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The Global Initiative for

Asthma
Charles G. Macias MD, MPH
Baylor College of Medicine
Attending Physician, Texas Childrens Hospital
Emergency Department
Houston, Texas
Global Initiative for Asthma
Initiated in 1989
US National Heart, Lung and Blood Institute
National Institute of Health
World Health Organization
Objectives
Increase appreciation for global public health
perspective of asthma
Recommend diagnosis and management
strategies
Identify areas for future investigation
Global burden of asthma
Report on 20 different worldwide
regions
300 million people with asthma
Additional 100 million persons by 2025
Prevalence in countries from 0-30%
Western lifestyles/urbanization increase
asthma prevalence (45-59%)
Global burden of asthma
Asthma accounts for 1 in every 250
deaths worldwide
Suboptimal long-term care
Limited access to care for final events
Developed economies: 1-2 % of total health care
expenditures on asthma with increasing costs
Poorly controlled asthma is expensive:
investment in prevention medication likely to
yield cost savings in emergency care
Trends in Prevalence of Asthma
By Age, U.S., 1985-1996
80 Rate/1,000 Persons
Age (years)
70
<18
60 18-44
45-64
50 65+
Total (All Ages)
40

30

20
85 86 87 88 89 90 91 92 93 94 95 96
Year
Hospitalization Rates for Asthma
by Age, U.S., 1974 - 2000

Rate/100,000 Persons
40
35 <15
30 15-44
25 45-64
65+
20
15
10
5
0
74 76 78 80 82 84 86 88 90 92 94 96 98 00

Year
Worldwide
Variation in
Prevalence of
Asthma
Symptoms

International Study
of Asthma and
Allergies in Children
(ISAAC)

Lancet 1998;351:1225
Barriers to care
Generic: poverty, education,
infrastructure
Environmental: indoor/outdoor
pollution
Public health priority overshadowed
by other diseases
Tendency of care to be acute rather
than routine
Patient barriers: information/culture
Diagnosis of Asthma
Most cases present <5 y/o
Infants and young children tend to
have episodic asthma (viral)
Asthma-like phenotypes in different
proportions at different ages
Based on data from Tucson
And Perth cohort studies and
ISAAC worldwide study
Inflammation in Asthma

Acute Chronic Airway


Response Inflammation Remodeling

Bronchoconstriction Cell recruitment Cellular proliferation


Edema Epithelial damage Extracellular matrix
Secretions Early structural increase
Cough changes Structural
changes
Diagnosis of asthma
History of 2 episodes of symptoms of
airflow obstruction:
Cough, wheeze, shortness of breath, or chest
tightness
Exercise-induced symptoms
Nocturnal symptoms (after 12 MN)
AND
Evidence of reversible bronchospasm
Objective measures:
improvement in PEFR, spirometry
Improvement in clinical signs/symptoms of
obstruction
HX: Cough, wheeze, SOB, chest tightness
Exam: breathlessness, RR, auscultation, retractions,
O2 Sat
Emergency management
Assess the severity: dont underestimate
Recognize high risk for death:
History of near-fatal asthma
Hospitalization, ED visit or prior intubation in
past year
Current or recent withdrawl of steroids
Overdependence of rapid acting agonist
Psychosocial problems or denial of asthma
Non-compliance with asthma treatments
Severity of Asthma Attacks
Mild Moderate Severe Impending
respiratory arrest
Breathless Walking Drowsy or
Can lie down confused
Talks in Sentences Phrases Words Drowsy

Alertness agitated Agitated Agitated Confused

Respiratory rate Increased Increased Marked increase Paradoxical


Access muscle Usually not Usually Usually Paradoxical thoraco-
and suprasternal abdominal
retractions movement
Wheeze Moderate or Loud Usually Loud Absence of wheeze
end expiratory
Pulse/min. < 100 100-120 > 120 Bradycardia
PEF % predicted Over 80% Approximately < 60% predicted or best
or best 60-80% or response lasts < 2 hrs
Pa02 (on air) < 45 mmHg 60 mmHg < 60 mmHg:
and/or Possible cyanosis
PaC02 < 45mmHg > 45 mmHg
Possible resp failure
SaO2% (on air) > 95% 91-95% < 90%
Management: ED care
Initial Assessment
History, exam (auscultation, use of accessory muscles,
HR, RR, PEF or FEV1, O2 sat)
( ABG if patient in extremis, and other tests as indicated)

