1. A 2017 Update on Asthma Management
Akshay Sood, MD, MPH
UNM Division of Pulmonary Medicine

2. Case Discussion
Question 1:What pointers exist in this case to suggest the diagnosis of asthma?

3. Initial Assessment & Diagnosis
Determine that:
History of episodic symptoms of airflow obstruction
Airflow obstruction is at least partially reversible
Alternative diagnoses are excluded

4. Detailed history Does patient have history of
episodic symptoms of airflow obstruction?
Wheeze, shortness of breath, chest tightness, or cough
Symptoms vary through the day/night and season
Absence of symptoms/signs at the time of exam does not exclude asthma

5. Spirometry Is airflow obstruction at least partially reversible?
Use spirometry to establish airflow obstruction:
FEV1/FVC below the lower limit of normal
Use spirometry to establish reversibility:
FEV1 increases >12% and at least 200 mL after using a short-acting inhaled beta2-agonist
Not always seen

6. Initial Assessment & Diagnosis
Are alternative diagnoses excluded?
Vocal cord dysfunction
Vascular rings & pulmonary embolism
Airway obstruction from foreign bodies/tumors
Tracheomalacia/tracheal stenosis
COPD
Other pulmonary diseases

7. Pathophysiology of Asthma

8. Case Discussion
Question 2: What additional tests would you perform on this patient?

9. Additional Tests Reasons for Additional Tests The Tests
Patient has symptoms but
spirometry
is normal or –
Bronchoprovocation test
near normal. ,
Suspect infection, large airway lesions, heart
– Chest x-ray
disease, or obstruction by foreign object
Suspect coexisting chronic obstructive pulmonary
– Additional pulmonary function studies
disease, restrictive defect, or central airway
– Diffusing capacity test
obstruction
Suspect other factors contribute to asthma
– Allergy tests—skin or in vitro
(These are not diagnostic tests for asthma.)
– Nasal examination –
Gastroesophageal
reflux assessment

10. Case Discussion
Question 3: How would you classify his asthma severity?

13. Asthma Control Test™ (ACT)
In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?
SCORE
During the past 4 weeks, how often have you had shortness of breath?
During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?
During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?
How would you rate your asthma control during the past 4 weeks?
A score of ≤19 means asthma may not be under control.
TOTAL
ACT is for patients with asthma 12 years and older.
Asthma Control Test is a trademark of QualityMetric Incorporated.
Copyright 2002, by QualityMetric Incorporated.

15. Case Discussion
Question 4: What are the goals of his asthma therapy?

16. Goals of Asthma Therapy
Prevent chronic and troublesome symptoms
Maintain (near-) “normal” pulmonary function
Maintain normal activity levels (including exercise and other physical activity)

17. Goals of Asthma Therapy (continued)
Prevent recurrent exacerbations and minimize the need for emergency department visits or hospitalizations
Provide optimal pharmacotherapy with minimal or no adverse effects
Meet patients’ and families’ expectations of, and satisfaction with, asthma care

18. Risk Factors for Asthma Mortality
prior intubation or prior ICU admission
history of sudden severe exacerbations
>2 hospital admits or >3 ED visits for asthma in the last year; admit or ED visit within last month
current oral steroid usage or recent taper
use of >2 canisters/month of -agonist MDI
comorbid illness, illicit drug use, urban area
lack of a written asthma action plan, sensitivity to Alternaria
Factors identified by NAEPP

19. Case Discussion
Question 5: What environmental and occupational factors are possibly contributing to his asthma severity and what measures would you suggest to control them?

20. Factors Contributing to Asthma Severity
Assess exposure and sensitivity to:
Inhalant allergens
Occupational exposures
Irritants:
Indoor air (including tobacco smoke)
Air pollution

21. Teach Patients To Reduce Exposure to Their Inhalant Allergens
Animal Dander
Remove pet from house (ideal)
Keep animal out of patient’s bedroom (at a minimum)
Seal or put a filter on air ducts that lead to bedroom

22. Teach Patients To Reduce Exposure to Their Inhalant Allergens (continued)
House-Dust Mites
Essential:
Encase mattress in an allergen-impermeable cover
Encase pillow in an allergen-impermeable cover or wash weekly
Wash sheets and blankets in hot water weekly (>130 F is necessary for killing mites)

23. Teach Patients To Reduce Exposure to Their Inhalant Allergens (continued)
Indoor mold
Fix all leaks and eliminate water sources associated with mold growth
Clean moldy surfaces
Consider reducing indoor humidity to less than 50%

24. Work-Aggravated Asthma: Evaluation
Recognize the potential for workplace-relatedness
Sensitizers (e.g., isocyanates, plant or animal products)
Irritants or physical stimuli (e.g., cold/heat, dust, humidity)

25. Case Discussion
Question 6: What other factors are possibly contributing to his asthma severity and what measures would you suggest to control them?

