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Asthma
ZhongminQiuDepartmentofRespiratoryMedicineTongjiHospitalofTongjiUniversityAsthma1WhatIsAsthma?
Asthmaisadiseasethatcharacterizedby:AirwayobstructionthatisreversibleeitherspontaneouslyorwithtreatmentchronicairwayinflammationIncreasedairwayresponsivenesstoavarietyofstimuliInflammationcausesrecurrentepisodesofwheezing,breathlessness,chesttightnessandcoughing,particularlyatnightorearlymorning
WhatIsAsthma?Asthmaisadi2
Epidemiology17-20millionAmericans(6-10%prevalence)1%estimatedprevalenceinmainlandofChina10millionmedicalvisits2millionemergencyvisits0.5millionhospitalization5000deathsannuallyMajorcauseofschoolandworkabsenceAtleast12billionperyear
Increasingburdenforyears Epidemiology17-20million3ImpactOfAsthmaOnPatients
Psychosocial:Poorself-esteemAnxietyaboutasthmaFearofbecomingillatout-doorAnxietyaboutexerciseFearofbeingdifferent
ImpactOfAsthmaOnPatients4DidYouKnow..
Asthmakillspeopleequallyregardlessofseveritylevel1/3ofdeathsareinthosewithmildasthma1/3ofdeathsareinthosewithmoderateasthma1/3ofdeathsareinthosewithsevereasthmaDidYouKnow..Asthmakills5WhatCausesAsthma?Asthmamaybecausedbygenetic,immuneand/orenvironmentalfactors,andisoftenassociatedwitheczemaandallergiesWedonotunderstandallofthecausesofasthmaoritsincreasingprevalenceItboilsdownto“Wejustdon’treallyknowforsure”WhatCausesAsthma?Asthmamay6WhatCausesAsthmaOfthe17millionasthmasufferersintheUS,10Million(approx.60%)haveallergicasthma.3millionofthosearechildrenExposuretocertainallergenstriggerasthmasymptomstobeginExposuretocertainirritantscanalsosetanasthmaepisodeinmotionWhatCausesAsthmaOfthe17m7TriggersandIrritantsTriggersandIrritants8CommonAllergens(Triggers) SeasonalPollensAnimaldandersaliva/urineDustMitesCockroaches/Mice/RatdroppingsandurineMoldSomemedicationsSomeFoods
CommonAllergens(Triggers) S9CommonIrritants(Triggers)ExerciseColdAirChalkDustViral/upperrespiratoryinfectionsAirpollutionTobaccosmokeorsecondhandsmokeChemicalirritantsandstrongsmellsStrongemotionalfeelingsDieselfumesCleaningsuppliesCommonIrritants(Triggers)Exe10AirwayHyperresponsivenessPlasmaleakageMucushypersecretionInflammatorycellrecruitmentandactivationNeuralactivationVirus-infectedepitheliumRV-InducedAirwayInflammationAirwayPlasmaMucusInflammatory11VirusescauseasthmaexacerbationsRVscause~60%ofvirus-inducedexacerbationsofasthmaRVsdirectlyinfectthebronchialairwaysTheresponsetoviralinfectionisshapedbythehost’santiviralresponseRV-InducedAsthmaVirusescauseasthmaexacerbat12Nakano,Y.etal.Chest2002;122:271S-a-275S-aPathophysiologicschemaforthedevelopmentofasthmaNakano,Y.etal.Chest2002;113
TheAllergicReactionTheAllergicReaction14TheAsthmaCascadeTheAsthmaCascade157支氣管哮喘-雙語(yǔ)-課件16MediatorPhasesEarly-phasereactioncausedbymediatorrelease,usuallypeakswithinanhourafterinitialexposuretotheallergen.Threetofourhoursafteranacuteasthmaepisode,a"late-phasereaction"mayoccurandmaylastupto24hoursMediatorPhasesEarly-phaserea17TheEndResultsOfTheCascade LocalizedmucosaledemainthewallsofthesmallbronchiolesSecretionofthickmucusintothebronchiolarlumens(Clogsandnarrowstheairways)SpasticcontractionofbronchiolarsmoothmuscleTheEndResultsOfTheCascade18NormalBronchioleInflamedBronchiole