Initial Treatment
Inhaled rapid-acting 2 agonist, q20 x 3
Oxygen for O2 sat> 95%
Glucocorticosteroids
Sedation is contraindicated in the treatment of attacks


Repeat Assessment
Physical Exam, PEF or FEV1, O2 saturation
(other tests as needed)

Management: ED care

Moderate Episode Severe Episode
PEF 60-80% predicted/ PEF, 60% predicted/ personal best
personal best Physical exam: severe symptoms at rest, chest
Physical exam: moderate retraction
Symptoms, accessory muscle History: high-risk patient
use No improvement after initial treatment
Inhaled 2 agonist every Inhaled 2 agonist every 60 minutes and inhaled
60 minutes anticholinergic
Consider inhaled Oxygen
anticholinergic Systemic glucocorticosteroid
Systemic Consider subcutaneous, intramuscular, or
glucocorticosteroids intravenous 2 agonist
Continue treatment 1-3 Consider intravenous methylxanthines
hours, Consider intravenous magnesium
provided there is improvement

Management: ED care

Good Response Incomplete Response in 1- Poor Response Within 1
Response sustained 60 2 hrs Hour
min History: high-risk History: high-risk
Normal exam patient patient
PEF > 70% Mild-to-moderate sxs Symptoms severe,
No distress PEF < 70% drowsiness, confusion
O2 sat> 95% O2 sat not improving PEF < 30%
PCO2 > 45 mmHg
PO2 < 60 mmHg

Management: ED care

Discharge Home Admit to Hospital Admit to Intensive Care
Continue treatment with Inhaled agonist + agonist
inhaled agonist inhaled anticholinergic hourly/continuous
Consider, in most cases, Systemic Anticholinergic
oral glucocorticosteroid glucocorticosteroid IV glucocorticosteroid
Oxygen Consider SQ, IM, or IV
Patient education: Consider intravenous agonists
Take medicine correctly methylxanthines Oxygen
Review action plan Monitor PEF, O2 sat, Consider IV
Close medical follow-up pulse, theophylline methylxanthine
Possible intubation

Improved Not Improved


Discharge Home Admit to Intensive Care
If PEF > 60% predicted/ best and If no improvement within 6-12 hrs
sustained on oral/inhaled meds
Quick Relief Weight Dosage

Beta Agonist Albuterol MDI <12 kg 2-4 puffs up to every


Acute 2-3 hrs
Care 12-16 kg 2-5 puffs up to every
2-3 hrs
16-25 kg 2-6 puffs up to every
2-3 hrs
25-35 kg 2-8 puffs up to every
2-3 hrs
>35 kg Up to 10 puffs up to
every 2-3 hrs
Nebulized Acute 0.1- .3 mg/kg/dose every 3 hrs in 2.5-3ml Normal Saline
Min dose 1.25 mg
Care Max dose 5mg

Levalbuterol Children and Adults .63mg 3times /day at intervals


of 6-8 hrs via nebulizer
(Xopenex)
Dosage may be increased to 1.25 3 times/day

Oral Prednisone 1-2mg/kg/day in divided doses 1-2 times a day (up to


60-80 mg/day)
Steroids
Anticholinergic Ipratropium Nebulized acute care (EC):
Bromide 250-500 mg every 20-40 minutes up to 4 doses with
(Atrovent) beta agonists inhalation
Acute management
Do:
Adequate dosing of agonist
Early introduction of gluccocorticoids
Oxygen for hypoxemic patients
Epinephrine for acute anaphylaxis and
angiodema
Dont:
Sedatives
Mucolytic drugs (worsen cough)
Chest physical therapy (increases discomfort)
Hydration with large volumes
Antibiotics for a simple attack
Six-part asthma management
program

