Asthma Lecture Cagayan de Oro Pediatric A 2008

UPDATES IN THE
DIAGNOSIS,
MANAGEMENT AND
PREVENTION OF
ASTHMA IN CHILDREN
Raymund L. Manuel M.D.,
D.P.P.S.,D.P.A.P.P.
Pediatric Pulmonologist
OBJECTIVES
• To present and compare the GINA
2002 with GINA
2006 guidelines
• To update clinicians with the newer
approach to the management asthma
in children
GLOBAL INITIATIVE FOR ASTHMA
(G.I.N.A.)
Initiated in 1989
• US National Heart, Lung and Blood Institute
• National Institute of Health
• World Health Organization
• Undergone 3 major revisions (1995, 2002, 2006)
OBJECTIVES:
• To increase appreciation for global public health
perspectives of asthma
• Recommend diagnostic and management strategies
• Identify areas for future investigations
GLOBAL INITIATIVE FOR ASTHMA
(G.I.N.A.)
Undergone 3 major revisions (1995, 2002, 2006)
Why was a revision necessary ?
5. Current level of control around the world fall

short of GINA goals
7. The Philippines is also “missing the mark”

Global Initiative for Asthma (GINA)
2006 Updates
The cost to control asthma seems high,
but the cost of not treating asthma
correctly is even higher.
Concept of “Difficult to treat Asthma” is

introduced. Patients with difficult to
treat asthma are often rarely insensitive
to the effects of glucocorticoid
medications and may sometimes be
unable to achieve the same level of
control as other asthma patients.
GINA ASTHMA GUIDELINES:
2002 2006
OPERATIONAL DEFINITION:
“ Asthma is a chronic inflammatory disorder of the airways
in which many cells and cellular elements play a role. The chronic
inflammation is associated with airway hyper responsiveness that
leads to recurrent episodes of wheezing, breathlessness, chest
tightness, and coughing, particularly at night or in the early
morning. These episodes are usually associated with widespread,
but variable, airflow obstruction within the lung that is often
reversible either spontaneously or with treatment”
2002 2006
PATHOLOGY: Acute and Chronic Inflammation
Inflammation is persistent
Inflammation affects all airways

more in the medium sized bronchi
2002 2006
Pathophysiology: Airway Narrowing :

- Airway smooth muscle contraction
- Airway edema
- Airway thickening
- Mucus hyper secretion
Airway Hyper responsiveness

GINA ASTHMA
GUIDELINES:
2002 2006
Factors Influencing the Development and Expression of Asthma
HOST FACTORS
Genetic, e.g.,
Genes pre-disposing to atopy
Genes pre-disposing to airway hyperresponsiveness
Obesity
Sex
ENVIRONMENTAL FACTORS
Allergens
Indoor: Domestic mites, furred animals(dogs, cats, mice) cockroach
allergen, fungi, molds, yeast
Outdoor: Pollens, fungi, molds, yeasts
Infections (predominantly viral)
Occupational sensitizers
Tobacco smoke
Passive smoking
Active smoking
Outdoor/Indoor Air Pollution
Diet
2006 updates
Lung function testing by spirometry of
Peak expiratory flow (P.E.F.) continues to
be recommended as an aid to the
diagnosis and monitoring.
Measuring the variability of airflow is the
key to both asthma diagnosis and the
assessment of asthma control.
ASTHMA: Diagnosis
Predicted normal PEFR in Filipino Children
between 6 – 17 years with height of at
least 100 cms.
3) Males: (Height in cm. – 100) 5 + 175
2) Females: (Height in cm – 100) 5 + 170

ASTHMA: Diagnosis
Peak Flow Highest reading - Lowest

Variability reading X
= Highest Reading 100
2006 updates
The previous classification by

asthma severity into Intermittent,
Mild Persistent, Moderate Persistent
and Severe Persistent is now
recommended only for research
purposes.
2
002
Diagnosis and Classification
Classification of Asthma Severity by Clinical Features Before Treatment
Intermittent: Mild Moderate Severe

Persistent: Persistent: Persistent:
Symptoms less than Symptoms more Symptoms daily Symptoms daily

once a week Than once a week Exacerbations may Frequent
Brief exacerbations But less than once Affect activity and exacerbations
Nocturnal symptoms A day sleep Frequent Nocturnal
NOT more than twice Exacerbations may Nocturnal symptoms asthma symptoms
a month Affect activity and more than once a week Limitation of physical
FEV1 or PEF≥80% Sleep Daily use of inhaled short activities
Predicted Nocturnal symptoms acting β2-agonist FEV1 or PEF ≤60%
PEF or FEV1 variability More than twice a FEV1 or PEF 60-80% Predicted
20-30% Month Predicted PEF or FEV1
FEV1 or PEF≥ 80% PEF or FEV1 Variability > 30%
Predicted variability>30%
variability>30
PEF or FEV1 variability
20-30%
Classification of Asthma Based on
Severity:
(GINA 2002)
Severity INTERMITTENT
PERSISTENT
Mild Moderate
Severe
Daytime Symptoms < 1x a week ≥1x/wk Daily Daily

Affects daily Limits
daily
activities
activities
Nighttime Symptoms ≤ 2x/month >2x/month >1x/week
Frequent
PEF ≥ 80% ≥80% >60-<79% <60%

predicted predicted predicted predicted
PEF Variability ≤ 20% 20-30% >30%

2006 updates
Instead, the GINA report of 2006,
recommends a classification of asthma by
level of control: Controlled, Partly
Controlled, or Uncontrolled.
This reflects the understanding that
asthma severity does not only involve the
severity of the underlying disease but also
its responsiveness to treatment.
GINA 2006, 2007
REDUCE
LEVEL OF CONTROL TREATMENT OF ACTION
maintain and find lowest

controlled
controlling step
consider stepping up to
partly controlled gain control
INCREASE
uncontrolled step up until controlled
exacerbation treat as exacerbation

2002 2006
EMPHASIS: CLASSIFICATION ASTHMA MANAGEMENT
OF PATIENT BY BASED ON CLINICAL
SEVERITY CONTROL
DEFINITION: IMPACT OF THE CLINICAL,PHYSIOLOGICAL

DISEASE ON LUNG AND PATHOLOGICAL
FUNCTION CHARACTERISTICS
- airflow limitation - episodic shortness of
- its reversibility breathing
- airway hyper- - wheezing
responsiveness - cough
GINA ASTHMA GUIDELINES 2002, 2006, 2007
DIAGNOSIS:
2002 2006 - 07
Reversibility of Often prompted by symptoms:
measurements episodic breathlessness
of lung function wheezing
enhances cough
confidence chest tightness
in making a Assessment of the severity of airflow
diagnosis of limitation
asthma Reversibility and variability confirms the
Diagnosis of asthma
Asthma severity: Asthma severity is measured NOT

Amount of daily by severity of the underlying disease
medications required BUT its responsiveness to treatment
for optimal treatment
Measurement of allergic state helps to identify

Risk factors that causes asthma symptoms in patients
How do I Implement it in my
Clinic ?
Asthma Patient
Exacerbation ?
Yes No
Management of Chronic
Therapy
Exacerbation
Level of Control
Chronic Therapy
ASTHMA CONTROL
(GINA 2006)
• Refers to control of the clinical

symptoms of the disease
• Treatment is aimed at controlling
the clinical features of disease
2002 2006-07
Clinical Control of asthma is defined as:

