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Chronic Asthma Guidelines

-GINA 2019 - Global Initiative for Asthma
-EPR-3 - Diagnostic/Management of Asthma


Asthma Defintions

-Heterogeneous disease
-Chronic airway inflammation
-History of symptoms that vary over time and in severity
-Variable expiratory airflow limitation


Asthma Presentations

-Episodes of dyspnea
-Episodes of wheezing
-Tightness in chest
-Chronic daily OR intermittent symptoms
-Intervals between symptoms - weeks, months, year
-Characterized by recurrent exacerbations/remissions


Asthma Clinical Phenotypes

-Allergic asthma
-Non-allergic asthma
-Adult-onset asthma
-Asthma with persistent airflow limitation
-Asthma with obesity


Asthma Diagnosis - Need to determine...

-History of variable respiratory symptoms
-Confirm expiratory airflow limitation
-Make sure alternative diagnoses are excluded


Asthma Diagnosis Methods

-Detailed medical history
-Physical exam


Asthma - Medical History questions

-Types of symptoms
-Pattern of symptoms
-Precipitating/aggravating factors
-Development of disease/treatment
-Family history
-Social history
-Profile of typical exacerbation
-Impact of asthma on patient/family
-Assessment of patient/family perceptions


Asthma Triggers

-Respiratory infections - viral
-Environment factors - smoke, bakers, farmers
-Psychological factors - stress, depression
-Obesity - may increase prevalence and decrease control
-Gastroesophageal reflux - noctural symptoms associated with reflux
-Female hormones - increase symptoms during periods and premenstrual times
-Preservatives - benzalkonium chloride, sulfite sensitivity


Asthma Physical Exam Findings

The following increases the probability of asthma...
-Hyperexpansion of thorax
-Atopic dermatitis/eczema
-Can also be noctural


Pulmonary Function Tests

-Used to establish diagnosis of asthma
-Spirometry to establish reversibility
-FEV1 increases by more than 12% after using a SABA
-Perform initial visit, then retest 3-6 months afterwards
-Then perform test every 1-2 years once treatment is established


<5 y.o. Diagnosis - Asthma

-Recurrence of wheezing is common in large portion of kids due to viral URI
-Certain factors that increase or decrease asthma probability


< 5 y.o. Increased Asthma Factors

-Wheezing/coughing occurs with exercise, laughing, or crying with no infection
-History of other allergic diseases (eczema, allergic rhinitis)
-Asthma in primary relatives
-Clinical improvement over 2-3 months of controller treatment and worsening after cessation


< 5 y.o. Decreased Asthma Factors

-Isolated cough with no other respiratory symptoms
-Chronic production of sputum
-SOB with dizziness, light headed, peripheral tingling
-Chest pain
-Exercise-induced dyspnea with noisy inspiration (stridor)


2 Domains to Control with Asthma

Symptom Control
-Burden to patients
-Increases risk of exacerbations if they aren't controlled

Future Risk of Adverse Asthma Outcomes
-Loss of lung function
-Medication SE


Severe Risk Factors - Exacerbations

-Uncontrolled asthma symptoms
-Inadequate ICS: not prescribed, adherent, or incorrect technique
->= 1 exacerbation in past year
-Higher bronchodilation reversibility
-Major psychological or socioeconomic problems
-Comorbidities: chronic sinusitis, obesity, confirmed food allergy
-Sputum or blood eosinophilia
-Increased fractional concentration of exhaled NO (FNEO)
-Exposures: smoking, allergens, pollution
-Low FEV1 (<60% of predicted)
-High SABA use
-Ever intubated or ICU for asthma


Risk Factors: Decreased Lung Function

-Preterm birth
-Lack of ICS treatment
-Exposures: tobacco smoke, noxious chemicals, occupational exposure


Risk Factors: Medication SE

-Systemic rises from frequent oral CS use
-Long term, high dose ICS can also cause it
-Taking P450 inhibitors increases the risk for systemic SE as well
-Local SE rise from high dose ICS and poor inhaler technique


Asthma Goals of Therapy

-Avoid daytime and noctural symptoms
-Need little or no reliever medication
-Maintain normal activity levels
-Normal or near normal lung function
-Avoid serious asthma flare-ups
-Patient specific goals
-Minimize adverse effects


