1. 1 1 BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

2. Objectives To describe how to make the diagnosis of asthma utilizing the Saudi Asthma Guidelines. To discuss the efficacy of nebulizers versus metered dose inhalers and other medications in the treatment of asthma To describe the following methods for monitoring disease severity and any evidence supporting one method over the other Symptoms based (i.e. medication frequency and dose based upon symptoms) Daily peak flow meter monitoring (i.e. red, yellow, green zones) 2

3. DEFINITION OF ASTHMA CHRONIC INFLAMATORY DISORDER OF THE AIRWAY ASSOCIATED WITH WIDESPREAD BUT VARIABLE AIRFLOW LIMITATION (PARTLY REVERSIBLE WITH OR WITHOUT TREATMENT ) AND WITH INCREASED AIRWAY HYPERRESPONSIVENESS TO VARIETY OF STIMULI 3

4. WHAT IS THE PREVALENCE IN SAUDI ARABIA ? 4

5. The prevalence of asthma among school children in KSA Range 4%-23% Riyadh 10% Jeddah 12% ( AL Frayh, et al, 2001 )

6. Diagnosis

7. history Required a full detailed medical history and clinical exam. Including peak expiratory flow (PEF)rate. 1-Symptoms: – Cough – Wheezing – Shortness of breath

8. How frequent, how severe, what intervention needed. Interfere with sport or normal physical activity Trouble some cough between attacks Symptoms improve by asthma medication

9. 2- atopy :skin eczema,itchy eye,frequent nasal blockage,discharge or sneezing especialy in the morning 3- family history of atopic diseases. 4- environmental history 5- exclusion of other medical conditions

10. Physical examination Hight and weight(growth in childern) Nose,throat, sinusis(polyps,deviated nasal septum,post nasal drip,pale-pink or congested nasal turbinate. Feature of atopy Examination of the respiratory system – May be normal between attacks – wheeze brochi,tachypnea,chest deformity suggest asthma – Stridor,clubbing,heart murmers ----other than bronchial astha

11. Peak expiratory flow rate (PEF): Should be performed in every patient>5 yrs In certain patient measuring PEF prior to and after a bronchodilator may help in confirming the diagnosis. Measuring PEF variability comparing the morning and evening PEF over a period of 2 weeks

12. Variability over 15% conferms but not essential for diagnosis PEF may be normal between attacks

13. Investigation Usually not necessary CXR Usually not necessary except in Severe cases Foreign body Infection Arterial blood gases in severe cases

14. Differential diagnosis In children < 5 yrs : Upper airway allergies,rhinitis, sinusitis GERD Foreign body aspiration Recurrent viral LRTI Cystic fibrosis Congenital heart disease

15. Differential diagnosis In older children and adults: Upper airway allergies, rhinitis, sinusitis GERD Heart disease COPD Vocal cord dysfunction Inhalation of foreign body Hyperventilation and panic attack Cough secondary to drugs(β-blockers and ACE inhibtors) Bronchiachtiasis Laryngeal dysfunction

16. classification

17. Etiology: – Allergic and non allergic asthma – Help in determining prognosis and in determining allergen to be avoided Severity: – Intermittent, mild persistent, moderate persistent, severe persistent. – Management at the initial assessment of a patient Control: – Useful for ongoing therapy

18. Classification: asthma Severity: classificationintermittentMild persistent Moderate persistent Severe persistent Minor symptoms <1/week1-3/week4-5/weekcontinuous Exacerbations/ nocturnal <1/month1/month2-3/month>4/month PEF between attacks >80% 60-80%<60% Pharmacological therapy step1step2step3step4

19. Classification: asthma control charachtarsticcontrolled(all the following) Partly controlled (any in any week) uncontrolled Day time symptomsNone(twice or less/week) More than twice/week Three or more Feature of partly controlled asthma present in any week Limitation of activity NoneAny Nocturnal symptoms /awaking NoneAny Need for reliever /rescue treatment None (twice or less/week) More than twice/week Lung function (PEF or FEV1) Normal<80 % predicted or Personal best

20. Management

21. Goals of successful management Achieve and maintain control of symptoms Maintain normal activity level,including exercise Maintain (near) "normal" pulmonary function. Prevent recurrent exacerbations of asthma Avoid adverse effects from asthma medication Prevent asthma medication

22. Component of asthma therapy 1)Develop patient /doctor partenership asthma education 2)Identify and reduce exposure to risk factors 3)Assess treat and monitor asthma 4)Manage asthma exacerbation emergencies 5)Special consideration coexisting and related condition

23. Component 1:Develop patient /doctor partnership asthma education Asthma education Asthma follow up and referal

24. Component 1:Develop patient /doctor partnership asthma education Asthma education Objectives: 1- improving knowledge of asthma 2-changing attitude and behavior 3-Improving management skills 4- improving satisfaction and overall quality of life

25. Component 1:Develop patient /doctor partnership asthma education Elements of patient education : 1- basic facts about asthma: Disease, medication and goal of therapy 2- socio-cultural misconception: Asthma as infectious disease,asthma medication are addictive, 3- medication Advantage of inhaled over systemic medications The need for more than one inhaler