• No (twice or less/weekly) daytime symptoms
• No limitations of daily activities, including
exercise
• No nocturnal symptoms or awakening because
of asthma
• No (twice or less/week) need for reliever
treatment
• Normal or near normal lung function
• No exacerbations
2006
Levels of Asthma Control
Characteristic Controlled Partly Controlled Uncontrolled
(All of the ff) (Any measure
present in any
week)
Daytime symptoms None (2x or </wk.) More than 2x/wk Three or more
features of partly
Limitations of None Any controlled asthma
activities present in any week
Nocturnal symptoms/ None Any

awakening
Need for None (2x or More than 2x/ wk

reliever/rescue tx less/week)
Lung function (PEF or Normal <80% predicted or

FEV1)+ personal best (if
known)
Exacerbations None One or more/ yr* One in any wk╪
2006 updates
Treatment options are organized into five

“Steps” reflecting the intensity of
treatment. At all steps, a reliever
medication should be provided for as
needed use. At steps 2 through 5, a variety
of controller medications are available.
2006 Updates
Entry Point ?
Step 2: Is the initial treatment for most

treatment naïve patients with persistent
asthma symptoms
Step 3: Commence treatment here if

symptoms at the initial consult suggest
that asthma is severely uncontrolled
Treating to Achieve Asthma Contr
Step 1 – As-needed reliever medication
 Patients with occasional daytime symptoms of short
duration
 A rapid-acting inhaled β2-agonist is the
recommended reliever treatment (Evidence A)
 When symptoms are more frequent, and/or worsen
periodically, patients require regular controller
treatment (step 2 or higher)
Treating to Achieve Asthma
Control
Step 2 – Reliever medication plus a single controller
 A low-dose inhaled glucocorticosteroid is
recommended as the initial controller treatment
for patients of all ages (Evidence A)
 Alternative controller medications include
leukotriene modifiers (Evidence A) appropriate for
patients unable/unwilling to use inhaled
glucocorticosteroids
Control
Step 3 – Reliever medication plus one or two
controllers
 For adults and adolescents, combine a low-dose
inhaled glucocorticosteroid with an inhaled long-
acting β2-agonist either in a combination inhaler
device or as separate components (Evidence A)
 Inhaled long-acting β2-agonist must not be used as
monotherapy
 For children, increase to a medium-dose inhaled
glucocorticosteroid (Evidence A)
CAUTION
Long acting β 2 agonists should
be used regularly only with
inhaled steroids.
Long acting β 2 agonists should
not be used as a rescue
therapy.
TOLERANCE
• Subsensitivity/down-regulation
of β2 receptors
CLINICAL SIGNIFICANCE OF
TOLERANCE
Decreased bronchoprotection
Increased vulnerability to
attacks
Normal lung function in between

attacks
Control
Additional Step 3 Options for Adolescents and Adults
 Increase to medium-dose inhaled
glucocorticosteroid (Evidence A)
 Low-dose inhaled glucocorticosteroid combined
with leukotriene modifiers (Evidence A)
 Low-dose sustained-release theophylline
(Evidence B)
Control
Step 4 – Reliever medication plus two or more
controllers
 Selection of treatment at Step 4 depends
on prior selections at Steps 2 and 3
 Where possible, patients not controlled on
Step 3 treatments should be referred to a
health professional with expertise in the
management of asthma
Control
Step 4 – Reliever medication plus two or more controllers
 Medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled β2-agonist
(Evidence A)
 Medium- or high-dose inhaled glucocorticosteroid
combined with leukotriene modifiers (Evidence A)
 Low-dose sustained-release theophylline added to
medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled β2-agonist
(Evidence B)
Control
Step 5 – Reliever medication plus additional controller options
 Addition of oral glucocorticosteroids to other
controller medications may be effective (Evidence D)
but is associated with severe side effects (Evidence
A)
 Addition of anti-IgE treatment to other controller
medications improves control of allergic asthma when
control has not been achieved on other medications
(Evidence A)
Treating to Maintain Asthma
Control
Stepping down treatment when asthma is controlled
 When controlled on medium- to high-dose
inhaled glucocorticosteroids: 50% dose
reduction at 3 month intervals (Evidence
B)
 When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily
dosing (Evidence A)
Control
Stepping down treatment when asthma is controlled
 When controlled on combination inhaled
glucocorticosteroids and long-acting inhaled β2-
agonist, reduce dose of inhaled
glucocorticosteroid by 50% while continuing the
long-acting β2-agonist (Evidence B)
 If control is maintained, reduce to low-dose
inhaled glucocorticosteroids and stop long-
acting β2-agonist (Evidence D)
Control
Stepping up treatment in response to loss of control
 Rapid-onset, short-acting inhaled β2-
agonist bronchodilators provide temporary
relief.
 Need for repeated dosing over more than
one/two days signals need for possible
increase in controller therapy
Control
Stepping up treatment in response to loss of control
 Use of a combination rapid and long-acting inhaled
β2-agonist (e.g., formoterol) and an inhaled
glucocorticosteroid (e.g., budesonide) in a single
inhaler both as a controller and reliever is effective in
maintaining a high level of asthma control and
reduces exacerbations (Evidence A)
 Doubling the dose of inhaled glucocortico-steroids is
not effective, and is not recommended (Evidence A)
Asthma Patient
Exacerbation ?
Yes No
Management of Chronic
Therapy
Exacerbation
Level of Control
2002 2006-07
Asthma in Acute Exacerbation

INA 2002, 2006, 2007
Severity of Asthma
Exacerbations
MILD MODERATE SEVERE RESPIRATORY
ARREST
IMMINENT
Breathless Walking Talking At rest

Infants – softer Infants- Stops
shorter cry feeding
Can lie flat Prefers sitting *Hunched forward
Talks in Sentences Phrases Words
Alertness May be agitated Usually agitated Usually agitated
Respiratory Rate Increased Increased *Often >30/min Bradypnea
GUIDE TO RATES OF BREATHING ASSOCIATED WITH

RESPIRATORY DISTRESS IN AWAKE CHILDREN
AGE NORMAL RATE
> 2 months < 60/min
2-12 months < 50/min
1-5 years < 40/min
6-8 years < 30/min
INA 2002, 2006, 2007
Severity of Asthma Exacerbations

ARREST IMMINENT
Accessory None Present Present Present

Muscles & Thoraco-abdominal
Suprasternal Movement
Retraction
Wheeze Audible with Audible with Audible w/o Absence of wheeze

stethoscope stethoscope stethoscope with decreased to
absent breathe sounds
Pulses/min <100 100-120 >120 Bradycardia
GUIDE TO LIMITS OF NORMAL PULSE RATE IN CHILDREN

Age Normal Limits
Infants 2-12 months <160/min
Preschool 1-2 years <120/min
School Age 2-6 years <110/min
GINA 2002,2006,2007
Severity of Asthma
Exacerbations
ARREST
IMMINENT
Pulses Paradoxus Absent May be present Often present Absence suggests

<10mm Hg 10—20mm Hg 20-40mm Hg respiratory muscle
fatigue
PEF ≥ 80% 60-79% <60%

%predicted
Or
%personal best
PaO2 RA Normal ≥60mm Hg <60mmHg

test NOT usually Possible Cyanosis
necessary
PaCO2 ≤45 mm Hg ≤45 mm Hg >45 mm Hg possible

respiratory failure
SaO2 RA ≥95% 90-94% <90%

Hypercapnea (hypoventilation) develops more rapidly in young children
GINA ASTHMA GUIDELINES: (2002, 2006,2007)
Management of Asthma Exacerbation in Acute Care
Initial Assessment
History, Physical Examination(auscultation, use of accessory muscles,
HR, RR, PEF or FEV1, O2 saturation, ABG’s if patient in extremis)
Initial Treatment
Oxygen to achieve O2 saturation ≥90% (95% in children)
Inhaled rapid β2-agonist continuously for one hour
Systemic GCS, if no immediate response, or if patient recently took
Oral GCS, of if episode is severe
SEDATION is CONTRAINDICATED in the treatment of an exacerbation
Reassess after 1 hour : PE, PEF, O2

saturation & other tests as needed
Criteria for MODERATE Episode: Criteria for SEVERE Episode:

