ASTHMA

GI NA 2014

Asthma
Is a heterogeneous disease, usually characterized by chronic airway
inflammation
It is defined by the history of respiratory symptoms
Wheeze
Shortness of breath
Chest tightness
Cough
Symptoms vary over time and in intensity, together with variable
expiratory airflow limitation
Variations are triggered by factors such as exercise, allergen or irritant
exposure, change in weather, or viral respiratory infections

Asthma phenotype
ASTHMA PHENOTYPE DESCRIPTION
Allergic asthma Starts in childhood, with hx of allergic diseases (eczema, rhinitis);
responds well to ICS
Non-allergic asthma May be eosinophilic/neutrophilic or few inflammatory cells
(paucigranulocytic); responds less well to ICS
Late-onset asthma Adults (women), non-allergic; requires higher doses of ICS (relatively
refractory)
Asthma with fixed airflow limitation Thought to be due to airway wall remodeling
Asthma with obesity Prominent respiratory symptoms and little eosinophilic airway
inflammation
DIAGNOSING
ASTHMA
Increases risk of px having asthma
>1 symptom (wheeze, shortness of breath, cough, chest
tightness), especially in adults
Symptoms often worse at night or early in the morning
Symptoms vary over time and in intensity
Symptoms are triggered by viral infections (common colds),
exercise, allergen exposure, changes in weather, laughter
or irritants (car exhaust fumes, smoke or strong smells)

Decreases risk of px having asthma
Isolated cough with no other respiratory symptoms
Chronic production of sputum
Shortness of breath associated with dizziness, light-
headedness or peripheral tingling (paresthesia)
Chest pain
Exercise-induced dyspnea with noisy inspiration
Diagnosing Asthma
Respiratory symptoms such as wheezing, dyspnea,
chest tightness, cough
Variable expiratory airflow limitation

DIAGNOSTIC FEATURE CRITERIA
1. History of variable respiratory symptoms
Wheezes, shortness of
breath, chest tightness
and cough
Generally more than one type of
respiratory symptom
Sx occur variably over time and vary in
intensity
Sx are often worse at night or on waking
Sx are often triggered by exercise,
laughter, allergens, cold air
Sx often appear or worsen with viral
infections
DIAGNOSTIC FEATURE CRITERIA
2. Confirmed variable expiratory airflow limitation
Documented excessive
variability in lung function

AND documented airflow
limitation
The greater the variations, or the more occasions excess
variation is seen, the more confident the diagnosis

At least once during diagnostic process when FEV1 is low,
confirm that FEV1/FVC is reduced (normally >0.75-0.80 in
adults, >0.90 in children)
Positive bronchodilator (BD)
reversibility test (more likely
positive if BD medication is
withheld before test: SABA
4h, LABA 15h
Adults: increase in FEV1 of >12% and >200 ml from
baseline, 10-15 minutes after 200-400 mcg albuterol or
equivalent (greater confidence if increase is >15% and
>400 ml)
Children: increase in FEV1 of >12% predicted
Excessive variability in 2x-daily
PEF over two weeks
Adults: average daily diurnal PEF variability >10%
Children: average daily diurnal PEF variability >13%
DIAGNOSTIC FEATURE CRITERIA
2. Confirmed variable expiratory airflow limitation
Significant increase in lung
function after 4 weeks of anti-
inflammatory treatment
Adults: Increase in FEV1 >12% or >200 ml from baseline
after 4 weeks of treatment, outside of respiratory
infections
Positive exercise challenge test Adults: fall in FEV1 of >10% and >200 ml from baseline
Children: fall in FEV1 of >12% predicted, or PEF >15%
Positive bronchial challenge
test (usually only performed in
adults)
Fall in FEV1 from baseline of 20% with standard doses
of methacholine or histamine, or 15% with standardized
hyperventilation , hypertonic saline or mannitol challenge
Excessive variation in lung
function between visits (less
reliable)
Adults: variation in FEV1 of >12% and >200 ml between
visits, outside of respiratory infections
Children: variation in FEV1 of >12% in FEV1 or >15% in
PEF between visits
History and PE
There is an increased risk that respiratory problems
are due to asthma if :
Respiratory symptoms start in childhood
History of allergic rhinitis or eczema
Family history of asthma or allergy
Nonspecific