3 Asthma Medication Categories

1. Controlled - ICS, LABA
2. Reliever (Rescue) - SABA, SA anticholinergics, SCS
3. Add-on (Severe asthma)


Controller Medications

-Regular maintenance treatment
-Decreased inflammation
-Controls symptoms
-Decreases future risk of exacerbations and decreased lung function


Reliever Medications

-All patients with asthma should have one
-Relieve breakthrough symptoms
-Prevention of exercise-induced bronchoconstriction


Add-On Medications

-Severe Asthma
-For those with persistent symptoms/exacerbations with high dose controller meds
EX: leukotriene modifiers, long-acting mus. antagonists, OCS, methylxanthones, cromolyn, biologics


Presenting Symptom: Infrequent Symptoms

Initial Treatment: PRN low dose ICD - formoterol


Presenting Symptom: Asthma symptoms/reliever needed 2 times+/month

Initial Treatment: Low dose ICD or LTRA (less effective, theophylline)


Presenting Symptom: Troublesome asthma symptoms most days or waking asthma 1 times+/week

Initial Treatment: Medium dose ICS or Low dose ICD + LABA


Presenting Symptom: Severely uncontrolled asthma or acute exacerbations

Initial Treatment: Short course OCS AND high dose ICS
Medium dose ICS + LABA


How severe is the asthma?

-Assessed retrospectively from level of treatment required to control symptoms and exacerbations
-Assessed once controller treatment for severe months and, if appropriate, after step down therapy has been attempted


Step 1 Therapy

-Preferred Controller: None, PRN ICS + Formoterol
-Other Controller Options: Low dose ICS
-Reliver: PRN SABA
-Mild asthma


Step 2 Therapy

-Preferred Controller: Low dose ICS
-Other Controller Options: LTRA
-Reliever: PRN SABA
-Mild asthma


Step 3

-Preferred Controller: Low dose ICS + LABA OR Medium dose ICS (preferred for 6-11 y.o.)
-Other Controller Options: Medium dose ICS, low dose ICS + LABA
-Reliver: PRN SABA
-Moderate asthma


Step 4

-Preferred Controller: Medium dose ICS + LABA and a specialist
-Other controller options: Add-on tiotropium, high dose ICS, add-on LTRA
-Reliever: PRN SABA
-Severe asthma


Step 5

-Preferred Controller: High dose ICS + LABA and a specialist
-Other controller options: Low dose OCS, tiotropium, LTRA, biologics
-Reliever: PRN SABA
-Severe asthma


Step Down Therapy

-Considered after 3 months of control and lung function hits a plateau
-Few data on optimal timing, sequence, or magnitude
-Decrease ICS dose by 25-30% at 3 months intervals is safe for MOST
-Step-down approach based on patient's current medications and doses


Step Down Option: High dose ICS/LABA + OCS
OR High dose ICS/LABA + other add-on

-Continue high dose ICS/LABA, reduce OCS
-Alternate-day OCS
-Refer for expert advice


Step Down Option: Medium-high dose ICS/LABA
OR High dose ICS + second controller

-Continue combination; reduce ICS by 50%
-Discontinuing LABA may lead to deterioration
-Reduce ICS by 50% and continue second controller


Step Down Option: Low dose ICS/LABA
OR Moderate or high dose ICS

- Reduce ICS/LABA to once daily
- Discontinuing LABA may lead to deterioration
- Reduce ICS dose by 50%


Step Down Option: Low Dose ICS

- Once daily dosing
- Adding LTRA may allow ICS step down


Non-Pharm for Asthma

-Smoking cessation and environmental tobacco smoke avoidance
-Avoid occupational exposures
-Avoid medications that worsen asthma
-Avoid indoor/outdoor allergnes
-Weight loss
-Dealing with emotional stress


Check Following before Increasing Meds

-Inhaler technique
-Adherence to prescribed medications
-Environment changes
-Consider alternative diagnosis


Basic Asthma Educations

-Provide to ALL asthmatics
-Contrast normal and asthmatic airways
-What happens during an attack


Role of Medication Education

-Provide to ALL asthmatics
-Controller v.s. relievers


Skills Asthma Education

-Provide to ALL asthmatics
-Inhaler technique/device use
-Avoid environmental exposures
-How to use written action plan