• PEF 60-80% predicted/personal best • History of risk factors for near fatal
• Physical exam: moderate symptoms, asthma
• Accessory muscle use • PEF < 60% predicted/personal best
Treatment: • PE: severe symptoms at rest, chest
O2, retraction
Inhaled β2 agonist + anticholinergic NO improvement after initial treatment
every 60 min Treatment:
Oral GCS O2,
Continue treatment for 1-3 Inhaled β2 agonist + anticholinergic
hours,provided Systemic GCS
There is improvement IV Magnesium
Continuation next slide
GINA ASTHMA GUIDELINES: (2002, 2006,2007)
Management of Asthma Exacerbation in Acute Care

Reassess after 1 – 2 hours
Good Response within 1-2 Incomplete Response within 1-2 Poor Response within 1-2 hours:
hours: hours: Risk factors fro near fatal asthma
Response sustained 60 minutes Risk Factors for near fatal asthma PE : symptoms severe, drowsiness,
after last treatment PE : mild to moderate signs confusion
PE normal: no distress PEF < 60% PEF : < 30%
PEF > 70% O2 saturation: NOT IMPROVING PCO2 : > 45mmHg
O2 saturation > 90% (95% in PO2: < 60mmHg
children) ADMIT to ACUTE CARE Setting
• Oxygen ADMIT to INTENSIVE Care
• Inhaled β2-agonist ± • Oxygen
anticholinergic • Inhaled β2-
• Systemic GCS agonist+anticholinergic
• Intravenous Magnesium • IV GCS
•Monitor PEF, O2 saturation, Pulse •Consider IV β2 agonist
• Consider IV theophylline
• Possible intubation
Improved: Criteria for Discharging Home • mechanical ventilation
PEF > 60% predicted / personal best
Sustained on oral/inhaled medications
Reassess at Intervals
HOME TREATMENT:
• Continue inhaled β2 agonist Poor Response:
•Consider in most cases, oral GCS • Admit to intensive Care
•Consider adding a combination inhaler Incomplete response in 6-12 hours
•Patient education: take medicine correctly • Consider admission to Intensive Care
review action plan Improved •If No improvement within hours
close medical check up
Inhaled short acting
β2-agonists are the
mainstay of therapy in
acute asthma.
However, once response to the
initial β2-agonists is
minimal, incomplete or poor
COMBINATION of INHALED β2-
AGONIST and INHALED
ANTICHOLINERGIC is
RECOMMENDED
What is the role of
Salbutamol – Ipratropium in
acute asthmatic attacks?
INTERMITTENT
No added benefit over Salbutamol

alone if attack is mild
However, any moderate to severe

attack of asthma regardless of
severity classification can benefit
from the combination.
GINA ASTHMA PHARMACOLOGIC TREATMENT
GUIDELINES (2002, 2006, 2007)
Medicines in Childhood Asthma

Relievers Controllers
Rapid-acting inhaled Inhaled and systemic
Beta (B)2 agonist corticosteroids
Inhaled anti- Leukotriene modifiers
cholinergics Long-acting B2
Short acting
agonist (LABA) with
theophylline
Inhaled
Short acting B2
Corticosteroid ICS
agonist
Sustained release
(SABA)
theophyllines
Cromones
GINA ASTHMA PHARMACOLOGIC
TREATMENT GUIDELINES (2002, 2006-
07)
Inhaled Corticosteroids:
Cornerstone in the Management
Of Asthma
Inhaled Corticosteroids
• Most effective long-term control for persistent
asthma
• Small risk for adverse events at recommended
dosage
• Benefits of daily use
– Reduction of
• asthma symptoms
• frequency of exacerbations
• airway inflammation
• airway responsiveness
• asthma mortality
– Improvement of
• lung function
• quality of life
Inhaled Corticosteroids
Adverse Events
• Small risk for adverse events at
recommended doses
• Reduce potential for adverse events by:
– Using spacer
– Rinsing mouth
GINA ASTHMA GUIDELINES 2002,2006,2007
Maintenance Therapy:
Stepping Down
When asthma is controlled with:
• IGCS alone in medium to high dose a 50% reduction in dose

should be attempted at 3 months interval (Evidence B)
• IGCS in low dose of alone treatment may be switched to once-
daily dosing (Evidence A)
• Combination of IGCS and LABA, reduce dose of IGCS by 50%
while continuing LABA (Evidence B) If control is maintained,
further reduce IGCS until low dose is reached, then LABA may be
stopped. (Evidence D) OR switch the combination treatment to
once daily dosing OR discontinue the LABA at an earlier stage
and substitute the combination with IGCS monotherapy. In some
patients these alternative approaches lead to loss of asthma
control (Evidence B)
cont. Maintenance Therapy:

Stepping Down
IGCS and controllers other the LABA,

reduce dose of IGCS by 50% until low dose of
IGCS is reached, then may stop combination
treatment (Evidence D)
Controller treatment may be stopped if

the patient’s asthma remains controlled on
the lowest dose of controller and no
recurrence of symptoms for ONE YEAR
(Evidence D)
Stepping Up
When asthma is NOT controlled with:
• Rapid onset, short acting or long acting β2 agonist

bronchodilators.
Repeated dosing with bronchodilators in this class provides
temporary relief until the cause of the days signals the need for
review and possible increase of controller therapy.
• Inhaled glucocorticosteroids. Temporarily doubling the dose of

IGCS has not been demonstrated to effective and is no longer
recommended (Evidence A).
Stepping Up
• Combination of Inhaled Glucocorticosteroids and rapid

and LABA (formoterol) for combined relief and control.
The use of the combination of a rapid and long acting β2-
agonist(formoterol) and an inhaled glucocorticosteroid
(budesonide) in a single inhaler both as a controller and a r
reliever is effective in maintaining a high level of asthma control
and reduces exacerbation requiring systemic GCS and
hospitalization (Evidence A)
GINA ASTHMA GUIDELINES 2002, 2006, 2007
2002 2006 2007
Not
IGCS mentioned Not recommended As maintenance and rescue
+ LABA As form of For children ≤ 5 Medication has shown to
therapy years reduce exacerbations in
children ≥ 4 years with
moderate & severe asthma
GINA ASTHMA GUIDELINES 2002, 2006
Estimated Equipotent Daily Doses of

Inhaled Corticosteroids for Children
Drug Low Daily Dose Medium Daily Dose High Daily Dose
(µg) (µg) (µg)
omethasone 100 – 200 >200 – 400 >400

opionate
sonide 100-200 >200- 400 >400
sonide 80-160 >160-320 >320
solide 500-750 > 750-1250 > 1250
casone 100-200 > 200 – 500 >500
etasone 100-200 >200 – 500 >400

te
mcinolone 400-800 >800 – 1200 > 1200
onide
oosing an Inhaler Device for Children with Asth
Age Group Preferred device Alternate Device
Younger than 4 years Pressurized metered Nebulizer with face

dose inhaler plus mask
dedicated spacer
with face mask
4 – 6 years Pressurized metered Nebulizer with

dose inhaler plus mouth piece
dedicated spacer
with mouth piece
Older than 6 years Dry powder inhaler, Nebulizer with mouth

or breath-actuated piece
pressurized metered-
dose inhaler or
pressurized metered
dose inhaler with spacer
mouth piece
Leukotriene Pathway
LEUKOTRIENE MODIFIER
2002 2006-07
“ADD-ON” Treatment Controller Option