withMucus NormalBronchioleInflamed19AirwayObstructionCopyright3MPharmaceuticals2004AirwayObstructionCopyright3M207支氣管哮喘-雙語(yǔ)-課件21RemodelingPhasesAirwaywallthickening.SubepithelialfibrosisSmoothmusclehyperplasiaandhypertrophyMyofibroblasthyperplasiaMucusmetaplasiaRemodelingPhasesAirwaywallt22Vignola,A.M.etal.Chest2003;123:417S-a-422S-aIncreasedthicknessofthebasementmembrane(arrow),andenhancedandabnormaldepositionoffibronectin,whichisidentifiedbyimmunohistochemistryusingaspecificmonoclonalantibody(dashedarrow),inthebronchialsubmucosaVignola,A.M.etal.Chest2023Increasedthicknessofthebasementmembrane,andenhancedandabnormaldepositionofcollageninthebronchialsubmucosaIncreasedthicknessofthebas24ALotGoingOnBeneathTheSurfaceAirwayinflammationAirflowobstructionBronchialhyperresponsiveness
SymptomsALotGoingOnBeneathTheSur25CommonSymptomsOfAsthmaFrequentcough,especiallyatnightShortnessofbreathorrapidbreathingChesttightnessChestpainWheezingFatigueCommonSymptomsOfAsthmaFrequ26Early
SignsOfAnAsthma“Episode”MildcoughDropinPeakFlowreadingItchy,wateryorglassyeyesItchy,scratchyorsorethroatRunnynoseStomachacheHeadacheSneezingCongestionRestlessnessDarkcirclesundereyesIrritabilityEarlySignsOfAnAsthma“Epis27MeasuresOfAssessment
AndMonitoringTwoAspects:InitialassessmentanddiagnosisofasthmaPeriodicassessmentandmonitoringMeasuresOfAssessment
AndMo28InitialAssessment&
DiagnosisofAsthmaDeterminesThat:PatienthasahistoryorpresenceofepisodicsymptomsofairflowobstructionAirflowobstructionisatleastpartiallyreversibleAlternativediagnosesareexcludedInitialAssessment&
Diagnosi29
MethodsforEstablishing
DiagnosisDetailedmedicalhistoryPhysicalexam:wheezeandrhonchus(rhonchi)SpirometrytodemonstratereversibilityMethodsforEstablishing
Dia30Diagnosisofasthma
Objectivemeasurements>20%diurnalvariationon3daysin
aweekfor2weeksonPEFdiaryorFEV1
15%(and200ml)increaseaftershortacting?2agonistorsteroidtabletsorFEV115%decreaseafter6minutesofrunningexercisehistamineormethacholinechallengeindifficultcasesSymptoms(episodic/variable)wheezeshortnessofbreathchesttightnesscoughSignsnone(common)wheeze–diffuse,bilateral,expiratory(inspiratory)tachypneaHelpfuladditionalinformationpersonal/familyhistoryofasthmaoratopyhistoryofworseningafteraspirin/NSAID,
blockeruserecognisedtriggers–pollens,dust,animals,exercise,viralinfections,chemicals,irritantspatternandseverityofsymptomsandexacerbationsConsiderthediagnosisofasthmainpatientswithsomeorallofthesefeaturesDiagnosisofasthma
Objective31
AsthmaLungAssessment
Spirometry
SpirometryisGoldstandardtoassistinasthmadiagnosisPerformedbeforeandafterbronchodilatordosetolookforairwayobstruction
reversibilityCanalsobedonewithhistamineormethylcholinechallenge,oranexercisechallengeinthecaseofexercise-inducedasthma
AsthmaLungAssessmentSpirom32
IsAirflowObstructionAtLeastPartiallyReversible?Use
spirometrytoestablishairflowobstructionFEV1<80%ofpredictedFEV1/FVC<70%UsespirometrytoestablishreversibilityFEV1increases>15%andatleast200mLafterusingashort-actinginhaledbeta2-agonistIsAirflowObstructionAtLea33PeakExpiratoryFlowVariability
