaluation requires long term follow-up care
function
i
Treatment related side effects Medication side effects can vary intensity from none to very
s troublesome. The level of intensity does not correlate to
k specific levels of control but should be considered in the
overall assessment of risk.

8. Classification of asthma severity (≥12 years of age)
Components of severity Persistent
Intermittent
Mild Moderate Severe
Impairment Symptoms ≤ 2 days/week > 2days/week but Daily Throughout day
not daily
• Normal Night-time ≤ 2x/month 3-4x/month >1x/week but not Often 7x/week
FEV1/FVC: awakenings nightly
8-19 yrs SABA use for ≤2days/week >2days/week but not Daily Several times per day
85 percent symptom control daily, and not more
• 20-39 yrs (not prevention than 1x on any day
80 percent of EIB)
• 40-59 yrs Interference with None Minor limitation Some limitation Extremely limited
75 percent normal activity
• 60-80 yrs Lung functions - Normal FEV1 - FEV1 ≥ 80 percent - FEV1>60 but <80 - FEV1/FVC reduced >
70 percent between predicted percent predicted 5 percent
exacerbation - FEV1/FVC normal - FEV1/FVC
- FEV1>80 percent reduced 5 percent
predicted
- FEV1/FVC normal
Risk Exacerbations 0-1/year ≥2/years
requiring oral Consider severity and interval since last exacerbation
systemic Frequency and severity may fluctuate over time for patients in any severity category
corticosteroids Relative annual risk of exacerbations may be related to FEV1
Recommended step for Step 1 Step 2 Step3 Step 4 or 5
initiating treatment And consider short course of oral systemic
corticosteroids
In 2-6 weeks, evaluate level of asthma control that is achieved and adjust therapy

9. Assessment of impairment
• Has your asthma awakened you at night or in the
early morning?
• Have you needed your quick-acting relief
medication more than usual?
• Have you needed any unscheduled care for your
asthma, including calling in, an office visit, or an
emergency department visit?
• Have you been able to participate in school/work
and recreational activities as desired?
• If you are measuring your peak flow, has it been
lower than your personal best?
• Have you had any side effects from your asthma
medications?

10. Assessment of risk
• Have you taken oral glucocorticoids for your
asthma in the past year?
• Have you been hospitalized for your asthma? If
yes, how many times have you been hospitalized
in the past year?
• Have you been admitted to the intensive care unit
or been intubated because of your asthma? If yes,
did this occur within the past five years?
• Do you currently smoke cigarettes?
• Have you ever noticed an increase in asthma
symptoms after taking aspirin or a non-steroidal
anti-inflammatory agent (NSAID)?

11. NON-PHARMACOLOGICAL
THERAPY
Trigger avoidance and Patient education
1. Trigger avoidance — Elimination or avoidance
of known triggers. History taking - exposure to
environmental allergens and irritants in the
home, school, and/or workplace
1. Patient education — ongoing process, create
a partnership between the patient and provider
in achieving and maintaining asthma control.
educational materials, personalized asthma
action plan that gives detailed instructions about
how to self-administer medications at baseline
and during exacerbations

14. PHARMACOLOGICAL
TREATMENT

15. All Asthma Drugs Should Ideally
Be
Taken Through The Inhaled
Route

16. WHY INHALATIONAL ROUTE?
ORAL INHALED
• Slow Onset of Action • Rapid Onset of Action
• Large Dosage Required • Less Amount of Drug
Used
• Greater Side Effects
• Better Tolerated
• Not Useful in Acute
Symptoms • Treatment of Choice in
Acute Symptoms

17. Reliever
• Reliever (also known as rescue medication)
• Bronchodilator (beta 2 agonist)
• Quickly relieves symptoms (within 2-3
minutes)
• Action lasts 4-6 hrs
• Not for regular use

18. RELIEVERS
• Short acting B2 agonists
Salbutamol
Levosalbutamol
• Anti-cholinergics
Ipratropium bromide
• Xanthines
Theophylline, Aminophylline
• Adrenaline

19. Rescue Medication
• SALBUTAMOL INHALER 100 mcg:
1 or 2 puffs as necessary
• LEVOSALBUTAMOL INHALER 50 mcg :
1 or 2 puffs as necessary

