Dr Mazen Qusaibaty MD, DIS / Head Pulmonary and Internist Department Ibnalnafisse Hospital Ministry of Syrian health – Dr Mazen Qusaibaty MD, DIS / Head Pulmonary and Internist Department Ibnalnafisse Hospital Ministry of Syrian health – Asthma 07

Goals of Asthma Care 2

3

4 National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma (EPR-3) Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; August NIH publication no BetterQuality of life Better Quality of life

Reduce Impairment 5

None need to Reliever Medications (2 / week) (2 or less / week) Reduce Impairment

Free night symptoms Reduce Impairment

Normal Physical activity

with minimal or No adverse effects No adverse effects 9 National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma (EPR-3) Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; August NIH publication no Reduce Impairment

Reduce Risk 10

Prevent reduced lung growth at children 11

12 Prevent progressive loss of lung function 1 Time (sec) 2345 FEV 1 Volume Normal Subject Asthmatic (After Bronchodilator) Asthmatic (Before Bronchodilator)

Reduce Risk Minimize the need for ED visits/Hospital 13 National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma (EPR-3) Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; August NIH publication no

14 NoExacerbation

No Exacerbation NNNNo Systemic steroid NNNNo Emergency department NNNNo Hospital admission

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17

National Asthma Education and Prevention Program: Expert Panel Report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD. National Heart, Lung, and Blood Institute, 2007

Quick Relief Medications Relief Medications

Quick Salbutamol Short-Acting inhaled β2- Agonists (SABA) Terbutaline

Quick Relief Medications Relief Medications Salbutamol Short-Acting inhaled β2- Agonists (SABA) Terbutaline Ipratropium bromide Anticholinergics (SAMA)

Quick Relief Medications Relief Medications Moderate or Severe asthma exacerbation Earlyshort course of oral glucocorticoids Early short course of oral glucocorticoids Rachelefsky G. Treating exacerbations of asthma in children: the role of systemic corticosteroids. Pediatrics 2003; 112:382./Rowe BH, Spooner C, Ducharme FM, et al. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev 2001; :CD002178

Quick Relief Medications Relief Medications Moderate or Severe asthma exacerbation Early short course of oral glucocorticoids 1.Reduces the duration of exacerbation 2.Can prevent hospitalization and relapse In systematic review and meta-analysis Rachelefsky G. Treating exacerbations of asthma in children: the role of systemic corticosteroids. Pediatrics 2003; 112:382./Rowe BH, Spooner C, Ducharme FM, et al. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev 2001; :CD002178

Quick Relief Medications Relief Medications Higher doses of inhaled glucocorticoids (more than two times the usual dose) Foresi A, Morelli MC, Catena E. Low-dose budesonide with the addition of an increased dose during exacerbations is effective in long-term asthma control. On behalf of the Italian Study Group. Chest 2000; 117:440.

Quick Relief Medications Relief Medications Higher doses of inhaled glucocorticoids (more than two times the usual dose) May be an alternative for: 1.Mild to moderate exacerbations (No Wheeze) 2.Have serious adverse effects with systemic glucocorticoids Foresi A, Morelli MC, Catena E. Low-dose budesonide with the addition of an increased dose during exacerbations is effective in long-term asthma control. On behalf of the Italian Study Group. Chest 2000; 117:440.

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Controller Medications Inhaled glucocorticosteroids (ICS : Budesonide, Fluticasone, Beclomethasone, Flunisolide, Mometasone, Ciclesonide )

Controller Medications Inhaled glucocorticosteroids (ICS : Budesonide, Fluticasone, Beclomethasone, Flunisolide, Mometasone, Ciclesonide ) Long-Acting inhaled β2-Agonists (LABA : Salmeterol, Formoterol )

Controller Medications Inhaled glucocorticosteroids (ICS : Budesonide, Fluticasone, Beclomethasone, Flunisolide, Mometasone, Ciclesonide ) Long-Acting inhaled β2-Agonists (LABA : salmeterol, formoterol ) ICS + LABA

Controller Medications Inhaled glucocorticosteroids (ICS : Budesonide, Fluticasone, Beclomethasone, Flunisolide, Mometasone, Ciclesonide ) Long-Acting inhaled β2-Agonists (LABA : salmeterol, formoterol ) ICS + LABA Leukotrienes Modifiers (LM : Montelukast, Zafirlukast, Zileuton )

Controller Medications Inhaled glucocorticosteroids (ICS : Budesonide, Fluticasone, Beclomethasone, Flunisolide, Mometasone, Ciclesonide ) Long-Acting inhaled β2-Agonists (LABA : salmeterol, formoterol ) ICS + LABA Leukotrienes Modifiers (LM : Montelukast, Zafirlukast, Zileuton ) Sustained release Theophylline