AnanotherwaytoevaluateairwayobstructionThereisthedifferencebetweenthemorningandeveningPEFreadingsPEFreadingstendtobehigherintheeveningthaninthemorningPeakExpiratoryFlowVariabili34PeakFlowMetersPeakFlowMeters35
Differentialdiagnosisof
asthma
SomeofsymptomsofasthmaaresharedwithdiseasesofothersystemsNumerousrelativelycommonlungdiseasesNeedtodifferentiatefrominfectionsandrestrictivelung
disorders,andbetweenlocalandgeneralisedobstructionDifferentialdiagnosesinclude:COPDcardiacdiseaselaryngeal,trachealorlungtumourbronchiectasisforeignbodyinterstitiallungdiseasepulmonaryemboliaspirationvocalcorddysfunctionhyperventilationDifferentialdiagnosisof
ast36AsthmaSeverityLevelsMildIntermittentMildPersistentModeratePersistentSeverePersistentAsthmaSeverityLevelsMildIn37AsthmaSeverityLevelsBySymptomsMildIntermittent-Sx<2days/week Sx<2nights/monthMildPersistent-Sx>2x/weekbut<1x/day Sx>2nights/monthModeratePersistent-Sxeveryday Sx>1night/weekSeverePersistent- ContinualdaytimeSx FrequentSxatnight
AsthmaSeverityLevelsBySymp38MildIntermittentSymptoms￡2days/weekwithnighttimesymptoms￡2nights/monthAsymptomaticwithnormalpeakflowsbetweenexacerbationsExacerbationsarebrief(hourstoafewdays)PeakFlows380%predictedwithvariability<20%MildIntermittentSymptoms￡239MildPersistentSymptoms>2days/weekbut<1x/daywithnighttimesymptomsgreaterthan2nights/monthExacerbationsmayaffectactivityPeakflow380%predictedwithvariabilityof<20-30%MildPersistentSymptoms>2da40ModeratePersistentChildislikelytohavedailysymptomsanduserelieverdailyChildiswakingupatleastonceaweekduetoasthmasymptomsPeakflows60-80%ofpredictedwithvariabilityof>30%ActivityisaffectedandexacerbationsmaylastdaysModeratePersistentChildisli41SeverePersistentContinualdaytimesymptomswithfrequentnighttimesymptomsVerylimitedphysicalactivityFrequentexacerbationsPeakflows￡60%ofpredictedandvariabilityofmorethan30%TreatmentinvolvesacombinationofmanydrugtherapiesSeverePersistentContinualday42GoalsOfAsthmaTherapyPreventchronicandtroublesomesymptomsMaintain“normal”pulmonaryfunctionMaintainnormalactivitylevels-includingexerciseandotherphysicalactivityMinimizetheneedforemergencyroom/urgentcarevisitsorhospitalizationsGoalsOfAsthmaTherapyPrevent43
GoalsOfAsthmaTherapy
Continued…PreventrecurrentexacerbationsofsymptomsProvideoptimalpharmacotherapywithminimalornoadverseeffectsSatisfythepatient’sandthefamily’sgoalsforasthmacareGoalsOfAsthmaTherapy44
StepwiseApproachTo Asthma TherapyOutcome:BestPossibleResultsReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnController:OnedailymedicationPossiblyaddlongactingbronchodilatorAnti-leukotrienesController:DailyinhaledcorticosteroidDailylongactingbronchodilatorAnti-leukotrieneController:DailyinhaledcorticosteroidDailylongactingbronchodilatorDaily/alternatedayoralcorticosteroidWhencontrolled,reducetherapyMonitorPEF:≥80%PEF:≥80%PEF:<60%STEP1:IntermittentSTEP2:MildPersistentSTEP3:ModeratePersistentSTEP4:SeverePersistentStepdownOutcome:ControlofAsthmaPEF:60-80% StepwiseApproachToOutcome:45BronchodilatorsRelaxingbronchialsmoothmuscletoopenuptheairway.Anti-inflammatoryagentsInhibitingthedevelopmentofairwayinflammationandstoppingongoinginflammation.Incombination,treatandpreventreversibleairwayobstructionandairwayhyperresponsiveness,relievethesymptomanddecreasetheexacerbation.CommonDrugsforAsthmaBronchodilatorsCommonDrugsfo46Long-termcontrolmedication(Controller)CorticosteriodsCromolyn/nedocromilLongactingb2agonists(LABA)LeukotrienemodifierQuickreliefmedication(Rescuer)Short-actingb2agonistsTheophyllineAnticholinergicsSystemicCorticosteriodsCommonDrugsforAsthmaLong-termcontrolmedication(477支氣管哮喘-雙語(yǔ)-課件48Stepwisemanagementof
asthmainadultsStep1:MildintermittentasthmaInhaledshortacting?2agonistasrequiredStepwisemanagementof
asthma49Stepwisemanagementof
asthmainadultsStep1:MildintermittentasthmaStep2:RegularpreventertherapyAddinhaledsteroid200-800mcg/day*400mcgisanappropriatestartingdoseformanypatientsStartatdoseofinhaledsteroidappropriatetoseverityofdisease.*BDPorequivalentStepwisemanagementof
asthma50Stepwisemanagementof
asthmainadultsStep1:MildintermittentasthmaStep3:Add-ontherapys1.Addinhaledlong-acting?2agonist(LABA)2.Assesscontrolofasthma:good
responsetoLABA–continueLABAbenefitfromLABAbutcontrolstillinadequate–continueLABAandincreaseinhaledsteroiddoseto800mcg/day*(ifnotalreadyonthisdose)noresponsetoLABA–stopLABAandincreaseinhaledsteroidto
800mcg/day*.Ifcontrolstillinadequate,institutetrialofothertherapies
(e.g.leukotrienereceptorantagonistorSRtheophylline)Step2:RegularpreventertherapyStartatdoseofinhaledsteroidappropriatetoseverityofdisease.*BDPorequivalentStepwisemanagementof
asthma51Stepwisemanagementof
asthmainadultsStep1:MildintermittentasthmaStep2:RegularpreventertherapyStartatdoseofinhaledsteroidappropriatetoseverityofdisease.*BDPorequivalentStep3:Add-ontherapyStep4:PersistentpoorcontrolConsidertrialsof:increasinginhaledsteroidupto2000mcg/day*additionoffourthdrug(e.g.leukotrienereceptorantagonist,SRtheophylline,?2agonisttablet)Stepwisemanagementof
asthma52Stepwisemanagementof
asthmainadultsStep1:MildintermittentasthmaStep2:RegularpreventertherapyStartatdoseofinhaledsteroidappropriatetoseverityofdisease.*BDPorequivalentStep3:Add-ontherapyStep4:PersistentpoorcontrolStep5:ContinuousorfrequentuseoforalsteroidsUsedailysteroidtabletinlowestdoseprovidingadequatecontrolMaintainhighdoseinhaledsteroidat2000mcg/day*ConsiderothertreatmentstominimisetheuseofsteroidtabletsReferpatientforspecialistcareStepwisemanagementof
asthma53Stepwisemanagementof
asthmainadultsStep1:MildintermittentasthmaStep5:ContinuousorfrequentuseoforalsteroidsStep4:PersistentpoorcontrolStep3:Add-ontherapyStep2:RegularpreventertherapyStepwisemanagementof
asthma54OxygentherapyandmechanicalventilationShort-actingb2agonistsAminophyllineAnticholinergicsCorticosteriods
ManagementforAcuteExacerbation
ofAsthmaOxygentherapyandmechanical55SameasacuteexacerbationofasthmaFluidinfusionModificationofacidosisAntibioticsMaintenanceofelectrolytebalanceResolutionofcomplications
ManagementforStatusAsthmaticsSameasacuteexacerbationof56Asthma
ZhongminQiuDepartmentofRespiratoryMedicineTongjiHospitalofTongjiUniversityAsthma57WhatIsAsthma?
