rattapon uppala, md division of pulmonology faculty of medicine khon kaen university update asthma...

Rattapon Uppala, MDDivision of Pulmonology

Faculty of MedicineKhon Kaen University

Update asthma guideline 2014

Scenario

Case เด็�กหญิ�งอายุ� 3 ปี�CC: หายุใจหอบเหนื่��อยุ 12 ชม.ก�อนื่มา รพ.

PI: 2 วั�นื่ก�อนื่มา รพ. ม�นื่��าม กใส ไม�ม�ไข้$ ไม�ม�หายุใจหอบเหนื่��อยุ อาการอ��นื่ๆปีกติ�

1 วั�นื่ก�อนื่มา รพ. ม�ไอเปี'นื่ช�ด็ๆ ไม�ม�หายุใจหอบ ไม�ม�ไข้$

12 ชม.ก�อนื่มา รพ. เร��มม�หายุใจหอบ หนื่$าอกบ�(ม ไม�ม�ไข้$อาการอ��นื่ๆปีกติ�

• PH: - G1/2 NL BW 2800 g., no complication after birth - ไม�ม�ปีระวั�ติ� foreign body aspiration

- เคยุม�ปีระวั�ติ�ม�ผื่��นื่แด็งติามติ�วัเปี'นื่ๆ หายุๆ เคยุมาติรวัจที่�� OPD Dx allergic rash ได็$ร�บการร�กษาโด็ยุให$ chlorpheniramine เวัลาม�อาการ

- เคยุหายุใจหอบติอนื่อายุ� 1 ปี�คร1�ง Dx viral pneumonia ได็$พ�นื่ Ventolin 3 วั�นื่ จากนื่��นื่ไม�ม�อาการหอบ

- 1 เด็�อนื่ก�อนื่ ม�ไข้$ไอ หายุใจหอบ มาติรวัจที่�� AE รพ.ศร�นื่คร�นื่ที่ร3 DDX acute asthmatic attack, viral pneumonia Rx: oxygen, dexamethasone iv, Ventolin, Beradual NB home med: azithromycin, Ventolin MDI prn, prednisolone

นื่�ด็ follow up OPD gen ped แติ�ผื่ $ปี4วัยุ loss follow up• FH: - บ�ด็า มารด็าและนื่$องชายุ เปี'นื่ allergic rhinitis - บ�ด็าส บบ�หร��

Physical examinationA Thai girl, alert, good consciousnessBT 36.5 C, PR 151 bpm, RR 60 bpm, BP 109/63 mmHgHEENT : not pale, no jaundice, pharynx and tonsils not injected, no flaring alar nasiHeart : normal S1,S2 , no murmurLung : dyspnea, suprasternal notch, subcostal retraction, generalize wheezing both lungs, no stridorAbdomen : soft, not tender, liver and spleen impalpable, no massCapillary refill <2 sec

Problem list

• Recurrent wheezing

Differential diagnosis

- Viral induced wheezing- Asthma exacerbations

© Global Initiative for Asthma

Probability of asthma diagnosis or response to asthma treatment in children ≤5 years

GINA 2014, Box 6-1 (1/2)

Viral induced

wheezing

Asthma


Symptom patterns in children ≤5 years

GINA 2014, Box 6-1 (2/2)

Scenario

Case เด็�กหญิ�งอายุ� 3 ปี�• 2 วั�นื่ก�อนื่มา รพ. ม�นื่��าม กใส ไม�ม�ไข้$• หายุใจหอบเหนื่��อยุ 12 ชม.ก�อนื่มา รพ.• เคยุหายุใจหอบติอนื่อายุ� 1 ปี�คร1�ง และ 1

เด็�อนื่ก�อนื่• FH: บ�ด็ามารด็าเปี'นื่ allergic rhinitis

บ�ด็าส บบ�หร��

Scenario

ประวั�ติ�เพิ่�มเติ�ม• ผื่ $ปี4วัยุม�อาการหายุใจหอบ มาที่��งหมด็ 3 คร��ง

แติ�ละคร��งเปี'นื่นื่านื่ปีระมาณ 5 วั�นื่• ผื่ $ปี4วัยุม�อาการหอบ โด็ยุเฉพาะเวัลากลางค�นื่หร�อ

ช�วังที่��อากาศเยุ�นื่• ม�อาการไอบ�อยุๆเม��อออกก�าล�งกายุหร�อวั��งเล�นื่• ม�กม�อาการไอนื่านื่เก�อบ 2 ส�ปีด็าห3หล�งเปี'นื่หวั�ด็