1. Educate patients
2. Assess/monitor severity
3. Avoid triggers
4. Develop chronic
management plans
5. Establish plans for
exacerbations
6. Provide regular follow-
up care
Chronic asthma severity is a
continuum

Severe persistent
Moderate persistent
Mild persistent
Mild intermittent

Any patient can experience a severe exacerbation


Asthma Severity Classification
NAEPP Expert Panel Guidelines, 2002 Update

Symptoms Symptoms FEV1 or


(days) (nights) (Peak Flow
Variability)

Severe Continual Frequent <60%


persistent Limited physical (> 30%)
activity
Moderate Daily >1/ week >60- <80%
persistent (>30%)
Mild >2/ week >2/ month >80%
persistent < 1x/day (20-30%)
Mild < 2/ week < 2/ month >80%
intermittent Usually brief (< 20%)
Rules of Two
Baylor Health Care System, Dallas TX Mild Persistent Asthma
Yes to any of these indicates need for
anti-inflammatory therapy:
Take a quick-relief inhaler > 2
times a week
Awaken at night with asthma > 2
times per month
Refill quick-relief inhaler > 2 times
per year
Pharmacologic therapy
Reliever Controller
Medications: Medications:
Rapid-acting inhaled Inhaled
2-agonists glucocorticosteroids
Systemic Systemic
glucocorticosteroids glucocorticosteroids
Anticholinergics Cromones
Methylxanthines Methylxanthines
Short-acting oral 2- Long-acting inhaled 2-
agonists agonists
Long-acting oral 2-
agonists
Leukotriene modifiers
Anti-IgE
Stepwise approach to therapy in
children > 5y/o
Outcome: Asthma Control Outcome: Best
Possible Results

Controller:
High-dose
inhaled
corticosteroid When
Controller: plus long

asthma is
Controller: Low to medium- acting inhaled controlled,
Controller: Low-dose dose inhaled 2-agonist reduce
None inhaled corticosteroid plus (if needed) therapy
corticosteroid plus long-acting -Theophylline-SR
inhaled 2- -Leukotriene
agonist Monitor
-Long-acting inhaled
2- agonist
-Oral corticosteroid

Reliever: Rapid-acting inhaled 2-agonist prn


STEP 1: STEP 2: STEP 3: STEP 4: STEP Down
Intermittent Mild Persistent Moderate Severe
Persistent Persistent
Inhaled gluccocorticoid therapy by
<5 y/o vs >5y/o (in micrograms)
Beclomethasone-CFC 200-500 100-250 500-1000 250-500 >1000 >500

Beclomethasone-HFA 100-250 50-200 250-500 200-400 >500 >400

Budesonide-DPI 200-600 100-200 600-1000 200-600 >1000 >600

Budesonide-Neb 500-1000 250-500 1000-2000 500-1000 >2000 >1000


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

Fluticasone 100-250 100-200 250-500 200-400 >500 >400

Mometasone furoate 200-400 400-800 >800

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


Stepwise approach to therapy in
children younger than 5 years
Outcome: Asthma Control Outcome: Best
Possible Results

Controller:
High-dose
inhaled
corticosteroid When
Controller: plus long

asthma is
Controller: Medium-dose acting inhaled controlled,
Controller: Low-dose inhaled 2-agonist reduce
None inhaled corticosteroid plus (if needed) therapy
corticosteroid -Theophylline-SR
-Leukotriene
Monitor
-Long-acting inhaled
2- agonist
-Oral corticosteroid

Reliever: Rapid-acting inhaled 2-agonist prn


STEP 1: STEP 2: STEP 3: STEP 4: STEP Down
Intermittent Mild Persistent Moderate Severe
Persistent Persistent
If asthma control is poor....
Review:
Inhaler technique
Compliance
Environmental control
consider alternative diagnosis
Who should be referred to an
asthma specialist?
Life-threatening asthma exacerbation
Complicating conditions (ex CF)
Additional diagnostic testing
Consideration for immunotherapy
Severe persistent asthma or <3 y/o
moderate or severe persistent
>2 bursts of oral steroids in 12 mo
The future of ED asthma
management
Utilization of MDI protocols
CDC and AAAAI ER recommendations
in Pediatrics fall 2005
Chronic care
Surveillance
Education
Primary care physician
PREGUNTAS?
www.ginasthma.com

cgmacias@texaschildrenshospital.org
Managing Asthma in Children NAEPP
recommended therapies
Severe Persistent aily medications