Asthmaisadiseasethatcharacterizedby:AirwayobstructionthatisreversibleeitherspontaneouslyorwithtreatmentchronicairwayinflammationIncreasedairwayresponsivenesstoavarietyofstimuliInflammationcausesrecurrentepisodesofwheezing,breathlessness,chesttightnessandcoughing,particularlyatnightorearlymorning
WhatIsAsthma?Asthmaisadi58
Epidemiology17-20millionAmericans(6-10%prevalence)1%estimatedprevalenceinmainlandofChina10millionmedicalvisits2millionemergencyvisits0.5millionhospitalization5000deathsannuallyMajorcauseofschoolandworkabsenceAtleast12billionperyear
Increasingburdenforyears Epidemiology17-20million59ImpactOfAsthmaOnPatients
Psychosocial:Poorself-esteemAnxietyaboutasthmaFearofbecomingillatout-doorAnxietyaboutexerciseFearofbeingdifferent
ImpactOfAsthmaOnPatients60DidYouKnow..
Asthmakillspeopleequallyregardlessofseveritylevel1/3ofdeathsareinthosewithmildasthma1/3ofdeathsareinthosewithmoderateasthma1/3ofdeathsareinthosewithsevereasthmaDidYouKnow..Asthmakills61WhatCausesAsthma?Asthmamaybecausedbygenetic,immuneand/orenvironmentalfactors,andisoftenassociatedwitheczemaandallergiesWedonotunderstandallofthecausesofasthmaoritsincreasingprevalenceItboilsdownto“Wejustdon’treallyknowforsure”WhatCausesAsthma?Asthmamay62WhatCausesAsthmaOfthe17millionasthmasufferersintheUS,10Million(approx.60%)haveallergicasthma.3millionofthosearechildrenExposuretocertainallergenstriggerasthmasymptomstobeginExposuretocertainirritantscanalsosetanasthmaepisodeinmotionWhatCausesAsthmaOfthe17m63TriggersandIrritantsTriggersandIrritants64CommonAllergens(Triggers) SeasonalPollensAnimaldandersaliva/urineDustMitesCockroaches/Mice/RatdroppingsandurineMoldSomemedicationsSomeFoods
CommonAllergens(Triggers) S65CommonIrritants(Triggers)ExerciseColdAirChalkDustViral/upperrespiratoryinfectionsAirpollutionTobaccosmokeorsecondhandsmokeChemicalirritantsandstrongsmellsStrongemotionalfeelingsDieselfumesCleaningsuppliesCommonIrritants(Triggers)Exe66AirwayHyperresponsivenessPlasmaleakageMucushypersecretionInflammatorycellrecruitmentandactivationNeuralactivationVirus-infectedepitheliumRV-InducedAirwayInflammationAirwayPlasmaMucusInflammatory67VirusescauseasthmaexacerbationsRVscause~60%ofvirus-inducedexacerbationsofasthmaRVsdirectlyinfectthebronchialairwaysTheresponsetoviralinfectionisshapedbythehost’santiviralresponseRV-InducedAsthmaVirusescauseasthmaexacerbat68Nakano,Y.etal.Chest2002;122:271S-a-275S-aPathophysiologicschemaforthedevelopmentofasthmaNakano,Y.etal.Chest2002;169
TheAllergicReactionTheAllergicReaction70TheAsthmaCascadeTheAsthmaCascade717支氣管哮喘-雙語(yǔ)-課件72MediatorPhasesEarly-phasereactioncausedbymediatorrelease,usuallypeakswithinanhourafterinitialexposuretotheallergen.Threetofourhoursafteranacuteasthmaepisode,a"late-phasereaction"mayoccurandmaylastupto24hoursMediatorPhasesEarly-phaserea73TheEndResultsOfTheCascade LocalizedmucosaledemainthewallsofthesmallbronchiolesSecretionofthickmucusintothebronchiolarlumens(Clogsandnarrowstheairways)SpasticcontractionofbronchiolarsmoothmuscleTheEndResultsOfTheCascade74NormalBronchioleInflamedBronchiole