Option
(Children Younger than 5 Years)
• Provide clinical benefit at all levels of

severity (but less than ICS)
• Partial protection against exercise-
induced bronchoconstriction within hours
after adminsitration
• Add on in children where asthma is
insufficiently controlled by low dose of
ICS
(Children Older than 5 Years)
• Provide clinical benefit at all levels of severity (but
less than ICS)
• Partial protection against exercise-induced
bronchoconstriction within hours after
adminsitration
• Add on in children where asthma is insufficiently
controlled by low dose of ICS
• Reduce viral induced asthma exacerbation
2006 Updates
1. The cost to control asthma seems high,
2. Concept of “Difficult to treat Asthma” is

2006 updates
3. Lung function testing by spirometry of
2006 updates
4. The previous classification by

asthma severity into Intermittent,
Mild Persistent, Moderate Persistent
and Severe Persistent is now
recommended only for research
purposes.
2006 updates
5. Instead, the GINA report of 2006,
recommends a classification of asthma by
level of control: Controlled, Partly
Controlled, or Uncontrolled.
This reflects the understanding that
asthma severity does not only involve the
severity of the underlying disease but also
its responsiveness to treatment.
2006 updates
6. The goal of asthma treatment is to
achieve and maintain control. Asthma
control is defined as:
-No (twice or less/week) daytime symptoms
-No limitations of daily activities
-No nocturnal symptoms or awakening because
of asthma
-No (twice or less/week) need for reliever
treatment
-Normal or near-normal lung function results
-No exacerbations
2006 updates
7. Increased use, especially daily use, of reliever
medication is a warning of deterioration of
asthma control and indicates the need to reassess
treatment
8. The roles in therapy of several medications

have evolved:
1. A possible risk of asthma related death

associated with the use of long acting β-2
agonists in a small group of individuals has
resulted to the recommendation that long
acting β-2 agonists should not be used as
monotherapy in asthma, and must only be used
in combination with appropriate dose of inhaled
glucocorticosteroid.
2006 updates
have evolved:
2. Leukotriene modifiers now have a more

prominent role as controller treatment in
asthma, particularly in adults. Long acting oral
β-2 agonists alone are no longer presented as
an option for add-on treatment at any step of
therapy, UNLESS accompanied by inhaled
glucocorticosteroids
3. Monotherapy with cromones is no longer

given as an alternative to monotherapy with a
low dose of inhaled corticosteroids in adults
2006 updates
9. Treatment options are organized into five

“Steps” reflecting the intensity of
treatment. At all steps, a reliever
medication should be provided for as
needed use. At steps 2 through 5, a variety
of controller medications are available.
2006 Updates
10. If asthma is not controlled on the current
treatment regimen, treatment should be
stepped up until control is achieved. When
control is maintained, can be stepped
down in order to find the lowest step and
dose of treatment that maintains control.
lobal Initiative for Asthma (GINA) 2006 Update
11. The emphasis of GINA 2006-07 is the

classification of asthma disease based on control
rather than severity
12. Inhaled B2 agonist is still the mainstay treatment

of patients in acute exacerbation across all severity
classification. In non-responders, combination of B2
agonist and an anticholinergic is recommended.
13. Inhaled Steroids remain the cornerstone in the

long term management of asthma
14. GINA 2006-07 places Montelukast a controller

option in the management of asthma
THANK YOU
Immunomodulation in Asthma
Anti-IgE: Omalizumab (Xolair)
Recombinant humanized monoclonal IgG
Binds to IgE preventing binding to target
cells (mast cells, basophils)
Indications:
Moderate-severe persistent atopic
asthmatics uncontrolled by steroids
Age 12 and above
• Risk of anaphylaxis is similar to specific

immunotherapy
ASTHMA: Diagnosis
In mild asthmatics whose pulmonary
function and response to B2-agonist are
equivocal:
1. Methacholine/Histamine
bronchoprovocation test;
2. Exercise challenge test;
3. Twice daily recording of peak flow
to determine diurnal variation; or
4. A therapeutic trial of five days
steroid and bronchodilator course
ASTHMA: Diagnosis

MANAGEMENT OF
ACUTE
EXACERBATIONS
LONG TERM MANAGEMENT OF
BRONCHIAL ASTHMA
Specific
Immunotherapy
• Immunotherapy: subcutaneous injection
over time of gradually increasing doses
of specific allergic extracts
• Should be considered when avoiding
allergens is not possible or when less
than complete control of asthma
symptoms is achieved with
bronchodilator drugs or inhaled
corticosteroids. When used in
appropriate patients, it reduces the
degree of allergy and thereby reduces
Specific Immunotherapy
The decision to initiate immunotherapy
should
be guided by the following considerations:
– There must be a convincing history

that natural exposure to
aeroallergens induces clinically
significant symptoms
– An immediate hypersensitivity
response to relevant environmental
allergens by appropriate diagnostic
tests (skin test, IgE antibody) should
The decision to initiate immunotherapy
should
be guided by the following considerations:
3) The symptoms are severe enough to be

disabling or interfering with the
patient’s quality of life
4) Inability to control symptoms by

avoidance procedures or when
pharmacotherapy has been only
5) There is progression of allergic

rhinitis to asthma; and
6) Can be administered in children

above 5 years of age.
In general, immunotherapy is more
effective in children and young
adults than in later life.
Asthma Action Plan
Action Plan
The asthma action plan is a written asthma
management plan that is jointly prepared by
the doctor and the patient.
This written instruction to the patient should be

updated every visit as changes in peak flow
measurements or asthma severity category
may occur.
ASTHMA ACTION PLAN Whenever possible, stay away from the
Instructions to ER
Name_________________________ things that bring on your asthma
Physician_____________________ symptoms.
Parent________________________
Phone No. __________________
Guardian______________________
Address_______________________
Hospital _____________________ Identify triggers (check all that apply)
Home phone___________________
Phone No. __________________ ___Exercise
Work phone____________________ ___Stress
___Respiratory infections
Peak Flow Monitoring ___Strong odor
Personal Best Peak Flow_____ ___Changes in temperature
Monitoring times ____ ____ ____ ___Tobacco/smoke
___Allergen
DATE ACCOMPLISHED________ ___Others
This plan will help you control your Three ways to control your asthma:
- asthma and know what to do if you have 1. Follow your GREEN zone plan everyday
an asthma episode. to prevent most asthma
- Keeping your asthma under control will symptoms from starting.
help you: 2. Recognize your symptoms of an an acute
asthma attack.
- Take part in normal physical activity like
being active in exercise and in sports. Follow the YELLOW zone plan to
prevent a asthma attack from
-Sleep through the night without having
asthma episodes. getting worse.
- Prevent asthma attacks. 3. In cases of emergency , follow the RED
zone plan.
- Have the best possible peak flow number.
- Avoid side effects from medicines.
* See your doctor regularly.
* This action plan will need to be updated as
the patient’s condition changes
ASTHMA ACTION PLAN
Name_________________________
Parent________________________Guardian______________________
Address_______________________
Home phone___________________Work phone____________________
Peak Flow Monitoring