Controller Medications Inhaled glucocorticosteroids (ICS : Budesonide, Fluticasone, Beclomethasone, Flunisolide, Mometasone, Ciclesonide ) Long-Acting inhaled β2-Agonists (LABA : salmeterol, formoterol ) ICS + LABA Leukotrienes Modifiers (LM : Montelukast, Zafirlukast, Zileuton ) Sustained release Theophylline Systemic Glucocorticoids

Controller Medications Inhaled glucocorticosteroids (ICS : Budesonide, Fluticasone, Beclomethasone, Flunisolide, Mometasone, Ciclesonide ) Long-Acting inhaled β2-Agonists (LABA : salmeterol, formoterol ) ICS + LABA Leukotrienes Modifiers (LM : Montelukast, Zafirlukast, Zileuton ) Sustained release Theophylline Systemic Glucocorticoids Anti -IgE Therapy

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CORTICOSTEROIDS Cellular Effects of Corticosteroids Eosinophil T-lymphocyte Mast cell Macrophage Dendritic cell  Numbers (apoptosis)  Cytokines  Numbers  Cytokines  Numbers Inflammatory cells Epithelial cell Endothelial cell Airway smooth muscle Mucus gland  Cytokines  Mediators  Leak  ß 2 -Receptors  Mucus secretion Structural cells  Cytokines Barnes, P. J. et. al. Ann Intern Med 2003;139:

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The management of chronic childhood asthma in children aged 0 to years

We recommend the initiation of controller therapy for children at high risk of developing persistent asthma (Grade 1A) We recommend the initiation of controller therapy for children at high risk of developing persistent asthma (Grade 1A) 41

The children at high risk of developing persistent asthma ?

43 Castro-Rodriguez JA. The Asthma Predictive Index: early diagnosis of asthma. Curr Opin Allergy Clin Immunol 2011; 11:157.

Castro-Rodriguez JA. The Asthma Predictive Index: early diagnosis of asthma. Curr Opin Allergy Clin Immunol 2011; 11:157.

45 Castro-Rodriguez JA. The Asthma Predictive Index: early diagnosis of asthma. Curr Opin Allergy Clin Immunol 2011; 11:157.

46 Castro-Rodriguez JA. The Asthma Predictive Index: early diagnosis of asthma. Curr Opin Allergy Clin Immunol 2011; 11:157.

We suggest the use of daily controller therapies for the following children We suggest the use of daily controller therapies for the following children (Grade 2C) (Grade 2C)

48 Johnston NW, Mandhane PJ, Dai J, et al. Attenuation of the September epidemic of asthma exacerbations in children: a randomized, controlled trial of montelukast added to usual therapy. Pediatrics 2007; 120:e702.

50 Upper Respiratory Infections

We suggest intermittent high-dose inhaled glucocorticoids and not using an oral glucocorticoid  Begun at the onset of a URI  Before wheezing has occurred  Continued for up to 10 days (Grade 2B) 51 Bacharier LB. Viral-induced wheezing episodes in preschool children: approaches to therapy. Curr Opin Pulm Med 2010; 16:31.

Fluticasone 750 mg inhaled twice daily Fluticasone propionate 750 mg inhaled twice daily Budesonide 1 mg nebulized twice daily Budesonide 1 mg nebulized twice daily 52

53

The management of chronic childhood asthma in children aged 0 4 years 0 to 4 years Oral Steroid Theophylline Long acting B2 agonist Leukotriene antagonist Short acting B2 agonist

55 The management of chronic childhood asthma in children aged 5 11 years chronic childhood asthma in children aged 5 to 11 years

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57

58

59

The benefits of Combination therapy Strategy

long-term control of asthma symptoms long-term control of asthma symptoms Prevent Prevent  Nocturnal symptoms  Exercise-induced bronchoconstriction 61 Nino G, Grunstein MM. Current concepts on the use of glucocorticosteroids and beta-2- adrenoreceptor agonists to treat childhood asthma. Curr Opin Pediatr 2010; 22:290.

(ICS + LABA) versus High dose of ICS 62 Castro-Rodriguez JA, Rodrigo GJ. A systematic review of long-acting 2-agonists versus higher doses of inhaled corticosteroids in asthma. Pediatrics 2012; 130:e650.

63 Initial assessment

4-6 weeks 3-6 months Steeping up 3-6 months Steeping down

65 Asthma Control Stepping

66 ICS (D)

01 67

01 68

01 69

LABA + ICS (H-M-L) once daily LABA + ICS (H-M-L) once daily70

03 71

03 72

The use of inhaler devices in patients 74

75 Arch Dis Child 2007;92: doi: /adc BottleSpacer

78 National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, (NIH publication no ) (Accessed on September 01, 2007).

79 Triggers