withMucus NormalBronchioleInflamed75AirwayObstructionCopyright3MPharmaceuticals2004AirwayObstructionCopyright3M767支氣管哮喘-雙語(yǔ)-課件77RemodelingPhasesAirwaywallthickening.SubepithelialfibrosisSmoothmusclehyperplasiaandhypertrophyMyofibroblasthyperplasiaMucusmetaplasiaRemodelingPhasesAirwaywallt78Vignola,A.M.etal.Chest2003;123:417S-a-422S-aIncreasedthicknessofthebasementmembrane(arrow),andenhancedandabnormaldepositionoffibronectin,whichisidentifiedbyimmunohistochemistryusingaspecificmonoclonalantibody(dashedarrow),inthebronchialsubmucosaVignola,A.M.etal.Chest2079Increasedthicknessofthebasementmembrane,andenhancedandabnormaldepositionofcollageninthebronchialsubmucosaIncreasedthicknessofthebas80ALotGoingOnBeneathTheSurfaceAirwayinflammationAirflowobstructionBronchialhyperresponsiveness
SymptomsALotGoingOnBeneathTheSur81CommonSymptomsOfAsthmaFrequentcough,especiallyatnightShortnessofbreathorrapidbreathingChesttightnessChestpainWheezingFatigueCommonSymptomsOfAsthmaFrequ82Early
SignsOfAnAsthma“Episode”MildcoughDropinPeakFlowreadingItchy,wateryorglassyeyesItchy,scratchyorsorethroatRunnynoseStomachacheHeadacheSneezingCongestionRestlessnessDarkcirclesundereyesIrritabilityEarlySignsOfAnAsthma“Epis83MeasuresOfAssessment
AndMonitoringTwoAspects:InitialassessmentanddiagnosisofasthmaPeriodicassessmentandmonitoringMeasuresOfAssessment
AndMo84InitialAssessment&
DiagnosisofAsthmaDeterminesThat:PatienthasahistoryorpresenceofepisodicsymptomsofairflowobstructionAirflowobstructionisatleastpartiallyreversibleAlternativediagnosesareexcludedInitialAssessment&
Diagnosi85
MethodsforEstablishing
DiagnosisDetailedmedicalhistoryPhysicalexam:wheezeandrhonchus(rhonchi)SpirometrytodemonstratereversibilityMethodsforEstablishing
Dia86Diagnosisofasthma
Objectivemeasurements>20%diurnalvariationon3daysin
aweekfor2weeksonPEFdiaryorFEV1
15%(and200ml)increaseaftershortacting?2agonistorsteroidtabletsorFEV115%decreaseafter6minutesofrunningexercisehistamineormethacholinechallengeindifficultcasesSymptoms(episodic/variable)wheezeshortnessofbreathchesttightnesscoughSignsnone(common)wheeze–diffuse,bilateral,expiratory(inspiratory)tachypneaHelpfuladditionalinformationpersonal/familyhistoryofasthmaoratopyhistoryofworseningafteraspirin/NSAID,
blockeruserecognisedtriggers–pollens,dust,animals,exercise,viralinfections,chemicals,irritantspatternandseverityofsymptomsandexacerbationsConsiderthediagnosisofasthmainpatientswithsomeorallofthesefeaturesDiagnosisofasthma
Objective87
AsthmaLungAssessment
Spirometry
SpirometryisGoldstandardtoassistinasthmadiagnosisPerformedbeforeandafterbronchodilatordosetolookforairwayobstruction
reversibilityCanalsobedonewithhistamineormethylcholinechallenge,oranexercisechallengeinthecaseofexercise-inducedasthma
AsthmaLungAssessmentSpirom88
IsAirflowObstructionAtLeastPartiallyReversible?Use
spirometrytoestablishairflowobstructionFEV1<80%ofpredictedFEV1/FVC<70%UsespirometrytoestablishreversibilityFEV1increases>15%andatleast200mLafterusingashort-actinginhaledbeta2-agonistIsAirflowObstructionAtLea89PeakExpiratoryFlowVariability
AnanotherwaytoevaluateairwayobstructionThereisthedifferencebetweenthemorningandeveningPEFreadingsPEFreadingstendtobehigherintheeveningthaninthemorningPeakExpiratoryFlowVariabili90PeakFlowMetersPeakFlowMeters91
Differentialdiagnosisof
asthma
SomeofsymptomsofasthmaaresharedwithdiseasesofothersystemsNumerousrelativelycommonlungdiseasesNeedtodifferentiatefrominfectionsandrestrictivelung