The most likely diagnosis

Asthma with acute

exacerbations

Definition of asthma

• A chronic inflammation disease of the airways• Features : - Variable and partially reversible airway obstruction ( spontaneously or with treatment) - Bronchial hyper-responsiveness to triggers - Structural changes in the airway ( airway remodeling)

GINA 2014

Diagnosis

• A characteristic pattern of symptoms

• Confirmed the variable expiratory airflow limitation by pulmonary function tests( if possible)

GINA 2014


Features suggesting asthma in children ≤5 years

Feature Characteristics suggesting asthma

Cough Recurrent or persistent non-productive cough that may be worse at night or accompanied by some wheezing and breathing difficulties.Cough occurring with exercise, laughing, crying or exposure to tobacco smoke in the absence of an apparent respiratory infection

Wheezing Recurrent wheezing, including during sleep or with triggers such as activity, laughing, crying or exposure to tobacco smoke or air pollution

Difficult or heavy breathing or shortness of breath

Occurring with exercise, laughing, or crying

Reduced activity Not running, playing or laughing at the same intensity as other children; tires earlier during walks (wants to be carried)

Past or family history Other allergic disease (atopic dermatitis or allergic rhinitis)Asthma in first-degree relatives

Therapeutic trial with low dose ICS and as-needed SABA

Clinical improvement during 2–3 months of controller treatment and worsening when treatment is stopped

GINA 2014, Box 6-2

A characteristic pattern of symptoms

• Increase the probability - More than one symptom - Symptoms often worse at night or the early morning - Symptoms vary over time and in intensity - Symptoms are triggered by viral infection, exercise, allergen exposure, changes in weather, laughter, or irritants such as car exhaust fumes, smoke or strong smells

A characteristic pattern of symptoms

• Decrease the probability - Isolated cough with no other respiratory symptoms - Chronic production of sputum - Shortness of breath associated with dizziness, light-headedness or peripheral tingling (paresthesia) - Chest pain - Exercise-induced dyspnea with noisy inspiration (stridor)

Confirmed the variable expiratory airflow limitation

Documented excessive variability in lung function (one or more of the test below) AND documented airflow limitation

The greater the variations, or the more occasions excess variation is seen, the more confident the diagnosisAt least once during diagnostic process when FEV1 is low, confirm that FEV1/FVC is reduced (normally >0.75-0.8 in adults,>0.9 in children)

Positive bronchodilator (BD) reversibility test (more likely to be positive if BD medication is withheld before test: SABA≥4hr, LABA≥15hr

Adults: increase in FEV1 of >12% and >200 ml from baseline, 10-15 minutes after 200-400 mcg albuterol or equivalent (greater confidence if increase is >15% and >400ml).Children: increase in FEV1 of >12% predicted

Excessive variability in twice-daily PEF over 2 weeks

Adults: average daily diurnal PEF variability >10%Children: average daily diurnal PEF variability >13%

ในื่กรณ�ไม�ม� spirometry ใช$ PEF variability แที่นื่ได็$


Time (seconds)

Volume

Note: Each FEV1 represents the highest of three reproducible measurements

Typical spirometric tracings

FEV1

1 2 3 4 5

Normal

Asthma (after BD)

Asthma (before BD)

Flow

Volume

Normal

Asthma (after BD)

Asthma (before BD)

GINA 2014

GINA guideline 2014

• Children 5 years and younger• Children 6 years and older (adults, adolescents)

Draft

Thai guideline

* ในเด็�กอายุ�น�อยุกวั�า 5 ป� ที่�ม�อาการ หายุใจเสี�ยุงหวั�ด็ที่� ติอบสีนองด็�ติ�อยุาขยุายุหลอด็ลมที่�ม�อาการร�นแรง ติ�อง

ได็�ร�บการร�กษาในโรงพิ่ยุาบาลหร%อติ�องได็�ร�บ systemic corticosteroids ติ�&งแติ� 2 คร�&งข(&นไปใน 6 เด็%อน

DraftThai guideline

Scenario

Management at AE แรกร�บ Dx acute bronchiolitis Rx: O2 canula, ventolin 1 NB q 4 hr, iv fluid วั�นื่ติ�อมา ยุ�งม�อาการไอ และหอบ แพที่ยุ3สายุนื่1กถึ1ง acute

asthmatic attack จ1ง start hydrocortisone 65 mg iv q 12 hr

หล�ง treat as acute asthmatic attack วั�นื่ติ�อมาผื่ $ปี4วัยุสบายุด็� ไอเล�กนื่$อยุ ไม�หอบ จ1ง discharge

Home med : prednisolone 1 MKDay budesonide (100 mg/puff) 1 puff bid ventolin MDI 1 puff prn for dyspnea

Management of asthma

• Management of Asthma exacerbations • Long term management - Medication - Treating modifiable risk factors - Non- pharmacologic therapies


GINA Global Strategy for Asthma Management and Prevention 2014

This slide set is restricted for academic and educational purposes only. Use of the slide set, or of individual slides, for commercial or promotional purposes requires approval from GINA.

