Asthma Diagnosis &

Treatment:
Update & Quality Care
Dr. Imad Salah Ahmed Hassan
MD MRCP MSc
Consultant Physician & Pulmonologist
 Burden of Asthma

 Asthma is one of the most common chronic

diseases worldwide
 Prevalence increasing in many countries,
especially in children
 A major cause of school/work absence
 An overall increase in severity of asthma
increases the pool of patients at risk for death
 Bronchial Asthma
Facts and Figures
•Problem Scale: 350 million people around the globe

• Deaths from this condition have reached 280,000 annually

• Worldwide, costs of asthma greater than Tuberculosis

and HIV / AIDS

• Major factors contributing to asthma morbidity and

mortality are under-diagnosis and inappropriate treatment

Ref. WHO Fact Sheet N 206, Revised January 2001

GINA guidelines 1998
 Headings

 Pathogenesis of Asthma
 Diagnosing Asthma
 Treatment:
Classification of severity
Therapeutic Modalities
Quality Care Interventions
 Indications for referral to the specialist
 Failed Treatment
 Pathogenesis of Asthma

 “Asthma is a chronic inflammatory disorder

of the airways.”
 Airway inflammation results in:
– Airway obstruction through airway edema, mucus
plugs and bronchoconstriction.
– Airway hyperresponsiveness.
– Airway remodeling.
 Pathogenesis of Asthma
 Understanding of the airway inflammatory process
continues to evolve
– mast cells
– eosinophils
– airway epithelial cells
– lymphocytes (Th2 response)
– cytokines
– leukotrienes
 Asthma is a variable disease
Symptoms and use of reliever
medication

Exacerbation Exacerbation
Oral course of
steroids

Effect of steroids during

periods of worsening

Time
Medication plans need to accommodate variability among patients as
well as within individual patients over time. An essential aspect of any
treatment plan is the need to monitor the effect of the treatment and
adapting the treatment to the variability of the asthma (GINA 2002).
What is in Bronchial Asthma?
 Chronic inflammatory disease
 Long-term therapy and care: financial,
psychosocial, medication S/E
compounding it.
 Intermittent or persistent with
progressive loss of lung function.
 Dynamic severity dictate the choice of
therapy: Stepwise approach.
 May be fatal: no complacency is allowed.
 Asthma Care Plan
Six-part Asthma Management Program

 Is it Asthma?
 Assessment of Severity?
 Pharmacological and non-
pharmacological therapy?
 Can I prevent re-modelling?
 Monitoring.
 Prevention of Asthma.
 Asthma Care Plan
 Is it Asthma?
– Detailed medical history: symptoms of asthma,
aggravators etc
– FH/SH/Occupational History/Drug
History/Allergies
– Physical exam
– Spirometry to demonstrate reversibility
Diagnosis of Asthma: History

 Episodes (especially recurrent) of cough,

wheeze, shortness of breath or chest
tightness

 Coldsthat go to the chest and stay there for

> 10 days
 Diagnosis of Asthma: History

 Cough, wheeze, shortness of breath or chest

tightness during particular seasons (Fall or
Spring) or with certain exposures (animals,
smoke, or strong odors) or under certain
conditions (exercise or strong emotions)

 Useof over-the-counter medications

(inhalers) which relieve these symptoms
 Historical Clues to Asthma

 Childhood lung disease (BPD, parental

smoking, pneumonias)

 Allergies, hay fever, sinusitis, rhinitis, nasal

polyps, eczema, aspirin sensitivity

 Family history of asthma

 Asthma Care Plan
 Is it Asthma: Spirometry

 Home PEFR Charting: 20% dips

 FEV1 < 80% predicted;
 FEV1/FVC <65% or below the lower limit of
normal
 Effect of bronchodilators: FEV1 increases >12% and
at least 200 ml after using a short-acting inhaled
beta2-agonist.
 Asthma Care Plan
 Is it Asthma: Spirometry

 Steroid Trial: Increase by 12% in FEV1 after

a 2 wks PO steroid or 6 wks inhaled steroid.

 Exercise test.

 Methacholine challenge
 Ladder of Asthma Knowledge
Patient/parent Confident ;
to manage own medication, 4
increasing and decreasing using
PEF,
start oral steroid and attend clinic.