20. Controller
• Anti-inflammatory
• Takes time to act (1-3 hours)
• Long-term effect (12-24 hours)
• Only for regular use (whether well or not
well)
• Prevent future attacks
• Long term control of asthma
• Prevent airway remodelling

21. CONTROLLERS
• Corticosteroids
Prednisolone, Betamethasone
Beclomethasone, Budesonide
Fluticasone
• Long acting B2 agonists
Bambuterol, Salmeterol
Formoterol
• COMBINATIONS
Salmeterol/Fluticasone
Formoterol/Budesonide
Salbutamol/Beclomethasone

22. Aerosol delivery systems
currently available
• Metered dose inhalers
• Dry powder inhalers
• Spacers / Holding chambers
• Nebulizer

23. WHICH DEVICE TO USE IN WHOM??????

24. Classification of asthma severity (≥12 years of age)
Components of severity Persistent
Intermittent
Mild Moderate Severe
Impairment Symptoms ≤ 2 days/week > 2days/week but Daily Throughout day
not daily
Normal Night-time ≤ 2x/month 3-4x/month >1x/week but not Often 7x/week
FEV1/FVC: awakenings nightly
• 8-19 yrs SABA use for ≤2days/week >2days/week but not Daily Several times per day
85 percent symptom control daily, and not more
• 20-39 yrs (not prevention than 1x on any day
80 percent of EIB)
• 40-59 yrs Interference with None Minor limitation Some limitation Extremely limited
75 percent normal activity
• 60-80 yrs Lung functions - Normal FEV1 - FEV1 ≥ 80 percent - FEV1>60 but <80 - FEV1/FVC reduced >
70 percent between predicted percent predicted 5 percent
exacerbation - FEV1/FVC normal - FEV1/FVC
- FEV1>80 percent reduced 5 percent
predicted
- FEV1/FVC normal
Risk Exacerbations 0-1/year ≥2/years
requiring oral Consider severity and interval since last exacerbation
systemic Frequency and severity may fluctuate over time for patients in any severity category
corticosteroids Relative annual risk of exacerbations may be related to FEV1
Recommended step for Step 1 Step 2 Step3 Step 4 or 5
initiating treatment And consider short course of oral systemic
corticosteroids
In 2-6 weeks, evaluate level of asthma control that is achieved and adjust therapy

26. Stepping Down Therapy
• When controlled on medium to high dose ICS, 50%
dose reduction at 3months interval
• When controlled on low dose ICS, switch to once
daily dosing.
• When controlled on ICS + LABA, reduce ICS by
50%
• If control is still maintained, reduce to low dose
ICS alone and stop LABA.

27. Stepping Up Therapy in
response to loss of control
• Rapid onset short or long acting beta 2 agonist as
reliever
• Need for repeated dosing over more than one/ two
days signals need for increase in controller
therapy – Increase the dose of ICS or consider
short course of oral corticosteroids
• Use of combination of rapid and long acting
inhaled beta 2 agonists and ICS in a single inhaler
both as controller and reliever (SMART) is
effective in maintaining a high level of asthma
control and reduces exacerbation.

28. Systemic GCS-Indications
• Acute exacerbations
• Symptoms not controlled with other treatment
• Steroid dependant Asthma
• ABPA with Asthma

29. Chronic Therapy
• Reassessed at each visit for asthma care
• Return visits should also allow for ongoing
patient/family education
• Therapy should be stepped up if asthma is not
well-controlled
• Stepped down if symptoms have been well-
controlled over a period of months
• Patients should be reevaluated every 2 to 6
weeks when therapy has been adjusted

30. SMART Therapy
SINGLE INHALER
MAINTAINANCE
AND
RELEIVER
THERAPY

31. LABA+ steroids better than high
dose inhaled steroids
Formetrol Salmetrol
Slower onset
Rapid onset
Short duration of side Long duration of side
effect effect
Response increase with
No such effect
dose
No cumulative side effect Cumulative side effect +

32. The actions of ICS and LABA
complement each other
• The two components of asthma are
– Airway inflammation
– Broncho-constriction
• ICS – Reduce and control inflammation
• LABA – Cause primarily broncho-dilation
• Thus, complementing each others action.

33. Advantages of SMART therapy
• Rapid onset of action
• Less side effects
• Decreased use of inhaled and oral steroids.