Asthma flare-ups (exacerbations)

Risk factors for exacerbations

Potentially modifiable independent risk factors

• Uncontrolled asthma symptoms• Excessive SABA use (>1 x 200-

dose canister/month)• Inadequate ICS: not prescribed

ICS; poor adherence; incorrect inhaler technique

• Low FEV1, especially if <60% predicted

• Major psychological or socioeconomic problems

• Exposures: smoking; allergen exposure if

sensitized• Comorbidities: obesity;

rhinosinusitis; confirmed food allergy

• Sputum or blood eosinophilia

• Pregnancy

GINA 2014

Objective assessments

• Measurement of lung function– this is strongly recommended. If possible, and without unduly

delaying treatment.

• Oxygen saturation: – this should be closely monitored, preferably by pulse oximetry. This

is especially useful in children if they are unable to perform PEF. – In children, oxygen saturation is normally >95%, and saturation

<92% is a predictor of the need for hospitalization(Evidence C). – Saturation levels <90% in children or adults signal the need for

aggressive therapy.

• Arterial blood gas measurements are not routinely • Chest X-ray (CXR) is not routinely

GINA 2014


Initial assessment of acute asthma exacerbations in children ≤5 years

Symptoms Mild Severe*

Altered consciousness No Agitated, confused or drowsy

Oximetry on presentation (SaO2)**

>95% <92%

Speech† Sentences Words

Pulse rate <100 beats/min >200 beats/min (0–3 years)>180 beats/min (4–5 years)

Central cyanosis Absent Likely to be present

Wheeze intensity Variable Chest may be quiet

*Any of these features indicates a severe exacerbation**Oximetry before treatment with oxygen or bronchodilator† Take into account the child’s normal developmental capability

GINA 2014, Box 6-8


Managing exacerbations in acute care settings

GINA 2014, Box 4-4 (1/4)

NEW!


Managing exacerbations in primary care

GINA 2014, Box 4-3 (1/3)

NEW!

Therapy Dose and administration

Supplemental oxygen

24% delivered by face mask (usually 1L/min) to maintain oxygen saturation 94-98%

Short-acting beta2-agonist (SABA)

2-6 puffs of salbutamol by spacer, or 2.5 mg of salbutamol by nebulizer, every 20 minutes for first hour, then reassess severity.If symptoms persist or recur, give an additional 2-3 puffs per hour.Admit to hospital if > 10 puffs required in 3-4 hours.

Systemiccorticosteroids

Give initial dose of oral prednisolone (1-2 mg/kg up to a maximum)

Additional options in the first hour of treatment

Ipratropium bromide For children with moderate-severe exacerbations, 2 puffs of ipratropium bromide 80 mcg (or 250 mcg by neulizer) every 20 minutes for 1 hour only

Magnesium sulfate Consider nebulized isotonic magnesium sulfate (150 mg) 3 doses in the first hour of treatment for children aged ≥ 2 years with severe exacerbation

GINA 2014

Oxygen Oxygen should be administered by nasal cannula or mask to achieve

arterial O2 sat of 93–95% (94–98% for children 6–11 years) In severe exacerbations, controlled low flow oxygen therapy using

pulse oximetry to maintain saturation at 93–95% is associated with better physiological outcomes than with high flow 100% oxygen therapy (Evidence B).

Inhaled short-acting beta2-agonists Inhaled SABA therapy should be administered frequently for patients

presenting with acute asthma. Systematic reviews of intermittent versus continuous nebulized

SABA in acute asthma provide conflicting results. There is no evidence to support the routine use of intravenous

beta2-agonists in patients with severe asthma exacerbations (Evidence A).

GINA 2014

Epinephrine (for anaphylaxis) Intramuscular epinephrine is indicated in addition to

standard therapy for acute asthma associated with anaphylaxis and angioedema.

It is not routinely indicated for other asthma exacerbations.

Systemic corticosteroids Systemic corticosteroids speed resolution of

exacerbations and prevent relapse. Systemic corticosteroids should be administered to the

patient within 1 hour of presentation. Route of delivery:

oral administration is as effective as intravenous. . GINA 2014

Inhaled corticosteroids Within the emergency department: high-dose ICS given within

the first hour after presentation reduces the need for hospitalization in patients not receiving systemic corticosteroids (Evidence A).