Patient/parent Knows ;
how to monitor PEF & symptoms, 3
when to increase dose of inhaled
steroids,
how to contact med practice.
Patient/parent ACCEPTS & AGREES ;
about use of medication, 2
importance of preventers,
recognition of symptoms.
Patient/parent UNDERSTANDS ;
what relief medication does,
side effects which may occur, 1
aims of treatment,
what is happening to them in their chest,
educational material is made available.
 Additional Tests
Reasons for Additional Tests The Tests
Patient has symptoms but spirometry – Assess diurnal variation of peak flow
is normal or near normal. over 1 to 2 weeks.

– Refer to a specialist for

bronchoprovocation with methacholine ,
histamine, or exercise; negative test
may help rule out asthma.

Suspect infection (TB), large airway lesions, heart – Chest x-ray

disease, or obstruction by foreign object
 Additional Tests
Reasons for Additional Tests The Tests
Suspect coexisting chronic obstructive pulmonary – Additional pulmonary function studies

disease, restrictive defect, or central airway – Diffusing capacity test

obstruction
.
– Nasal examination
Suspect other factors contribute to asthma
– Allergy tests—skin or in vitro
(These are not diagnostic tests for asthma.)
– Gastroesophageal
reflux assessment
 Asthma Care Plan

 Assessment of Severity?
 Symptoms

 Spirometry

 Others
 Classification of Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment

Symptoms Nocturnal FEV1 or PEF

Symptoms
STEP 4 Continuous 60% predicted
Limited physical Frequent
Severe Variability > 30%
Persistent activity

STEP 3 Daily 60 - 80% predicted

> 1 time week
Moderate Attacks affect activity Variability > 30%
Persistent
STEP 2 80% predicted
> 1 time a week > 2 times a month
Mild but < 1 time a day Variability 20 - 30%
Persistent

< 1 time a week

STEP 1 80% predicted
Asymptomatic and < 2 times a month
Mild normal PEF Variability < 20%
Intermittent between attacks

The presence of one feature of severity is

sufficient to place patient in that category.
 Seven Goals Asthma Management Program

Goals of Long-term Management

 Achieve and maintain control of symptoms

 Prevent asthma episodes or attacks
 Maintain pulmonary function as close to
normal levels as possible
 Maintain normal activity levels, including
exercise
 Avoid adverse effects from asthma
medications
 Prevent development of irreversible airflow
limitation
 Prevent asthma mortality
 Goals of Asthma
Therapy:
Control of Asthma

Least cost from medication

 Bronchial 
Asthma

Non­Pharmacological

Education

Avoidance of Control of 
Pharmacotherapy Immunotherapy
 Triggers Aggravators

GERD
Inhalants Anti­inflammatory Desensitization Sinusitis
Bronchodilators
Ingestants Drugs IgE Antibodies Smoking
Drugs
Pharmacotherapy in Asthma

•A stepwise approach to pharmacological therapy is

recommended

•The aim is to accomplish the goals of therapy with

the least possible medication

•Although in many countries traditional methods of

healing are used, their efficacy has not yet been
established and their use can therefore not be
recommended
Pharmacotherapy in Asthma

 Mild, intermittent  Moderate, persistent

– as-needed reliever – as-needed reliever
 Mild, persistent – two controllers
– as-needed reliever  Severe, persistent
– controller – as-needed reliever
– two controllers
– High dose ICS and
possibly oral CS
Relievers in Bronchial Asthma

•Rapid-acting inhaled β2-agonists

Salbutamol, Terbutaline
•Inhaled Long-acting β2-agonists
Formoterol
•Anticholinergics
Ipratropium
•Methylxanthines
Theophylline
•Short-acting oral β2-agonists
Salbutamol, Terbutaline
Long Term Controllers

1. Inhaled glucocorticosteroids
2. Long-acting inhaled β2-agonists
3. Leukotriene modifiers
4. Systemic glucocorticosteroids
5. Cromones
6. Methylxanthines
7. Long-acting oral β2-agonists
8. Anti-IgE
What’s New in the Guidelines?

 When to Use INHALED STEROIDS

Early use is recommended
 HIGH vs LOW DOSE inhaled steroids
High doses of inhaled glucocorticosteroids: limited
benefit and potential adverse events
 Therefore add other therapies to moderate doses
– -long-acting ß2-agonists
– -leukotriene receptor antagonists
– -theophylline
– At the consensus conference most would consider high dose more than 1000 µg. (400-500
µg in children) BDP equivalent
What’s New in the Guidelines?