26. Component 1:Develop patient /doctor partnership asthma education 4- management skills Technique: Inhalation devices,spacer, PEF Asthma self management: Name and dose of the medication Monitoring of asthma Sign suggest worsening of asthma Action in exacerbation How and when adjust medication How and when to seek medical attention

27. Component 1:Develop patient /doctor partnership asthma education Follow up Initial phase: Last until asthma control is optimum The diagnnosis is established Patient need to be seen at least every 3-6 weeks during this phase

28. Component 1:Develop patient /doctor partnership asthma education Second phase: The asthma is well controlled Interval history, examination,medication Special attention include: 1-need for emergency care 2-loss of time in work or school 3-freq. of β2 agonist usage 4-wheezing interfere with normal physical activity

29. Component 1:Develop patient /doctor partnership asthma education 5-use of oral steroid 6-Perform spirometry or PEF in clinic 7-go over PEF chart with the patient 8- observe inhalation technique 9- step up or down anti-inflammatory therapy 10-provide written instruction to certain patients Patient need to be seen every 3-6 months Or earlier if patient deteriorate

30. Component 1:Develop patient /doctor partnership asthma education Referral Primary health care centers: Manage asthma whose diagnosis is striaght forward and are easily controlled If asthma is partialy controlled or uncontrolled --  refer to secondary care

31. Component 2: Identify and reduce exposure to risk factors Domestic dust mites Air pollution Tobacco smoke Occupational irritants Cockroach Animal with fur Pollen

32. Respiratory (viral) infections Chemical irritants Strong emotional expressions Drugs ( aspirin, beta blockers)

33. Component 3:Assess treat and monitor asthma asthma Severity asthma control

34. Asthma control test

35. step1step2step3step4step5 As needed rapid –acting β2 agonist Low dose ICS Low dose ICS+LABAMedium to high dose ICS +LABA Step 4 +steriods Leukotriene modifier Low –dose ICS + Leukotriene modifier Medium to high dose ICS+ Leukotriene modifier STEP 4+anti IgE Medium to high dose ICS Medium to high dose ICS +LABA+ Leukotriene modifier Addition of sustained release theophylline may be considered

36. LEVEL OF CONTROLTREATMENT OPTION controlledStep down therapy Maintain therapy Partly controlledMaintain therapy Step up therapy UncontrolledStep up therapy Look up for reasons

37. Component 4:Manage asthma exacerbation emergencies Home management: Frequent β2 agonist preferaply via spacer device q 4h Dose of ICS to be increased 4 folds Action plan

38. Management of severe attack

40. Peak Flow Meter Zones Green Zone Green Zone (80 to 100 percent of your personal best) signals good control. Take your usual daily long-term-control medicines, if you take any. Keep taking these medicines even when you are in the yellow or red zones. Yellow Zone Yellow Zone (50 to 79 percent of your personal best) signals caution: your asthma is getting worse. Add quick-relief medicines. You might need to increase other asthma medicines as directed by your doctor. Red Zone Red Zone (below 50 percent of your personal best) signals medical alert! Add or increase quick-relief medicines and call your doctor now. 40

41. Component 5:special consideration Rhinitis Sinusitis Nasal polyps Respiratory infection GERD Asprin induced asthma(AIA) Pregnancy surgery

42. B. This patient has mild persistent asthma, which is defined as having asthma symptoms more than two times a week but less than one time a day. These patients also have nocturnal 42

43. Is the asthma of the patient in the previous question controlled or not? What recommendations might you give her regarding her therapy? A. Controlled, do not change her therapy B. Controlled, educate regarding triggers C. Not controlled, give a short burst of oral prednisone D. Not controlled, add a long-acting bronchodilator such as salmeterol E. Not controlled, add a low-dose inhaled corticosteroid or leukotriene antagonist 43

44. E. This patient is not well controlled since she is using her inhaler more than twice a week and experiencing symptoms so frequently. Addition of a low-dose inhaled corticosteroid or a leukotriene antagonist are appropriate options for mild persistent asthma. 44

45. The same 23-year-old patient comes in to your office 2 months later after having a kitchen fire at home and is complaining of shortness of breath. What factor on your history and physical might make you consider admitting her to the hospital? A. Wheezing on lung exam B. Pulse oximetry less than 93% C. Respiratory rate of 30 breaths per minute D. No response to one treatment with an albuterol nebulizer E. PaCO 2 of 25 45

46. C. A respiratory rate of greater than 28 or pulse of greater than 110 beats per minute would both indicate a severe episode. Wheezing is an unreliable indicator of the severity of attack. A pulse oximetry measurement of 90% is the goal unless the patient is pregnant or has cardiac disease. A PaCO 2 of 25 is expected in a patient who is hyperventilating. A PaCO 2 that is normal or elevated may be a sign of impending respiratory failure and such patients should be monitored closely in the intensive care unit 46

47. Thanks 47