Personal Best Peak Flow ________Monitoring times ____ ____ ____
DATE ACCOMPLISHED________
This plan will help you control your asthma and know what to do if you have
an asthma episode.
Keeping your asthma under control will help you:
• Take part in normal physical activity like being active in exercise and in
sports.
• Sleep through the night without having asthma episodes.
• Prevent asthma attacks.
• Have the best possible peak flow number.
• Avoid side effects from medicines.
Whenever possible, stay away from the things that bring on your asthma
symptoms.
Identify triggers (check all that apply)
___Exercise ___Stress
___Respiratory infections ___Strong odor
___Changes in temperature ___Tobacco/smoke
___Allergen ___Others
Three ways to control your asthma:

1. Follow your GREEN zone plan everyday to prevent most asthma
symptoms from starting.
2. Recognize your symptoms of an an acute asthma attack.
Follow the YELLOW zone plan to prevent a asthma attack from
getting worse.
3. In cases of emergency , follow the RED zone plan.
* See your doctor regularly.
* This action plan will need to be updated as the patient’s condition changes
Action Plan
GREEN ZONE: Doing Well

- No symptoms day and night (cough, wheeze,
chest tightness and shortness of breath)
- Can do usual activities
- Peak flow meter __________
(>80 % of your personal best or predicted)
ACTION:
- Continue with your current
medication as prescribed below:
YELLOW ZONE: Acute Attack
- Presence of at least 1 of the following: (cough,
wheeze, chest tightness or shortness of breath)
- Waking at night due to asthma
- Can do some but not all usual activities
- Peak flow meter: _____ to _____
(60 to 79% of your personal best)
ACTION:
-Take your quick-relief inhaled brochodilator_______________
every 20 minutes up to 3 doses until relieved
- Proceed to ER for further evaluation & possible admission if:
1. getting worse at anytime
2. if no relief after 3 doses of inhaled β2 agonist
On your way to ER, continue your quick relief inhaled
bronchodilator every 20 minutes and take 1 dose of oral steroids
as follows:__________________
RED ZONE: EMERGENCY!!!
- Presence of any:(Trouble walking or talking due to
shortness of breath, lips and fingernails are blue)
-Quick relief medicines have not helped
-Cannot do usual activities
-Symptoms are getting worse
-Peak flow meter: _____ (< 60 % of your personal best)
ACTION:
- Proceed to ER
- Take immediately 1 dose of your quick relief inhaled
bronchodilator and continue your inhaled bronchodilator
every 20 minutes while in transit
- Take 1 dose oral steroids as follows:
How will I know if my baby has
ASTHMA?
• Infantile asthma is recurrent
wheezing in infants who are at
risk of developing persistent
symptoms beyond infancy.
• Considered a syndrome that
starts during infancy and persists
up to adulthood.
• AVan
duration of at least
Bever.Indian 6 months
Pediatrics 2004;
and
41: frequency
1101-1104 of at least 3
attacks.
Is there a way of predicting if my
baby will have asthma later in life?
ASTHMA PREDICTIVE INDEX
• Recurrent episodes of wheezing:
>3 episodes in the past year that
lasted >1day and affected sleep.
• Major criteria:
1. Physician-diagnosed atopic
dermatitis
2. Physician-diagnosed parental
asthma
• Minor criteria:
1. Peripheral blood eosinophilia ≥
4%
2. Wheezing apart from colds
How is infantile asthma managed?
When do you start steroids in
infantile asthma?
Asthma Diagnosis: Cough
Causes Percentage
Post Nasal Drip (%) 41
Asthma 24
GER 21
Chronic Bronchitis 5
Bronchiectasis 4
MISC. 5
Representative Causes of Chronic Cough from a Prospective Study
Irwin et al. Ann. Rev. Resp. Dis. 1990
GINA ASTHMA GUIDELINES 2002,2006-
07
Estimated Equipotent Daily Doses of

Inhaled Corticosteroids for Children
Drug Low Daily Dose Medium Daily Dose High Daily Dose
(µg) (µg) (µg)
omethasone 100 – 200 >200 – 400 >400

opionate
sonide 100-200 >200- 400 >400
sonide 80-160 >160-320 >320
solide 500-750 > 750-1250 > 1250
casone 100-200 > 200 – 500 >500
etasone 100-200 >200 – 500 >400

te
mcinolone 400-800 >800 – 1200 > 1200
onide
Asthma Triggers
Asthma Triggers
1. Viruses
2. House Dust Mites
3. Cockroach
4. Cat and Dog dander
5. Pollens
6. Mold Allergens
Triggers of Asthma in Various Age
Groups
Infancy Early Late Adulthood
Childhood Childhood
Viral ++++ +++ ++ +++
Infections
Exercise + ++ +++ +++
Irritants + ++ +++ +++
Foods ++ + + +
Indoor + ++ +++ +++

Inhalants
Pollens ++ +++ +++
Emotions + + +
House Dust Mite
Cockroach
Exposure to >0.05 mcg/gm of cockroach
allergen increases the risk of asthma.
Arruda et al J of Allergy & Clin Immunol 2000
Sensitization to cockroach increased

the prevalence of allergic rhinitis &
bronchial asthma by 2 times.
Binas VWE, Andaya AG PSAAI 2002
Irritants
• Paint odors • Hair sprays
• Perfumes • Chemicals
• Pollutants • Cigarette smoke
Asthma Education
Objectives of an asthma education
program:
1) Increase level of knowledge regarding
asthma, its prevention and its
management
2) Recognize signs and symptoms of asthma
3) Identify his/her asthma triggers and
measures to avoid them
4) Demonstrate correct technique of using
inhalers and peak flow meters
5) Follow personalized asthma action plan
Immunomodulation in Asthma
Anti-IgE: Omalizumab (Xolair)
Recombinant humanized monoclonal IgG
Binds to IgE preventing binding to target cells
(mast cells, basophils)
Indications:
Moderate-severe persistent atopic
asthmatics uncontrolled by steroids
Age 12 and above
Risk of anaphylaxis is similar to specific

immunotherapy
Updates on
Childhood Asthma
from
Global Initiative for Asthma
(GINA ) 2006 Report
2006 Updates
1. The cost to control asthma seems high,
2. Concept of “Difficult to treat Asthma” is

2006 updates
3. Lung function testing by spirometry of
ASTHMA: Diagnosis
Predicted normal PEFR in Filipino Children
between 6 – 17 years with height of at
least 100 cms.
3) Males: (Height in cm. – 100) 5 + 175
2) Females: (Height in cm – 100) 5 + 170

ASTHMA: Diagnosis

Diagnosis of Asthma
Is it Asthma?
 Recurrent episodes of
wheezing
 Troublesome cough at night
 Cough or wheeze after
exercise
 Cough, wheeze or chest
tightness after exposure to
airborne allergens or
pollutants
Asthma Diagnosis
 History and patterns of symptoms
 Measurements of lung function
- Spirometry
- Peak expiratory flow
 Measurement of airway responsiveness
 Measurements of allergic status to identify
risk factors
 Extra measures may be required to diagnose
asthma in children 5 years and younger and
the elderly
Asthma Diagnosis
Therapeutic Trial
5 days SABA + steroids
Indications:
1. Children 5 years and younger

