Dr Aljohara Almeneessier 2013 Bronchial asthma Dr Aljohara Almeneessier 2013

Between 100 and 150 million people around the globe suffer from asthma and this number is rising. World-wide, deaths from this condition have reached over 180,000 annually World-wide, the economic costs associated with asthma are estimated to exceed those of TB and HIV/AIDS combined. Bronchial asthma Fact sheet N°206, http://www.who.int/mediacentre/factsheets/fs206/en/

By the end of this session , the learner should be able to: Highlight the prevalence of bronchial asthma in Saudi Arabia Highlight the etiology of bronchial asthma Understand the pathophysiology of bronchial asthma Discuss the clinical features of bronchial asthma Recognize the effect of bronchial asthma on individuals, family, community and environment. Discuss the evidence based approach and management (SINA) of bronchial asthma patients in family medicine setting

Epidemiology

It is one of the most common chronic diseases in Saudi Arabia, affecting more than 2 million Saudis. A recent study conducted by the STS investigated the prevalence of asthma and associated symptoms in 16- to 18 year-old adolescents in Riyadh. The prevalence of lifetime wheeze, wheeze during the past 12 months, and physician-diagnosed asthma was 25.3%, 18.5%, and 19.6%, respectively The prevalence of exercise-induced wheezing and night coughing in the past 12 months was 20.2% and 25.7%, respectively. The Saudi Initiative for Asthma (SINA): Guidelines for the diagnosis and management of asthma in adults and children www.sinagruop.org

Although the prevalence of asthma in Saudi Arabian adults is unknown, the overall prevalence of asthma in Saudi children has been reported to range from 8% to 25%, based on studies conducted over the past three decades. The highest prevalence of physician-diagnosed asthma in Saudi Arabia was reported to be 25% in 2004. The Saudi Initiative for Asthma (SINA): Guidelines for the diagnosis and management of asthma in adults and children www.sinagruop.org

Pathophysiology

What is the Pathophysiology? Trigger Factor Mast cell Mediators : histamine,prostaglandin,leukotrienes,as well as cytokines. Inflammatory cells Sustained Inflammatory response Contraction of airway smooth muscles (Bronchoconstriction)

Pathophysiology (Cont.) Airway wall swelling (mucosal edema) Airway hyper responsiveness Chronic changes Hypertrophy of the smooth muscles, thickening of the basement membrane Airway remodeling There is good evidence that asthma occurs in families.

Etiology Factors that can contribute to asthma or airway hyper-reactivity (trigger) may include any of the following: Environmental allergens (eg, house dust mites; animal allergens, especially cat and dog; cockroach allergens; and fungi) Viral respiratory tract infections Exercise, hyperventilation Gastroesophageal reflux disease Chronic sinusitis or rhinitis Drugs : Aspirin or nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity, sulfite sensitivity Use of beta-adrenergic receptor blockers (including ophthalmic preparations) Obesity

Environmental pollutants, tobacco smoke Occupational exposure Etiology Environmental pollutants, tobacco smoke Occupational exposure Irritants (eg, household sprays, paint fumes) Various high- and low-molecular-weight compounds (eg, insects, plants, latex, gums, diisocyanates, anhydrides, wood dust, and fluxes; associated with occupational asthma) Emotional factors or stress Perinatal factors (prematurity and increased maternal age; maternal smoking and prenatal exposure to tobacco smoke; breastfeeding has not been definitely shown to be protective

Diagnosis & assessment

The diagnosis of asthma is based on clinical assessment as there is no gold standard diagnostic test for asthma American Thoracic Society : 4 out of 5 Wheezing with colds Wheezing apart from colds. Dyspnea associated with wheeze. Wheeze after exertion Persistent cough

Patient may present with wheeze, breathlessness, chest tightness, and cough, particularly if symptoms are worse at night and in the early morning; occur in response to exercise, allergen exposure, and cold air; occur after taking aspirin or beta-blockers; occur even when the person has not got a cold. Hx History of atopic disorder. Family history of asthma and/or atopic disorder. PE Widespread wheeze (bilateral, predominantly expiratory). Prolonged expiration. Increased respiratory rate.

Relevant questions in the diagnosis of asthma Does the patient or his/her family have a history of asthma or other atopic conditions, such as eczema or allergic rhinitis? Does the patient have 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 pollens, dust, feathered or furry animals, exercise, viral infection, or environmental smoke (cigarettes, burning incense “Bukhoor,” or wood?

Relevant questions in the diagnosis of asthma Does the patient experience worsening of symptoms after taking aspirin/nonsteroidal antiinflammatory medication or use of B-blockers? Does the patient’s cold “go to the chest” or take more than 10 days to clear up? Are symptoms improved by appropriate asthma treatment? Are there any features suggestive of occupational asthma?

Pulse Oximetry Assessment Pulse oximetry measurement is desirable in all patients with acute asthma to exclude hypoxemia. Oxygen saturation of 97% or above constitutes mild asthma, 92-97% constitutes moderate asthma, less than 92% signifies severe asthma. Although an isolated pulse oximetry reading at triage is not predictive in most cases.

Pulmonary Function Testing (PFT) Spirometry assessments should be obtained as the primary test to establish the asthma diagnosis. Spirometry should be performed prior to initiating treatment in order to establish the presence and determine the severity of baseline airway obstruction. Optimally, the initial spirometry should also include measurements before and after inhalation of a short-acting bronchodilator in all patients in whom the diagnosis of asthma is considered.