PE
Often normal
Most frequent abnormality is expiratory wheezing (rhonchi) on
auscultation (this may be absent or heard only on forced
expiration)
Wheezing may also be absent in severe asthma exacerbations
due to severely reduced flow (silent chest)
Wheezing may also be heard in upper airway obstruction,
COPD, tracheomalacia, respiratory infection, and foreign body
PE
Crackles (crepitations) and inspiratory wheezing are not
features of asthma
Examination of nose may reveal rhinitis or nasal polyposis
FEV1 (Forced Expiratory Volume)
Lung disease or poor spirometric technique
Reduced ratio of FEV1 to FVC - indicates airflow limitation
Normal: FEV1/FVC >0.75-0.80; >0.90 in children
Once an obstructive defect has been
confirmed, variation in airflow limitation is
generally assessed from variation in FEV1
or PEF
VARIABILITY refers to improvement and/or
deterioration of symptoms and lung function
REVERSIBILITY
refers to rapid improvements in FEV1 or PEF measured
within minutes after inhalation of a rapid-acting
bronchodilator
or more sustained improvement over days or weeks after
the introduction of effective controller treatment
How much variation in expiratory
airflow is consistent with asthma?
The greater the variations in their lung function, or the
more times excess variation is seen, the more likely the
diagnosis is asthma
In adults with typical respiratory systems of asthma, an
increase or decrease in FEV1 of >12% and >200 ml of
baseline
(if spirometry is not available) a change of PEF of at least
20%
OTHER TESTS
1. Bronchial provocation test this test helps assess airway
hyperresponsiveness
2. Allergy tests allergen test or sIgE
o sIgE is preferred for uncooperative patients, those with widespread
skin disease, or hx suggests anaphylaxis)
3. Exhaled NO FENO is increased in eosinophilic asthma but also in
non-asthma conditions (e.g. eosinophilic bronchitis, atopy and
allergic rhinitis).
Age Condition Symptoms
6-11 years Chronic upper airway
cough syndrome
Inhaled foreign body
Bronchiectasis
Primary ciliary dyskinesia


12-39 years
40+ years

ASSESSMENT OF
ASTHMA
Assessment of asthma should
include the assessment of asthma
control (both symptom control and
future risk of adverse outcomes)
Ms X has good asthma symptom control, but she is at risk of increased of future exacerbations because she
has had a severe exacerbation within the last year



Asthma sx control tools in 6-11 y/o
Based on symptoms, limitation of activities and
use of rescue medication


Assessing Risk of adverse outcomes
Assess whether the patient is at risk of adverse
asthma outcome
Exacerbations
Fixed airflow limitation
Side effects of medication
Assessing Asthma Severity
MILD well controlled in Step 1or 2 treatment with
as-needed reliever medication alone or with low
intensity controller treatment
MODERATE well controlled in Step 3 treatment
SEVERE requires Step 4 or Step 5 treatment
TREATMENT
Long-term goals
To achieve good control of symptoms and maintain normal
activity levels
To minimize future risk of exacerbations, fixed airflow
limitation and side effects