2. Pulmonary function tests like spirometry and
PEFR measurement are not feasible/available.
Levels of Asthma
Controlled
Control
Partly controlled Uncontroll
Characteristic (All of the (Any present in any
week)
ed
following)
Daytime None (2 or less More than
symptoms / week) twice / week
Limitations of 3 or more
None Any features of
activities
Nocturnal partly
symptoms / None Any controlled
awakening
Need for rescue asthma
None (2 or less More than present in
/ “reliever”
/ week) twice / week any week
treatment < 80% predicted
Lung function or personal best
Normal
(PEF or FEV1) (if known) on any
day
One or more / year 1 in any
Exacerbation None
week
2006 updates
6. The goal of asthma treatment is to
achieve and maintain control. Asthma
control is defined as:
-No (twice or less/week) daytime symptoms
-No limitations of daily activities
-No nocturnal symptoms or awakening because
of asthma
-No (twice or less/week) need for reliever
treatment
-Normal or near-normal lung function results
-No exacerbations
REDUCE

controlled
controlling step
INCREASE
REDUCE INCREASE
TREATMENT STEPS
STEP STEP STEP STEP STEP
1 2 3 4 5
2006 updates
7. Increased use, especially daily use, of reliever
medication is a warning of deterioration of
asthma control and indicates the need to reassess
treatment

have evolved:
1. A possible risk of asthma related death

associated with the use of long acting β-2
agonists in a small group of individuals has
resulted to the recommendation that long
acting β-2 agonists should not be used as
monotherapy in asthma, and must only be used
in combination with appropriate dose of inhaled
glucocorticosteroid.
INDICATIONS FOR USE OF
LONG ACTING β2 AGONIST
• Exercise-induced asthma
• Nocturnal asthma
SALMETEROL VS. THEOPHYLLINE:
SLEEP AND EFFICACY OUTCOMES IN
PATIENTS WITH NOCTURNAL
ASTHMA
Salmeterol was superior to theophylline
in:
• Sustained improvement in morning PEF
• Protection from night time lung function
deterioration
• Reduction in salbutamol use
• Improvement in patient perception of
Wiegand, L Chest
sleep 1999
PHARMACOLOGICAL PROFILES
OF FORMOTEROL AND
SALMETEROL
FORMOTEROL SALMETEROL
Chemical class Formanilide Saligenin
Lipid solubility Moderate High
Selectivity for High Very high
B2-adrenoceptor
Receptor High affinity, High affinity,
binding reversible poorly reversible
Agonist activity Fullagonist Partialagonist
Onset of action 3 minutes 10-20 minutes
FDA approved >6yrs. old: 6ug BID >4yrs. old: 50ug
dose >12yrs. old: 12ug BID BID
Rapid Acting Inhaled β2 Agonists
Rapid acting inhaled β 2 agonists

are the medications of choice
for relief of bronchoconstriction
and for the treatment of
exercise-induced
bronchoconstriction, in both
adults and children of all ages.
Rapid Acting Inhaled β2 Agonists
Rapid acting inhaled β 2 agonists

are the medications of choice
for relief of bronchoconstriction
and for the treatment of
exercise-induced
bronchoconstriction, in both
adults and children of all ages.
2006 Updates
10. If asthma is not controlled on the

current treatment regimen,
treatment should be stepped up until
control is achieved. When control is
maintained, can be stepped down in
order to find the lowest step and
dose of treatment that maintains
control.
Immediate Care of
Asthma Exacerbations
Asthma Exacerbation
 Exacerbations of asthma are episodes of
progressive increase in shortness of
breath, cough, wheezing, or chest
tightness.
 Exacerbations are characterized by
decreases in expiratory airflow that can
be quantified and monitored by
measurement of lung function (FEV1 or
PEF).
 Severe exacerbations are potentially life-
threatening and treatment requires close
supervision.
Clinical Features
Mild Moderate Severe Resp. Arrest
Imminent
Breathless Walking Talking Infant – At rest Infant –
softer, shorter stops feeding
cry; difficulty
Can lie down feeding Hunched
Prefers sitting forward
Talks in Sentences Phrases Words
Alertness May be Usually agitated Usually agitated Drowsy or confused

agitated
Respiratory Increased Increased Often >30/min Bradypnea
rate
Acc muscles& None Present Present Paradoxical thoraco-

suprasternal abdominal movement
retractions
Wheeze Audible with Audible with Audible without (-) wheeze with
stethoscope stethoscope stethoscope ↓ /(-) breath sounds
Pulse/min < 100 100-120 > 120 Bradycardia
Objective Measures
Mild Moderate Severe Respiratory Arrest
Imminent
Pulsus Absent May be Often present Absence suggests
Paradoxus <10 mm Hg present 20-40 mm Hg respiratory muscle
10-20 mm Hg fatigue
PEF ≥ 80% 60-79% < 60 %
%predicted or
%personal
best
paO2 (on air) Normal ≥60 mm Hg < 60 mm Hg
Test not Possible
and/or usually cyanosis
paCO2 necessary ≤ 45 mm Hg ≥ 45 mm Hg
≤ 45 mm Hg Possible resp
failure
SaO2% (on air) ≥ 95% 90-94% < 90%
Figure 4.4-2: Management of Asthma Exacerbation in Acute Care Setting
Initial Assessment (see Figure 4.4-1)

• History,
physical examination (auscultation, use of accessory
muscles, heart rate, PEF or FEV1, oxygen saturation, arterial blood
gas if patient in extremis)
Initial Treatment
• Oxygen to achieve O2 saturation > 90% (95% in children)
• Inhaled rapid- acting B2 agonist continuously for one hour
• Systemic glucocorticosteroids if no immediate response, or if
patient recently took oral glucocorticosteroids, or if episode is
severe
• Sedation is contraindicated in the treatment of an exacerbation
Reassess after 1 Hour

Physical Examination, PEF, O2 saturation and other tests as needed
Criteria for Moderate Episodes: Criteria for Severe Episodes:

•PEF 60-80% predicted/personal •History of risk factors for near fatal
best asthma
•Physical Exam: moderate •PEF <60% predicted/personal best
symptoms, accessory muscle use •Physical Exam: severe symptoms at
rest, chest retraction
Treatment •No improvement after initial treatment
•Oxygen
•Inhaled B2-agonist and inhaled Treatment
anticholinergic every 60 min •Oxygen
•Oral glucocorticosteroids •Inhaled B2-agonist and inhaled
•Continue treatment for 1-3 hours, anticholinergic
provided there is improvement •Systemic glucocorticosteroids
•IV magnesium
Reassess after 1-2 Hours

Good Response within Incomplete Response Poor Response within 1-2
1-2 Hours: within 1-2 Hours: Hours:
•Response sustained 60 •Risk Factors for near fatal •Risk Factors for near fatal
min after last treatment asthma asthma
•Physical Exam normal: •Physical exam: mild to •Physical exam: symptoms
No distress moderate signs severe, drowsiness, confusion
•PEF>70% •PEF <60% •PEF <30%
•O2 saturation> 90% (95% •O2 saturation not improving •PO2 >45 mm Hg
children) •PO2 <60 mm Hg
Admit to Acute Care
Admit to Intensive Care:
Setting: •Oxygen
•Oxygen
•Inhaled B2-agonist+-
anticholinergic
anticholinergic •IV glucocorticosteroid
Improved: Criteria for •Systemic
•Consider IV B2-agonist
Discharge Home glucocorticosteroid •Consider IV theophylline
•PEF>60% •IV Magnesium
•Possible intubation and
predicted/personal best •Monitor PEF, O2 saturation,
mechanical ventilation
•Sustained on oral/inhaled pulse
medication Reassess at intervals
Home Treatment: Poor Response (see above):
•Continue inhaled B2-agonist •Admit to Intensive Care
•Consider, in most cases, oral
glucocorticosteroids Incomplete response in 6-12 hours (see
•Consider adding a combination inhaler above)
•Consider Admission to Intensive Care if no
•Patient education: 1.Take Medicine
improvement w/in 6-12 hrs
correctly 2. Review action plan 3. Close
medical follow-up Improved (see opposite)
Particular attention should be given to patients
who present with the following features, as they
are the ones most prone to develop acute
respiratory failure:
1) cyanosis
2) absence of wheeze
3) bradycardia and bradypnea
4) paradoxical thoraco-abdominal movement
5) drowsiness or confusion
6) a normal or elevated pCO2 in a patient with
severe distress
High Risk Patients
 special attention should be given to patients who are