disorders,andbetweenlocalandgeneralisedobstructionDifferentialdiagnosesinclude:COPDcardiacdiseaselaryngeal,trachealorlungtumourbronchiectasisforeignbodyinterstitiallungdiseasepulmonaryemboliaspirationvocalcorddysfunctionhyperventilationDifferentialdiagnosisof
ast92AsthmaSeverityLevelsMildIntermittentMildPersistentModeratePersistentSeverePersistentAsthmaSeverityLevelsMildIn93AsthmaSeverityLevelsBySymptomsMildIntermittent-Sx<2days/week Sx<2nights/monthMildPersistent-Sx>2x/weekbut<1x/day Sx>2nights/monthModeratePersistent-Sxeveryday Sx>1night/weekSeverePersistent- ContinualdaytimeSx FrequentSxatnight
AsthmaSeverityLevelsBySymp94MildIntermittentSymptoms￡2days/weekwithnighttimesymptoms￡2nights/monthAsymptomaticwithnormalpeakflowsbetweenexacerbationsExacerbationsarebrief(hourstoafewdays)PeakFlows380%predictedwithvariability<20%MildIntermittentSymptoms￡295MildPersistentSymptoms>2days/weekbut<1x/daywithnighttimesymptomsgreaterthan2nights/monthExacerbationsmayaffectactivityPeakflow380%predictedwithvariabilityof<20-30%MildPersistentSymptoms>2da96ModeratePersistentChildislikelytohavedailysymptomsanduserelieverdailyChildiswakingupatleastonceaweekduetoasthmasymptomsPeakflows60-80%ofpredictedwithvariabilityof>30%ActivityisaffectedandexacerbationsmaylastdaysModeratePersistentChildisli97SeverePersistentContinualdaytimesymptomswithfrequentnighttimesymptomsVerylimitedphysicalactivityFrequentexacerbationsPeakflows￡60%ofpredictedandvariabilityofmorethan30%TreatmentinvolvesacombinationofmanydrugtherapiesSeverePersistentContinualday98GoalsOfAsthmaTherapyPreventchronicandtroublesomesymptomsMaintain“normal”pulmonaryfunctionMaintainnormalactivitylevels-includingexerciseandotherphysicalactivityMinimizetheneedforemergencyroom/urgentcarevisitsorhospitalizationsGoalsOfAsthmaTherapyPrevent99
GoalsOfAsthmaTherapy
Continued…PreventrecurrentexacerbationsofsymptomsProvideoptimalpharmacotherapywithminimalornoadverseeffectsSatisfythepatient’sandthefamily’sgoalsforasthmacareGoalsOfAsthmaTherapy100
StepwiseApproachTo Asthma TherapyOutcome:BestPossibleResultsReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnReliever:InhaledbetaagonistprnController:OnedailymedicationPossiblyaddlongactingbronchodilatorAnti-leukotrienesController:DailyinhaledcorticosteroidDailylongactingbronchodilatorAnti-leukotrieneController:DailyinhaledcorticosteroidDailylongactingbronchodilatorDaily/alternatedayoralcorticosteroidWhencontrolled,reducetherapyMonitorPEF:≥80%PEF:≥80%PEF:<60%STEP1:IntermittentSTEP2:MildPersistentSTEP3:ModeratePersistentSTEP4:SeverePersistentStepdownOutcome:ControlofAsthmaPEF:60-80% StepwiseApproachToOutcome:101BronchodilatorsRelaxingbronchialsmoothmuscletoopenuptheairway.Anti-inflammatoryagentsInhibitingthedevelopmentofairwayinflammationandstoppingongoinginflammation.Incombination,treatandpreventreversibleairwayobstructionandairwayhyperresponsiveness,relievethesymptomanddecreasetheexacerbation.CommonDrugsforAsthmaBronchodilatorsCommonDrugsfo102Long-termcontrolmedication(Controller)CorticosteriodsCromolyn/nedocromilLongactingb2agonists(LABA)LeukotrienemodifierQuickreliefmedication(Rescuer)Short-actingb2agonistsTheophyllineAnticholinergicsSystemicCorticosteriodsCommonDrugsforAst
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