asthma

chronic inflammatory airway disease

Case
• 14 year old who is a known asthmatic presents with increased
salbutamol use for 3 days
• What issues do you consider
• How do you assess her asthma
• How do you decide if she needs to be referred to the ED
 Allergens - pollens, animal dander, mites
Issues Bronchial infection
Cold air, exercise
Drugs - aspirins, NSAIDS, Beta blockers
Emotions - stress, laugther

• Is it really asthma? Food - MSG, seafood, nuts

GERD
• Respiratory symptoms Hormones - pregnancy , menstruation
Irritants - Smoke, perfume, smells
• Wheeze – “heavy breathing” Job - wood dust, floor dust, animals,
• Cough chemicals
• Chest tightness – “heavy in chest”
• Shortness of breath
• Usually more than 1 respiratory symptoms present
• Variability over time and intensity ( eg night time, during exercise)
• Any diagnostic test done before?
• Any triggers ( ABCDEFGHIJ)

• DDx – chronic upper airway infection cough syndrome, congenital heart disease, alpha 1 anti-trypsin deficiency,
Cystic Fibrosis ( if she is an Ang Mo!) , Bronchiectasis,
• Other age group – COPD, PE, Medication related cough, parenchymal lung disease.
Issues
• Why did her asthma worsen ?
• Uncontrolled from the start vs recent changes.
• When was she diagnosed, how had she cope so far, what has changed.
• Adherence & inhaler technique ( most common , 80%)
• Adherence – intentional, unintentional.
• Technique – get patient to demonstrate it.
• Co-morbidities
• GERD, smoking, OSA, obesity, allergic rhinitis/sinusitis
• Check for triggers – if identified, to avoid it.
• Is it really something else?
Issues – poor adherence
• Poor Adherence ( ICE )
• Medication/regime factors –
• Burdensome regime ( multiple times per day)
• Multiple inhalers
• Difficulty to use ( not so for this case, eg arthritis)
• Unintentional poor adherence
• Misunderstand instruction ( eg using preventers for relief)
• Forgetful
• Absence of a daily routine
• Cost
• Intentional poor adherence
• Perception that treatment is not necessary
• Denial or anger that about asthma and its treatement
• Concerns about side effects
• Dissatisfied with health care providers
• Cost
• Stigmatization
How to assess her asthma
• Subjective and objective
• Spirometry
• Symptoms frequency
State of asthma Mild intermittent Mild persistent Moderate Sever

FEV1 of predicted >80% >80% 60-80% <60%

Day symptoms > 2
Day symptoms < 2
/weekly but not every Symptoms continuous
/weekly, Daily symptoms, nighT
day of the week with frequent
Symptoms frequency Night symptoms < 2 symptoms > once a
Night symptoms > 2 exacerbation, night
/monthly week
/monthly time symptoms
Activity not affected
Activity affected
 How to assess her asthma
• Assessment of severity guide treatment
State of asthma Mild intermittent
- PRN bronchodilators
- Prophylaxis of exercise induced
Medication regime
asthma, use oral LTRA if prolonged
exercise
Mild persistent Moderate
-PRN bronchodilator
-Daily moderate dose ICS with
LABA*
Requires daily low dose ICS
-Substitute LABA with LTRA
+ PRN bronchodilator
-substitute LABA with long
Use oral LTRA is worried
acting anti-cholingerinc
about steriods
antagonist
Sever
-PRN bronchodilator
-Daily high dose ICS with LABA
- Add on LAA if not well
controlled.
- Short course oral pred 40-
60mg 5-10 days if exacerbation
- Consider adding oral LTRA and
then step down ICS to lower
dose if well controlled.

LABA – Salmeterol Multicenter Asthma Research Trial (SMART) found 4x increase in asthma related death with LABA use , other meta analysis
show increase in sever exacerbation and hospitalization, possibly due to 15% of USA population that has a Arg/Arg genotype ( predominantly in
African Americans) that shows a decline in airflow with use of beta agonist. FDA actually recommends that LABA usage be stopped once
controlled is achieved.
ICS = inhaled corticosteroids ( 2nd generation such as fluticasone /mometasone/ budesonide has reduced system absorption)
LTRA = leukotriene receptor antagonist.
LABA = long acting beta agonist
LAA = long acting anti-cholingeric , eg tiotropium
 Treatment
• Patient has daily symptoms for 3 days
• At least mildly persistent level asthma
• Consider ICS for her , alternative is LKTRA
• If already taking ICS, increased dose of ICS + LABA or ICS + LKTRA
• Self monitoring with BD PEF and to self adjust controller dose when peak flow decline
• PEF – Peak Expiratory flow by patient – useful to assess response to treatment, evaluate triggers with ICS,
personal PEF (BD) is usually reach 2/52, average PEF will increase and diurnal variation will decrease for about 3
months.
• Review patient 1-3 months after starting treatment, and within 1 week after an exacerbation.
• Most controller medication works within days of treatment but full benefit takes 3-4 months to appear.
Treatment
Treatment - continued
• Stepping up treatment
• Sustained step up ( ie, increase dose) when patient do not respond to initial treatment review in 2-3
months and if no improvement, scale back to previous level and consider alternative treatment or
referral
• Must rule out other causes of symptoms, ensure adherence and technique and address modifiable risk factors.
• Short term step up – occasional short term increase in ICS for 1-2 weeks to cover for temporary triggers,
eg viral infection, menstruation, strike 4D etc.
• Stepping down treatment
• Patient often experiment with intermittent treatment due to concern about cost and risk.
• Emphasis to patient that lower dose can be achieved only if controller is taken everyday
• And If asthma controlled and lung function reached a plateau , can reduce treatment stepwise
• Minimize cost of treatment and side effects
Decision on referral to A&E
Decision on referral to A&E
 REFERENCES
The Salmeterol Multicenter Asthma Research Trial: A Comparison of Usual Pharmacotherapy for Asthma or Usual
Pharmacotherapy Plus Salmeterol
Harold S. Nelson, MD; Scott T. Weiss, MD, MS; Eugene R. Bleecker, MD; Steven W. Yancey, MS; Paul M. Dorinsky, MD; the
SMART Study Group CHEST. 2006;129(1):15-26.

Gina Guidelines 2017 : management of worsening asthma and exacerbation page 80, treating to control symtpoms and to
minimize future risk page 48, adherence with medication and other advice Page 57-58

Primary Care medicine Allan Goroll, Albert G, Chapter 48 : Management of Asthma, Pages 401, 412-413