1. Dr Mazen Qusaibaty MD, DIS / Head Pulmonary and Internist Department Ibnalnafisse Hospital Ministry of Syrian health – Email: Qusaibaty@gmail.com Dr Mazen Qusaibaty MD, DIS / Head Pulmonary and Internist Department Ibnalnafisse Hospital Ministry of Syrian health – Email: Qusaibaty@gmail.com Asthma 07

2. Goals of Asthma Care 2

3. 3

4. 4 National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma (EPR-3) 2007. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; August 2007. NIH publication no. 08-4051. BetterQuality of life Better Quality of life

5. Reduce Impairment 5

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

7. Free night symptoms Reduce Impairment

8. Normal Physical activity

9. 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) 2007. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; August 2007. NIH publication no. 08-4051. Reduce Impairment

10. Reduce Risk 10

11. Prevent reduced lung growth at children 11

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

13. 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) 2007. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; August 2007. NIH publication no. 08-4051.

14. 14 NoExacerbation

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

16. 16

17. 17

18. 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

19. Quick Relief Medications Relief Medications

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

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

22. 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

23. 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

24. 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.

25. 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.

26. 26

27. 27

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

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

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

31. 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 )

32. 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

33. 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

34. 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

35. 35

36. 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;139:359-370

37. 37

38. The management of chronic childhood asthma in children aged 0 to 4 44 4 years

40. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htmhttp://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

41. 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

42. The children at high risk of developing persistent asthma ?

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

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

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

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

47. 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. 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. 50 Upper Respiratory Infections

51. 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.

52. 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. 53

54. 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. 55 The management of chronic childhood asthma in children aged 5 11 years chronic childhood asthma in children aged 5 to 11 years

56. 56

57. 57

58. 58

59. 59

60. The benefits of Combination therapy Strategy

61. 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.

62. (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. 63 Initial assessment

64. 4-6 weeks 3-6 months Steeping up 3-6 months Steeping down

65. 65 Asthma Control Stepping

66. 66 ICS (D)

67. 01 67

68. 01 68

69. 01 69

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

71. 03 71

72. 03 72

74. The use of inhaler devices in patients 74

75. 75 Arch Dis Child 2007;92:142-146 doi:10.1136/adc.2006.101642 BottleSpacer

78. 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, 2007. (NIH publication no. 08-4051) www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on September 01, 2007).

79. 79 Triggers