2. ASTHMA MANAGEMENT AND PREVENTION

3. PREFACE Asthma affects an estimated 300 million individuals worldwide. Serious global health problem affecting all age groups increasing prevalence in many developing countries

5. What is asthma Asthma is a chronic inflammatory disease of the airways associated with widespread, variable outflow obstruction The outflow obstruction reverses either spontaneously or with medication The underlying inflammation is associated with bronchial hyper-responsiveness (BHR)

7. Clinical Manifestations Wheeze Cough Difficulty breathing Chest tightness

9. Risk factors Personal history of atopy. Family history of asthma or atopy. Triggers (eg, allergens such as pollens, animal dander), dust, exercise, viruses, chemicals, weather changes, emotional factors, irritants and smoke.[7]7 Urban environment. Socio-economic stresses. Obesity.[5]5

10. Risk factors Prematurity and low birth weight. Viral infections in early childhood. Maternal smoking. Smoking.[8]8 In vitro fertilisation. Early exposure to broad-spectrum antibiotics.[9]9 Breast-feeding possibly confers protection

11. MAKING THE DIAGNOSIS OF ASTHMA Asthma has two key defining features: 1- a history of respiratory symptoms such as wheeze, shortness of breath chest tightness and cough that vary over time and in intensity, often triggered by exercise, laughter, allergens or cold air Allergens : dust mites, molds, furry animals, cockroaches, and pollens… irritant-type exposures (eg, cigarette smoke, strong fumes, changes in weather, airborne chemicals or dusts) Viral infections are common triggers for asthma

12. MAKING THE DIAGNOSIS OF ASTHMA 2- variable expiratory airflow limitation. FEV1 increases by more than 12% and 200mLof the predicted value after inhaling a bronchodilator Average daily diurnal PEF variability is >10% FEV1 increases by more than 12% and 200mLfrom baseline after 4 weeks of anti-inflammatory treatment

15. MAKING THE DIAGNOSIS OF ASTHMA An other test to assist in diagnosis, is bronchial challenge(bronchoprovocation test by provocative stimulus (eg, inhaled methacholine, inhaled mannitol)methacholine mannitol Allergy tests are not useful for the diagnosis of asthma they can be helpful to confirm sensitivity to suspected allergic triggers of respiratory symptoms

17. Assessment of Asthma Control In the past 4 weeks, has the patient had : Daytime symptoms more than twice/week Any night waking due to asthma Reliever needed* more than twice/week Any activity limitation due to asthma Mesurement of FEV1

18. STEPWISE APPROACH FOR ADJUSTING TREATMENT STEP 1: As-needed SABA with no controller Symptoms are rare no night waking, no exacerbations in the last year, and normal FEV1)

20. STEPWISE APPROACH FOR ADJUSTING TREATMENT STEP 2: Regular low dose ICS plus as- needed SABA STEP 3: Low dose ICS/LABA either as maintenance treatment plus as-needed SABA, or as ICS/formoterol maintenance and reliever therapy

21. STEPWISE APPROACH FOR ADJUSTING TREATMENT STEP 4: Low dose ICS/formoterol maintenance and reliever therapy, or medium dose ICS/LABA as maintenance plus as-needed SABA STEP 5: Refer for expert investigation and add-on treatment: include anti-IgE (omalizumab) for severe allergic asthma low dose OCS

22. ASTHMA FLARE- UPS (EXACERBATIONS) Exacerbation is an acute or sub-acute worsening in symptoms and lung function from the patient’s usual status

23. Identifying patients at risk of Asthma-related Death A history of near-fatal asthma requiring intubation and ventilation Hospitalization or emergency care for asthma in last 12 months Not currently using ICS, or poor adherence with ICS Currently using or recently stopped using OCS Over-use of SABAs, especially more than 1 canister/month History of psychiatric disease or psychosocial problems Confirmed food allergy in a patient with asthma