On discharge home: the majority of patients should be prescribed regular ongoing ICS treatment since the occurrence of a severe exacerbation is a risk factor for future exacerbations (Evidence B).

Ipratropium bromide For adults and children with moderate-severe exacerbations,

treatment in the emergency department with both SABA and ipratropium, a short-acting anticholinergic, was associated with fewer hospitalizations and greater improvement in PEF and FEV1 compared with SABA alone.

GINA 2014

Aminophylline and theophylline Intravenous aminophylline and theophylline should not be

used in the management of asthma exacerbations, in view of their poor efficacy and safety profile, and the greater effectiveness and relative safety of SABA.

Magnesium Intravenous magnesium sulfate is not recommended for

routine use in asthma exacerbations. however, when administered as a single 2 g infusion over 20

minutes, it reduces hospital admissions in some patients, including adults with FEV1 <25–30% predicted at presentation; adults and children who fail to respond to initial treatment and have persistent hypoxemia; and children whose FEV1 fails to reach 60% predicted after 1 hour of care (Evidence A).

GINA 2014

Using an MDINeed a proper hand-lung synchronism

MDIs must be used

with spacer in children

• Follow up all patients regularly after an exacerbation, until symptoms and lung function return to normal

• The opportunity– Exacerbations often represent failures in chronic asthma care,

and they provide opportunities to review the patient’s asthma management

• At follow-up visit, check:– The patient’s understanding of the cause of the flare-up– Modifiable risk factors, e.g. smoking– Adherence with medications, and understanding of their purpose– Inhaler technique skills– Written asthma action plan

Follow-up after an exacerbation

GINA 2014, Box 4-5


GINA Global Strategy for Asthma Management and Prevention 2014

This slide set is restricted for academic and educational purposes only. Use of the slide set, or of individual slides, for commercial or promotional purposes requires approval from GINA.

Long term management of asthma in children 5 years and younger

GINA 2014

General principles of asthma management

• The long term goals of asthma management are:

- To achieve good control of symptoms and maintain normal activity levels - To minimize future risk of exacerbations, fixed airflow limitation and side-effect

GINA 2014


GINA assessment of asthma control in children ≤5 years

GINA 2014, Box 6-4 (1/2)


Risk factors for poor asthma outcomes in children ≤5 years

Risk factors for exacerbations in the next few months

• Uncontrolled asthma symptoms• One or more severe exacerbation in previous year• The start of the child’s usual ‘flare-up’ season (especially if autumn/fall)• Exposures: tobacco smoke; indoor or outdoor air pollution; indoor allergens (e.g.

house dust mite, cockroach, pets, mold), especially in combination with viral infection• Major psychological or socio-economic problems for child or family• Poor adherence with controller medication, or incorrect inhaler technique

GINA 2014, Box 6-4B




Risk factors for fixed airflow limitation

• Severe asthma with several hospitalizations• History of bronchiolitis




Risk factors for fixed airflow limitation

• Severe asthma with several hospitalizations• History of bronchiolitis

Risk factors for medication side-effects

• Systemic: Frequent courses of OCS; high-dose and/or potent ICS• Local: moderate/high-dose or potent ICS; incorrect inhaler technique; failure to protect

skin or eyes when using ICS by nebulizer or spacer with face mask


Control-based asthma management cycle in children ≤5 years

GINA 2014, Box 6-5

Strategies for asthma symptom control & risk reduction

• Medication • Treating modifiable risk factors• Non- pharmacologic therapies

GINA 2014


Stepwise approach – pharmacotherapy (Children 6 years and older)

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy

GINA 2014, Box 3-5, Step 1

Low dose inhaled corticosteroids (mcg/day) for children ≤5 years

Inhaled corticosteroid Low daily dose (mcg)

Beclometasone dipropionate (HFA) 100

Budesonide (pMDI + spacer) 200

Budesonide (nebulizer) 500

Fluticasone propionate (HFA) 100

Ciclesonide 160

Mometasone furoate Not studied below age 4 years

Triamcinolone acetonide Not studied in this age group

GINA 2014, Box 6-6

Low, medium and high dose inhaled corticosteroids Children 6–11 years

– This is not a table of equivalence, but of estimated clinical comparability– Most of the clinical benefit from ICS is seen at low doses– High doses are arbitrary, but for most ICS are those that, with prolonged use, are associated with

increased risk of systemic side-effects

Inhaled corticosteroid Total daily dose (mcg)Low Medium High

Beclometasone dipropionate (CFC) 100–200 >200–400 >400

Beclometasone dipropionate (HFA) 50–100 >100–200 >200

Budesonide (DPI) 100–200 >200–400 >400

Budesonide (nebules) 250–500 >500–1000 >1000

Ciclesonide (HFA) 80 >80–160 >160

Fluticasone propionate (DPI) 100–200 >200–400 >400

Fluticasone propionate (HFA) 100–200 >200–500 >500

Mometasone furoate 110 ≥220–<440 ≥440

Triamcinolone acetonide 400–800 >800–1200 >1200

GINA 2014, Box 3-6 (2/2)