The forced vital capacity (FVC), Pulmonary Function Testing (PFT) Spirometry measures: The forced vital capacity (FVC), The maximal amount of air expired from the point of maximal inhalation The forced expiratory volume in one second (FEV1). A reduced ratio of FEV1 to FVC, when compared with predicted values, demonstrates the presence of airway obstruction. Reversibility is demonstrated by an increase of 12% and 200 mL after the administration of a short-acting bronchodilator.

Differential Diagnoses Airway Foreign Body Allergic and Environmental Asthma Aspergillosis Bronchiectasis Bronchiolitis Chronic Obstructive Pulmonary Disease Churg-Strauss Syndrome Cystic Fibrosis GERD Heart Failure Pulmonary Embolism Pulmonary Eosinophilia Sarcoidosis Sinusitis, Chronic Tracheomalacia Upper Respiratory Tract Infection Vocal Cord Dysfunction

Management of Asthma

Approach Considerations Medical care includes treatment of acute asthmatic episodes and control of chronic symptoms, including nocturnal and exercise-induced asthmatic symptoms. the ultimate goal is to prevent symptoms, minimize morbidity from acute episodes, and prevent functional and psychological morbidity to provide a healthy (or near healthy) lifestyle

Achieve and maintain control of asthma symptoms Approach Considerations The goals for successful management of asthma outlined in the 2008 US National Heart, Lung, and Blood Institute publication "Global Strategy for Asthma Management and Prevention" include the following : Achieve and maintain control of asthma symptoms Maintain normal activity levels, including exercise Maintain pulmonary function as close to normal as possible Prevent asthma exacerbations Avoid adverse effects from asthma medications Prevent asthma mortality

Environmental Control Environmental exposures and irritants can play a strong role in symptom exacerbations. In patients who have persistent asthma, the use of skin testing or in vitro testing to assess sensitivity to perennial indoor allergens is important. Once the offending allergens are identified, counsel patients on avoidance from these exposures. In addition, education to avoid tobacco smoke (both first-hand and second-hand exposure) is important for patients with asthma

The key points of education include the following: Patient Education Patient education about asthma and establish a partnership between patient and clinician in the management of the disease. The key points of education include the following: Patient education should be integrated into every aspect of asthma care All members of the healthcare team, including nurses, pharmacists, and respiratory therapists, should provide education. Clinicians should teach patients asthma self-management based on basic asthma facts, self-monitoring techniques, the role of medications, inhaler use, and environmental control measures. SINA 2013, www.sinagroup.org

Patient Education (cont) The key points of education include the following: Treatment goals should be developed for the patient and family. A written, individualized, daily self-management plan should be developed. Several well-validated asthma action plans are now available and are key in the management of asthma and should therefore be reviewed: ACT (Asthma Control Test), ATAQ (Asthma Therapy Assessment Questionnaire), and ACQ (Asthma Control Questionnaire). SINA 2013, www.sinagroup.org

Patient Referal Refer any patient with moderate-to-severe persistent asthma that is difficult to control to a pulmonologist or allergist to ensure proper stepwise asthma management. Refer for further evaluation to help rule out other diagnoses such as vocal cord dysfunction. Abnormalities found on chest radiography screening should prompt referral to a specialist for further evaluation. Refer patients to an allergist or immunologist for skin testing to guide indoor allergen mitigation efforts and consideration of immunotherapy to treat seasonal allergic rhinitis. Refer patients to a pulmonologist for evaluation of symptoms consistent with exercise-induced asthma (EIA), or exercise-induced bronchospasm (EIB). Refer patients to an otolaryngologist for treatment of nasal obstruction from polyps, sinusitis, or allergic rhinitis or for the diagnosis of upper airway disorders.

General guidelines for asthma treatment

Stepwise Pharmacologic Therapy The pharmacologic treatment of asthma is based on stepwise therapy. Asthma medications should be added or deleted as the frequency and severity of the patient's symptoms change. Step 1 - Intermittent asthma The reliever medication is a short-acting beta-agonist as needed for symptoms. Step 2 - Mild persistent asthma The preferred controller medication is a low-dose inhaled corticosteroid. Step 3 - Moderate persistent asthma The preferred controller medication is either a low-dose inhaled corticosteroid plus a long-acting beta-agonist Step 4 - Moderate-to-severe persistent asthma The preferred controller medication is an inhaled medium-dose corticosteroid plus a leukotriene receptor antagonist (combination therapy).

Step 5 - Severe persistent asthma The preferred controller medication is an inhaled high-dose corticosteroid plus a leukotriene receptor agonist. Consider omalizumab for patients who have allergies. Step 6 - Severe persistent asthma The preferred controller medication is a high-dose inhaled corticosteroid plus a leukotriene receptor agonist plus an oral corticosteroid. Consider omalizumab for patients who have allergies. Quick relief medication can be used for all patients and severities listed above. A short-acting beta agonist, as needed for symptoms, can be used. The intensity of treatment depends on the severity of symptoms.

Clinical case Ahmed 16 years old come to primary care clinic complaining of chronic cough for the last 3 months, mainly at night . How will you approach this patient?

Summary Asthma is a common chronic disorder of the airways, characterized by variable reversible and recurring symptoms related to airflow obstruction, bronchial hyper-responsiveness, and underlying inflammation. Asthma is a chronic inflammatory disease that is associated with fluctuating control, based on factors such as allergen exposure and viral infections It remains a major public health burden and from a public health perspective being a major driver of health care costs.

Summary In the absence of access to medications, appropriate education on how to use medications, especially at the time asthma worsens, the patient will commonly have poorly controlled asthma. Its impact is manifested in patients, their families, and the community as a whole in terms of lost work and school days, poor quality of life, frequent emergency department visits, hospitalizations, and deaths.