Anti-inflammatory high-dose inhaled corticosteroid.

nd

Long Acting bronchodilator

nd

Corticosteroid tablets or syrup long term; make repeated


Moderate Persistent attempt to reduce systemic corticosteroids and maintain
aily medications
control with high dose inhaled corticosteroids.
Anti-inflammatory either medium-dose inhaled corticosteroid.

nd

Low to medium-dose inhaled corticosteroid and add a long


acting bronchodilator and long-acting bronchodilator, especially
for nighttime symptoms.

One daily medication:


Mild Persistent Anti-inflammatory: Low dose inhaled corticosteroids
Alternative for very mild: leukotriene modifier

No daily medications needed


Mild Intermittent
Long Term Control Medication Dosage

Control Cromolyn 20mg Nebulizer 2-2-4 Xday


Sodium (Intal
(Intal
) 2ppuffs MDI 2-
2 X day
- 4

Inhaled Medication Mild Moderate Severe


Corticosteroids
Beclovent
Beclovent- MDI 42 2-8 puffs/day 8-16 puffs/day >16 puffs/day
mcg/puff
Pulmicort
Pulmicort DPI 200 1 puff/day 1-2 puffs/day >2 puffs/day
mcg/puff
Aerobid
Aerobid- MDI250 2-3 puffs/day 4-5 puffs/day >5 puffs/day
mcg/puff

Pulmicort Respule
Respule
solution 0.25 mg bid 0.5 mg bid
.25mg and .5 mg vials

Flovent
Flovent-MDI 44mg 2-4 puffs/day 4-10 puffs/day >10 puffs/day

Flovent
Flovent- MDI 110mg 2-4 puffs/day >4 puffs/day

Oral Medication Dosage

Prednisolone (Prelone
Prelone, .05-
.05-2mg/kg/day in divided doses 1-
1-4 times/day
Orapred
Orapred)
Prednisone .5-
.5-2 mg/kg/day in divided doses 1-
1-4 times/day

Leukotrine Medication Dosage


Modifiers
Montelukast (Singulair
(Singulair
) 2-5 years: 4mg/daily-
4mg/daily- evening

6-14 years: 5mg/daily-


5mg/daily- evening

>14 yrs: 10mg/daily-


10mg/daily- evening

LongActing Beta2 Medication Dosage


Agonist
Salmeteral Xinafuate MDI 42mcg (2puffs twice daily) for maintenance 12 hours apart
(Serevent
Serevent)
Exercise induced asthma 42 mg (2 puffs)
Therapy for older than 5 years

Severity Daily Controller Other Options


Medications (in order of cost)
Step 1: None None

Intermittent
Therapy for older than 5 years

Severity Daily Controller Other Options


Medications (in order of cost)
Step 2: Low-dose inhaled Sustained-release

Mild glucocorticosteroid theophylline, or


Persistent Cromone, or

Leukotriene modifier

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more


than 3-4 times a day. Once control is achieved and maintained for at
least 3 months, gradual reduction of therapy should be tried.
Therapy for older than 5 years
Severity Daily Controller Other Options (in order of cost)
Medications
Step 3: Low-to medium dose Medium-dose inhaled glucocorticosteroid
Moderate inhaled glucocortico- plus sustained-release theophylline, or
persistent steroid plus long-acting
inhaled 2-agonist Medium-dose inhaled glucocorticosteroid
plus long-acting inhaled 2-agonist, or