Low, medium and high dose inhaled corticosteroids Adults and adolescents

(≥12 years)

– This is not a table of equivalence, but of estimated clinical comparability– Most of the clinical benefit from ICS is seen at low doses– High doses are arbitrary, but for most ICS are those that, with prolonged use, are

associated with increased risk of systemic side-effects

Inhaled corticosteroid Total daily dose (mcg)Low Medium High

Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000

Beclometasone dipropionate (HFA) 100–200 >200–400 >400

Budesonide (DPI) 200–400 >400–800 >800

Ciclesonide (HFA) 80–160 >160–320 >320

Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500

Mometasone furoate 110–220 >220–440 >440

Triamcinolone acetonide 400–1000 >1000–2000 >2000

GINA 2014, Box 3-6 (1/2)


Choosing an inhaler device for children ≤5 years

GINA 2014, Box 6-6

Age Preferred device Alternate device

0–3 years Pressurized metered dose inhaler plus dedicated spacer with face mask

Nebulizer with face mask

4–5 years Pressurized metered dose inhaler plus dedicated spacer with mouthpiece

Pressurized metered dose inhaler plus dedicated spacer with face mask, or nebulizer with mouthpiece or face mask

GINA 2014, Box 6-7


video

Treating modifiable risk factors

• Provide skills and support for guided asthma self-management

- This comprises self-monitoring of symptoms and/or PEF, a written asthma action plan and regular medical review

• Prescribe medications or regimen that minimize exacerbations

- ICS-containing controller medications reduce risk of exacerbations - For patients with ≥1 exacerbations in previous year, consider low dose ICS/formoterol maintenance and reliever regimen

GINA 2014

Treating modifiable risk factors

• Encourage avoidance of tobacco smoke• For patients with severe asthma : refer to

specialist center, if available.• For patients with confirmed food allergy: - Appropriate food avoidance - Ensure available of injectable epinephrine for anaphylaxis

GINA 2014

Non- pharmacologic therapies

• Avoidance of tobacco smoke exposure• Physical activity• Occupational asthma : remove sensitizer as

soon as possible• Avoid medications that may worsen asthma:

NSAIDs ,beta-blocker• Breathing technique• Allergen avoidance

GINA 2014

If poor symptom control and/or exacerbations despite treatment

Watch patient using their inhaler

Confirm the diagnosis of asthma

Remove potential risk factors & assess and manage comorbidities

Consider treatment step-upGINA 2014

General principles for stepping down controller treatment

• Aim : to find the lowest dose that controls symptoms and exacerbations, and minimizes the risk of side-effects

• When to consider stepping down - When symptoms have been well controlled and lung function stable for ≥3 months - no respiratory infection, patient not travelling, not pregnant

GINA 2014

General principles for stepping down controller treatment

• Prepare for step-down - record the level of symptom control and consider risk factors - make sure the patient has a written asthma action plan - book a follow-up visit in 1-3 month

• Step down through available formulations - stepping down ICS doses by 25-50% at 3 month intervals is feasible and safe for most patients

• Stopping ICS is not recommended in adults with asthma

GINA 2014

Scenario

• หล�ง start controller ผื่ $ปี4วัยุอาการด็�ข้1�นื่• หล�งอาการ stable ปีระมาณ 6 เด็�อนื่ ผื่ $ปี4วัยุ loss follow

up 6 เด็�อนื่• มา admit อ�ก 2 คร��ง ด็$วัยุ asthma with exacerbation

จ1งได็$เปีล��ยุนื่จาก budesonide เปี'นื่ seretide ร�วัมก�บ treat Allergic rhinitis ร�วัมด็$วัยุ หล�งจากนื่��นื่ไม�ม� acute exacerbation อ�ก

• บ�ด็ายุ�งคงส บบ�หร��• Current med :

– Avamys 1 puff hs– Seretide evohaler (125/25) 1 puff bid

rattapon uppala, md division of pulmonology faculty of medicine khon kaen university update asthma...

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