26. Control of Factors Contributing to Asthma Severity
Assess contribution of other factors:
Rhinitis/sinusitis
Gastroesophageal reflux
Obstructive sleep apnea
Drugs (NSAIDs, beta-blockers)
Viral respiratory infections
Sulfite sensitivity

27. Control Other Factors That Can Influence Asthma Severity
Rhinitis
Intranasal corticosteroids are most effective
Sinusitis
Promote drainage; antibiotics for complicating acute bacterial infection
Gastroesophageal reflux
Medications; no food before bedtime; elevate head of bed
Obstructive sleep apnea
Diagnosis and treatment helpful

28. Control Other Factors That Can Influence Asthma Severity (continued)
Viral infections
Annual influenza vaccination
Aspirin/nonsteroidal anti-inflammatory drugs (NSAIDs)
Ask adult patients about sensitivity
Counsel avoidance for those with sensitivity, severe asthma, or nasal polyps

29. Case discussion
Question 7: What is the correct pharmacological regimen for his asthma management?

30. Inhaled Medication Delivery Devices
Metered-dose inhaler (MDI)
Dry powder inhaler (DPI)
Spacer/holding chamber
Spacer/holding chamber and face mask
Nebulizer

31. Overview of Asthma Medications (continued)
As-needed: Quick Relief
Short-acting beta2-agonists
Anticholinergics
Systemic corticosteroids

32. Overview of Asthma Medications
Daily: Long-Term Control
Corticosteroids (inhaled and systemic)
Cromolyn/nedocromil
Long-acting beta2-agonists
Methylxanthines
Leukotriene modifiers
Omalizumab
Long-acting muscarinic antagonists

33. The Rule of Twos* (Who Needs Controller Therapy, >)
Two beta-agonist canisters/year
Two doses of beta-agonist/week
Two nocturnal awakenings/month
Two unscheduled visits/year
Two prednisone bursts/year
*Trademark of Baylor Health Care System

34. Inhaled Corticosteroids
Most effective long-term-control therapy for persistent asthma
Small risk for adverse events at recommended dosage
Reduce potential for adverse events by:
Using spacer and rinsing mouth
Using lowest dose possible
Using in combination with long-acting beta2-agonists
Monitoring growth in children

35. Long-Acting Beta2-Agonists
Not a substitute for anti-inflammatory therapy
Not appropriate for monotherapy
Beneficial when added to inhaled corticosteroids
Not for acute symptoms or exacerbations

36. Short-Acting Beta2-Agonists
Most effective medication for relief of acute bronchospasm
More than one canister per month suggests inadequate asthma control
Regularly scheduled use is not generally recommended
May lower effectiveness
May increase airway hyperresponsiveness

37. Stepwise Approach to Therapy: Gaining Control
1. Start high and step down.
2. Start at initial level of severity; gradually step up.
STEP 4
Severe Persistent
STEP 3 2 1
Moderate Persistent
STEP 2
Mild Persistent
STEP 1
Mild Intermittent

38. Step 6 Step 5 Step 4 Step 3 Step 2 Step 1
Intermittent Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3.
Step 6
Preferred:
High-dose ICS + LABA + oral corticosteroid
AND
Consider Omalizumab for patients who have allergies
Step up if needed
(first, check adherence, environmental control, and comorbid conditions)
Step down if possible
(and asthma is well controlled at least 3 months)
Step 5
Preferred:
High-dose ICS + LABA
AND
Consider Omalizumab for patients who have allergies
≥ 12 years old
Step 4
Preferred:
Medium-dose ICS + LABA
AlternativeMedium-dose ICS + either LTRA, Theophylline, or Zileuton
Step 3
Preferred:
Medium-dose ICS OR
Low-dose ICS + LABA
Alternative
Low-dose ICS + either LTRA, Theophylline, or Zileuton
Step 2
Preferred:
Low-dose ICS
AlternativeCromolyn, Nedocromil, LTRA, or Theophylline
Step 1
Preferred:
SABA PRN
Assess control
Patient Education and Environmental Control at Each Step
Steps 2-4: Consider SQ allergen immunotherapy for allergic patients
Quick-Relief Medication for All Patients
SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed.
Use of beta2-agonist >2 days a week for symptom control (not prevention of EIB) indicates inadequate control and the need to step up treatment.

39. Indicators of Poor Asthma Control
Step up therapy if patient:
Awakens at night with symptoms
Has an urgent care visit
Has increased need for short-acting inhaled beta2-agonists
Uses more than one canister of short-acting beta2-agonist in 1 month

40. Indicators of Poor Asthma Control (continued)
Before increasing medications, check:
Inhaler technique
Adherence to prescribed regimen
Environmental changes
Also consider alternative diagnoses

41. Other Targeted Therapies
Likely only specific asthma phenotypes may benefit from these therapies
Dupilumab
Blocks effects of IL-4 and IL-13 by blocking common subunit in their receptor
Wenzel NEJM :2455
Brodalumab
Anti-IL-17 receptor antibody
Busse Am J Respir Crit Care Med :1294
Lebrikizumab
Anti-IL-13 antibody

42. Bronchial Thermoplasty
Thermal energy to the airways during 3 bronchosopies to reduce smooth muscle mass.
No reduction in hyperresponsiveness or change in FEV1
Improved QOL, reduction in ED visits and rates of severe exacerbations
Wahidi AJRCCM :700

44. Questions

46. Websites for further info