considered high risk:
1) infants in moderate/severe exacerbation

2) current use or recent withdrawal (< 1 week) from systemic
corticosteroids
3) hospitalization for moderate or severe asthma in the past year
4) prior intubation or history of impending respiratory failure
from asthma
5) psychiatric disease or psychosocial problems
6) difficulty perceiving airflow obstruction or its severity, and
7) non-compliance with asthma medication plan.
High Risk Patients:
 These are the patients who have the

potential to go into sudden and severe
airway obstruction which may lead to
respiratory failure or death.
 They should be educated to seek medical

care early during an exacerbation.
Advanced Care of Asthma
Exacerbations
Hospitalization
The following features can serve as guides

on whether the patient requires
hospitalization:
1) severity of attack - severe exacerbation or

impending respiratory failure
2) persistent severe airflow obstruction
(PEFR < 60%)
3) history of severe exacerbations
4)current use or recent withdrawal from
systemic corticosteroids
5) inadequacy of support and home
conditions
Admission to Intensive Care Unit
Admission to the ICU is recommended in the

following situations:
1) progressive worsening of asthma

symptoms despite initial
management
2) presence of sensorial changes
(drowsiness, confusion) or loss
of consciousness
3) signs of respiratory fatigue (e.g. declining
respiratory rate)
4) impending respiratory arrest (paO2 < 60
mmHg on
Patient Discharge
From the Emergency Room
1) symptoms are absent or minimal

2) PEFR > 80% predicted
3) sustained response for at least four (4)
hours
( GOOD RESPONDERS)
Patient Discharge
From the Hospital
1) physical examination is normal or near

normal
2) no nocturnal awakenings
4) sustained response to inhaled short-acting
β 2 agonist (at least 4 hours)
2006 updates
9. The six-part asthma management program
has been changed. The current program
has 5 components:
Component 1: Develop Doctor Patient
Relationship
Component 2: Identify and Reduce
Exposure to Risk Factors
Component 3: Assess, Treat, and Monitor
Asthma
Component 4: Manage Asthma
Exacerbations
Component 5: Special Considerations
Objective Measures
Mild Moderate Severe Respiratory Arrest
Imminent
Pulsus Absent May be Often present Absence suggests
Paradoxus <10 mm Hg present 20-40 mm Hg respiratory muscle
10-20 mm Hg fatigue
PEF ≥ 80% 60-79% < 60 %
%predicted or
%personal
best
paO2 (on air) Normal ≥60 mm Hg < 60 mm Hg
Test not Possible
and/or usually cyanosis
paCO2 necessary ≤ 45 mm Hg ≥ 45 mm Hg
≤ 45 mm Hg Possible resp
failure
SaO2% (on air) ≥ 95% 90-94% < 90%
Figure 4.4-2: Management of Asthma Exacerbation in Acute Care Setting
Initial Assessment (see Figure 4.4-1)

• History,
physical examination (auscultation, use of accessory
muscles, heart rate, PEF or FEV1, oxygen saturation, arterial blood
gas if patient in extremis)
Initial Treatment
• Oxygen to achieve O2 saturation > 90% (95% in children)
• Inhaled rapid- acting B2 agonist continuously for one hour
• Systemic glucocorticosteroids if no immediate response, or if
patient recently took oral glucocorticosteroids, or if episode is
severe
• Sedation is contraindicated in the treatment of an exacerbation

Criteria for Moderate Episodes: Criteria for Severe Episodes:

•PEF 60-80% predicted/personal •History of risk factors for near fatal
best asthma
•Physical Exam: moderate •PEF <60% predicted/personal best
symptoms, accessory muscle use •Physical Exam: severe symptoms at
rest, chest retraction
Treatment •No improvement after initial treatment
•Oxygen
•Inhaled B2-agonist and inhaled Treatment
anticholinergic every 60 min •Oxygen
•Oral glucocorticosteroids •Inhaled B2-agonist and inhaled
•Continue treatment for 1-3 hours, anticholinergic
provided there is improvement •Systemic glucocorticosteroids
•IV magnesium
Reassess after 1-2 Hours

Good Response within Incomplete Response Poor Response within 1-2
1-2 Hours: within 1-2 Hours: Hours:
•Response sustained 60 •Risk Factors for near fatal •Risk Factors for near fatal
min after last treatment asthma asthma
•Physical Exam normal: •Physical exam: mild to •Physical exam: symptoms
No distress moderate signs severe, drowsiness, confusion
•PEF>70% •PEF <60% •PEF <30%
•O2 saturation> 90% (95% •O2 saturation not improving •PO2 >45 mm Hg
children) •PO2 <60 mm Hg
Admit to Acute Care
Admit to Intensive Care:
Setting: •Oxygen
•Oxygen
anticholinergic
anticholinergic •IV glucocorticosteroid
Improved: Criteria for •Systemic
•Consider IV B2-agonist
Discharge Home glucocorticosteroid •Consider IV theophylline
•PEF>60% •IV Magnesium
•Possible intubation and
predicted/personal best •Monitor PEF, O2 saturation,
mechanical ventilation
•Sustained on oral/inhaled pulse
medication Reassess at intervals
Home Treatment: Poor Response (see above):
•Continue inhaled B2-agonist •Admit to Intensive Care
•Consider, in most cases, oral
glucocorticosteroids Incomplete response in 6-12 hours (see
•Consider adding a combination inhaler above)
•Consider Admission to Intensive Care if no
•Patient education: 1.Take Medicine
improvement w/in 6-12 hrs
correctly 2. Review action plan 3. Close
medical follow-up Improved (see opposite)
Particular attention should be given to patients
who present with the following features, as they
are the ones most prone to develop acute
respiratory failure:
1) cyanosis
2) absence of wheeze
3) bradycardia and bradypnea
4) paradoxical thoraco-abdominal movement
5) drowsiness or confusion
6) a normal or elevated pCO2 in a patient with
severe distress
High Risk Patients
 special attention should be given to patients who are

considered high risk:
1) infants in moderate/severe exacerbation

2) current use or recent withdrawal (< 1 week) from systemic
corticosteroids
3) hospitalization for moderate or severe asthma in the past year
4) prior intubation or history of impending respiratory failure
from asthma
5) psychiatric disease or psychosocial problems
6) difficulty perceiving airflow obstruction or its severity, and
7) non-compliance with asthma medication plan.
High Risk Patients:
 These are the patients who have the

potential to go into sudden and severe
airway obstruction which may lead to
respiratory failure or death.
 They should be educated to seek medical

care early during an exacerbation.
Advanced Care of Asthma
Exacerbations
Hospitalization
The following features can serve as guides

on whether the patient requires
hospitalization:
1) severity of attack - severe exacerbation or

impending respiratory failure
2) persistent severe airflow obstruction
(PEFR < 60%)
3) history of severe exacerbations
4)current use or recent withdrawal from
systemic corticosteroids
5) inadequacy of support and home
conditions
Admission to Intensive Care Unit
Admission to the ICU is recommended in the

following situations:
1) progressive worsening of asthma

symptoms despite initial
management
2) presence of sensorial changes
(drowsiness, confusion) or loss
of consciousness
3) signs of respiratory fatigue (e.g. declining
respiratory rate)
4) impending respiratory arrest (paO2 < 60
mmHg on
Patient Discharge
From the Emergency Room
1) symptoms are absent or minimal