ASTHMA MEDICATIONS
Controller medications: used for regular maintenance treatment.
They reduce airway inflammation, control sx, and reduce future risks
such as exacerbations and decrease in lung function
Reliever (rescue) medications: as-needed relief for breakthrough
symptoms, also recommended for short-term prevention of
exercise-induced bronchoconstriction. REDUCING AND IDEALLY ELIMINATING
RELIEVER TX IS BOTH AN IMPT GOAL IN ASTHMA MGT AND A MEASURE OF SUCCESS OF ASTHMA TX
Add-on therapies for px with severe asthma: for px with persistent
sx and severe exacerbations, despite optimized tx of high-dose
controlled medications
Initial Controller Treatment
Regular daily controller should be started as soon as asthma
is diagnosed, because:
Early initiation of low dose ICS in px with asthma leads to greater
improvement in lung function than if sx have been present for >2-4
years
Patients not taking ICS who experience a severe exacerbation have
a greater long-term decline in lung function than those who have
already started ICS
For px with occupational asthma, early removal from exposure to
the sensitizing agent and early tx increase the probability of
recovery
1`

Stepwise approach
Once tx has started: assessment adjustment
review of response
Controller medication is adjusted up or down in a
stepwise approach
Once asthma has been controlled in 2-3months, tx
may be stepped down in order to find patients
minimum effective tx
If px has persisting sx despite 2-3 months of controller tx,
assess
Incorrect inhaler technique
Poor adherence
Persistent exposure at home/work such as allergens, tobacco
smoke, indoor or outdoor air pollution, or medications such as
beta-blockers, or NSAIDS
Comorbidities that may contribute to respiratory sx and poor
quality of life
Incorrect diagnosis


STEP 1
AS NEEDED-RELIEVER INHALER
Preferred option As-needed inhaled SABA insufficient evidence in safety of using alone, thus
preferred in px with occasional daytime sx of short duration, with no night waking
and with normal lung fxn. If not, regular controller tx is needed
Other option Regular low dose ICS in addition to SABA
Other options not
recommended for
routine use
Inhaled anticholinergic (ipratropium)
Oral SABA
Oral acting theophylline

But with slower set of action and higher side effects
The rapid onset LABA, formeterol, is as effective as SABA in reliever medication,
but use of frequent SABA without ICS is discouraged because of risk of
exacerbations
STEP 2
LOW DOSE CONTROLLER MEDICATION PLUS AS-NEEDED RELIEVER MEDICATION
Preferred option Regular low dose ICS plus as-needed SABA low doses ICS reduces asthma sx, inc
lung fxn, reduces risk of exacerbation and asthma-related hospitalizations or
deaths
Other option LTRA - alternative, or for px with allergic rhinitis
Other options not
recommended for
routine use
Sustained release in theophylline weak efficacy in asthma, side effects are
common, life-threatening at higher doses

Chromones (nedocromil sodium and sodium cromoglycate) favourable safety
profile but low efficacy, and their inhalers require burdensome daily washing to
avoid blockage
Step 3
ONE OR TWO CONTROLLERS PLUS AS-NEEDED RELIEVER MEDICATION
Preferred option Adults/adolescents: Combination low dose ICS/LABA as maintenance treatment
plus as needed SABA OR (fluticasone furoate/vilanterol; fluticasone
proprionate/formoterol; fluticasone proprionate/salmeterol,
beclometasone/formeterol, budesonide/formeterol.; mometasone/formeterol)


combination low dose ICS/formoterol (budesonide or
buclesonide) as both maintenance and reliever

Children (6-11 ) years old: moderate dose ICS plus as-needed SABA
Other option Increase ICS to medium dose but less effective than adding a LABA
Low dose ICS plus either LTRA or low dose, sustained theophylline
Step 4
TWO OR MORE CONTROLLERS MEDICATION PLUS AS-NEEDED RELIEVER MEDICATION
Preferred option Adults/adolescents: combination low dose ICS/formoterol as maintenance and
reliever tx OR combination medium dose ICS/LABA plus as-needed SABA, in >1
exacerbations/yr, low dose ICS/formoterol as maintenance and reliever treatment
is more effective than maintenance and high dose ICS/LABA

Children: refer to expert assessment and device
Other option Combination high dose ICS/LABA but increase in ICS dose has little benefi