High-dose inhaled glucocorticosteroid, or

Medium-dose inhaled glucocorticosteroid


plus leukotriene modifier

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more


than 3-4 times a day. Once control is achieved and maintained for at
least 3 months, gradual reduction of therapy should be tried.
Therapy for older than 5 years
Severity Daily Controller Medications Other Options

Step 4 High-dose inhaled glucocorticosteroid


Severe plus long-acting inhaled 2-agonist
persistent plus one or more of the following, if
needed:
- Sustained-release theophylline
- Leukotriene modifier
- Long-acting inhaled 2-agonist
- Oral glucocorticosteroid

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more


than 3-4 times a day. Once control is achieved and maintained for at
least 3 months, gradual reduction of therapy should be tried.
Therapy for children younger than
5 years old

Severity Daily Controller Other Options (in order


Medications of cost)
Step 1: None None
Intermittent
Therapy for children younger than
5 years old
Severity Daily Controller Other Options (in order
Medications of cost)
Step 2: Low-dose inhaled Sustained-release
Mild glucocorticosteroid theophylline, or
Persistent
Cromone, or

Leukotriene modifier

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more


than 3-4 times a day. Once control is achieved and maintained for at
least 3 months, gradual reduction of therapy should be tried.
Therapy for children younger than
5 years old
Severity Daily Controller Other Options (in order of cost)
Medications
Step 3: Medium-dose inhaled Medium-dose inhaled glucocorticosteroid
Moderate glucocorticosteroid plus sustained-release theophylline, or
persistent
Medium-dose inhaled glucocorticosteroid
plus long-acting inhaled 2- agonist, or

High-dose inhaled glucocorticosteroid, or

Medium-dose inhaled glucocorticosteroid


plus leukotriene modifier
Therapy for children younger than
5 years old
Severity Daily Controller Medications Other
Options
Step 4 High-dose inhaled glucocorticosteroid
Severe plus one or more of the following,
persistent if needed:
- Sustained-release theophylline
- Leukotriene modifier
- Long-acting inhaled 2- agonist
- Oral glucocorticosteroid
Classification of severity
CLASSIFY SEVERITY
Clinical Features Before Treatment

Symptoms Nocturnal FEV1 or PEF


Symptoms
STEP 4 Continuous 60% predicted
Limited physical Frequent
Severe Variability > 30%
Persistent activity

STEP 3 Daily 60 - 80% predicted


> 1 time week
Moderate Attacks affect activity Variability > 30%
Persistent
STEP 2 > 2 times a month 80% predicted
> 1 time a week
Mild but < 1 time a day Variability 20 - 30%
Persistent

< 1 time a week


STEP 1 80% predicted
Asymptomatic 2 times a month
Intermittent and normal PEF Variability < 20%
between attacks
Response to therapy is:
Good if Incomplete if Poor if
Symptoms subside Symptoms decrease Symptoms persist or
after initial agonist but return <3 hrs after worsen despite initial
sustained for 4 hrs agonist treatment

PEF >80% predicted or PEF is 60-80% PEF <60% predicted or


personal best predicted or best best

ACTIONS: ACTIONS: ACTIONS:


Continue agonist every Add oral Add oral
3-4 hours for 1-2 days glucocorticosteroid glucocorticosteroid.
Add inhaled Add inhaled
Contact physician anticholinergic Anticholinergic
or nurse for follow-up Continue agonist Repeat agonist
instructions. Consult clinician Immediate transport to
urgently ED
Goals of long-term management
Achieve and maintain control of symptoms
Prevent asthma episodes or attacks
Maintain pulmonary function as close to
normal levels as possible
Maintain normal activity levels
Avoid adverse effects from medications
Prevent development of irreversible
airflow limitation
Prevent mortality
Caveats to management
The most effective management is to
prevent airway inflammation by
eliminating the causal factors
Asthma can be effectively controlled
in most patients
The major factors for asthma
morbidity and mortality:
under-diagnosis
inappropriate treatment
Death Rates for Asthma
By Race, Sex, U.S., 1980-2000

Rate/100,000 Persons
5
Black Female

4
Black Male

3
White Female

White Male
1

0
1980 1985 1990 1995 2000
Year