3) sustained response for at least four (4)
hours
( GOOD RESPONDERS)
Patient Discharge
From the Hospital
1) physical examination is normal or near

normal
2) no nocturnal awakenings
4) sustained response to inhaled short-acting
β 2 agonist (at least 4 hours)
2006 updates
9. The six-part asthma management program
has been changed. The current program
has 5 components:
Component 1: Develop Doctor Patient
Relationship
Component 2: Identify and Reduce
Exposure to Risk Factors
Component 3: Assess, Treat, and Monitor
Asthma
Component 4: Manage Asthma
Exacerbations
Component 5: Special Considerations
WHAT DETERMINES DISEASE
CLASSIFICATION IN GINA 2002
• Worst feature determines the
severity classification
• Useful when decisions are being
made about management at the
initial assessment of a patient
ASTHMA SEVERITY
(GINA 2002)
• Involves both the severity of the

underlying disease and its
responsiveness to treatment.
• May change over months or years
VALUE OF GINA 2002 GUIDELINES
• Cross sectional means of
characterizing patients with asthma
who are not on inhaled
corticosteroids treatment
–No maintenance
–Newly diagnosed
–No previous consult
• No longer recommended as
basis for ongoing treatment
GINA ASTHMA
GUIDELINES:
Questions to consider in the Diagnosis of Asthma
• Has the patient had an attack or recurrent attacks of wheezing?
• Does the patient have a troublesome cough at night?
• Does the patient wheeze or cough after exercise?
• Does the patient experience wheezing, chest tightness or cough

after exposure to airborne allergens or pollutants?
• Do the patient’s colds “go to the chest” or take more than 10 days
to clear up?
• Are symptoms improved by appropriate asthma treatment?

2002
Recommended Medications by Level of Severity: Children
All Steps: In addition to daily controller therapy, rapid-acting inhaled β2 agonist* should be taken as
needed to relieve symptoms, but should not be taken more than 3 to 4 times a day.
INTERMITTENT PERSISTENT
MILD MODERATE SEVERE
Daily Controller • None IGCS 400-800µg BUD • IGCS >800µg BUD
• IGCS
Medications necessary 100-400mcg
PLUS one or more
of the following:
BUD
•IGCS< 800µg BUD • Sustained-

• Sustained-
Other release
PLUS release theophylline
Sustained released
Treatment Theophylline,
theophylline OR • Long Acting Inhaled
Options β-2 agonist
OR
• IGCS <800µg BUD
•PLUS LABA • Leukotriene modifier
• Cromone,
OR
OR
• IGCS >800µg OR • Oral glucocortico
• Leukotriene
•IGCS <800mcg PLUS steroid
modifier
• Leukotriene
modifier
In all steps: Once control of asthma is achieved and maintained for at least 3months, a gradual
reduction of the maintenance therapy should be tried in order to identify the minimum therapy
required to maintain control
GINA 2006, 2007
REDUCE

controlled
controlling step
INCREASE

GINA 2006, 2007
asthma education
environmental control
as needed
rapid
acting β2-
as needed rapid acting β2-
agonist SELECT agonist
SELECT ONE ADD ONE OR ADD ONE OR
ONE MORE BOTH
low-dose low-dose ICS Medium- or Oral gluco-
ICS* plus LABA high-dose ICS corticosteroid
CONTROLLER
plus LABA
leukotriene Medium- or leukotriene Anti-IgE
OPTIONS
modifier** high-dose modifier treatment

ICS ICS
low-dose sustained-
plus release
leukotriene theophylline
modifier
low-dose ICS
plus
leukotriene
* Inhaled glucocorticosteroid
modifier
** receptor antagonist or synthesis inhibitors
Montelukast+Budesonide vs.
Double Dose of Budesonide
Price, D.B. et. Al., Thorax 2003; 58: 211-216

Montelukast vs. Corticosteroid
based on Quality of Life
Price, D.B. et. Al., Thorax 2003; 58: 211-216

Asthma Lecture Cagayan de Oro Pediatric A 2008

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Asthma Lecture Cagayan de Oro Pediatric A 2008

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UPDATES IN THE

Why was a revision necessary ?

5. Current level of control around the world fall

7. The Philippines is also “missing the mark”

Concept of “Difficult to treat Asthma” is

PATHOLOGY: Acute and Chronic Inflammation

Inflammation affects all airways

Pathophysiology: Airway Narrowing :

Airway Hyper responsiveness

3) Males: (Height in cm. – 100) 5 + 175

2) Females: (Height in cm – 100) 5 + 170

Peak Flow Highest reading - Lowest

The previous classification by

Intermittent: Mild Moderate Severe

Symptoms less than Symptoms more Symptoms daily Symptoms daily

Daytime Symptoms < 1x a week ≥1x/wk Daily Daily

PEF ≥ 80% ≥80% >60-<79% <60%

PEF Variability ≤ 20% 20-30% >30%

maintain and find lowest

exacerbation treat as exacerbation

DEFINITION: IMPACT OF THE CLINICAL,PHYSIOLOGICAL

Asthma severity: Asthma severity is measured NOT

Measurement of allergic state helps to identify

• Refers to control of the clinical

Clinical Control of asthma is defined as:

Nocturnal symptoms/ None Any

Need for None (2x or More than 2x/ wk

Lung function (PEF or Normal <80% predicted or

Treatment options are organized into five

Step 2: Is the initial treatment for most

Step 3: Commence treatment here if

Normal lung function in between

Asthma in Acute Exacerbation

Breathless Walking Talking At rest

Talks in Sentences Phrases Words

Alertness May be agitated Usually agitated Usually agitated

Respiratory Rate Increased Increased *Often >30/min Bradypnea

GUIDE TO RATES OF BREATHING ASSOCIATED WITH

Severity of Asthma Exacerbations

Accessory None Present Present Present

Wheeze Audible with Audible with Audible w/o Absence of wheeze

Pulses/min <100 100-120 >120 Bradycardia

GUIDE TO LIMITS OF NORMAL PULSE RATE IN CHILDREN

Pulses Paradoxus Absent May be present Often present Absence suggests

PEF ≥ 80% 60-79% <60%

PaO2 RA Normal ≥60mm Hg <60mmHg

PaCO2 ≤45 mm Hg ≤45 mm Hg >45 mm Hg possible

SaO2 RA ≥95% 90-94% <90%

Reassess after 1 hour : PE, PEF, O2

Criteria for MODERATE Episode: Criteria for SEVERE Episode:

Management of Asthma Exacerbation in Acute Care

No added benefit over Salbutamol

However, any moderate to severe

Medicines in Childhood Asthma

When asthma is controlled with:

• IGCS alone in medium to high dose a 50% reduction in dose

cont. Maintenance Therapy:

IGCS and controllers other the LABA,

Controller treatment may be stopped if

When asthma is NOT controlled with:

• Rapid onset, short acting or long acting β2 agonist

• Inhaled glucocorticosteroids. Temporarily doubling the dose of

• Combination of Inhaled Glucocorticosteroids and rapid