 Place of long acting β 2 AGONISTS

• Many studies have repeatedly demonstrated that adding a
long-acting beta2-agonist to a lower dose of inhaled
corticosteroids produces superior outcomes compared with
doubling or even greater dosage increases in the IC
• Sole use (Salmeterol) may be fatal

 Place of anti-Leukotriene blockers

• Improves lung function when added to inhaled
corticosteroids
• Not as effective as inhaled corticosteroids
 Add-on Controllers
 Long-acting inhaled β2-agonists
Effective bronchodilators for 12 hours
Protects against nocturnal asthma
Protects against exercise induced
asthma
Improves asthma control more than
increasing dose of inhaled
corticosteroids
Allow a reduction in the dose of
inhaled steroid.
 Long-acting Inhaled ß2-
agonists
 Regular use with inhaled corticosteroids
reduces the rate of both mild and severe
exacerbations in asthma

 May be considered as an alternative to increased doses

of inhaled steroids and should be used as add-on
therapy to glucocorticosteroids

 Formoterol but not Salmeterol may be used for relief

of acute symptoms
 Add-on Controllers

 Montelukast
– Improves lung function and asthma control
– May protect against exercise induced and
aspirin-induced bronchoconstriction
– Improves lung function when added to inhaled
corticosteroids
– Not as effective as inhaled corticosteroids
 Asthma Non-pharmacological
Quality of Care Issues
Education:
 What is Asthma

 Avoidance of Precipitants/Triggers: Environmental Control

 Recognition of symptoms of poor-control

 Self-management plan: Home Peak Flow Meter
 Partnership Agreement

 Regular Follow-up: at least every 1 to 6 months.

Follow-up Indices of Control (Follow-up Form)
 Asthma Action Plan
(PEFR-Based Self Management Plan)
Best = Continue regular treatment

<80% = Double dose of:

<60% = Start prednisone & ring Doctor

Call emergency Dr. or Dial …

<40% =
…….for ambulance
 Asthma Action Plan
(Symptom-Based Self Management Plan)
Asthma under control Continue regular treatment

Waking with asthma at night Double dose of:

Increased breathlessness or Start prednisone & ring

poor response to Doctor

Call emergency Dr. or Dial

Severe attack ---- for ambulance
 ‫الخطة الذاتية لعلج الربو‬
‫وضعت هذه الخطة تحت إشراف طبيب مختص ولكل مريض خطة خاصة به يجب إتباعها حسب إرشادات الطبيب‬

‫ينبغي عمل التي‬ ‫الحالة المستقرة‬

‫( ذو‬ ‫‪ /1‬استخدام البخاخ الواقي )‬ ‫‪ ‬ممارسة الحياة بشكل طبيعي‪.‬‬
‫( مرة يوميا‬ ‫( شفطة )‬ ‫()‬ ‫اللون )‬
‫‪ ‬اختفاء أعراض الربو في الليل‪.‬‬
‫بشكل منتظم ‪.‬‬
‫‪ /2‬استخدام البخاخ الموسع للشعب الهوائية‬
‫‪ ‬ندرة استخدام البخاخ الموسع للشعب الهوائية‬
‫( شفطة ) ( مرة يوميا عند الضرورة‬ ‫)‬ ‫(لقل من مرتين أسبوعيا)‪.‬‬
‫‪ /3‬أدوية أخرى‪.......‬‬ ‫‪ ‬القدرة على نفخ الهواء ما بين ‪ %100-80‬من‬
‫المستوى الطبيعي‬

‫ينبغي عمل التي•‬ ‫الحالة المتوسطة الستقرار•‬

‫‪ ‬عند حدوث علمات أزمة الربو الولية ومنها‪:‬‬

‫( ذو‬ ‫‪ /1‬زيادة استخدام البخاخ الواقي )‬
‫‪ ‬استخدام البخاخ الموسع للشعب الهوائية أكثر من ‪ 3‬مرات‬
‫( يوميا لمدة عشرة‬ ‫( شفطة )‬ ‫()‬ ‫اللون )‬ ‫في اليوم‪.‬‬
‫أيام ثم الرجوع إلى الجرعة السابقة‪.‬‬ ‫‪ ‬الستيقاظ ليلً بسب أعراض الربو‪.‬‬
‫‪ ‬القدرة على نفخ الهواء ما بين ‪ %80 – 50‬من المستوى‬
‫‪ /2‬استشارة الطبيب في حالة عدم تحسن العراض فورا‪.‬‬ ‫الطبيعي‪.‬‬

‫ينبغي عمل التي•‬ ‫الحالة المتأزمة الحادة•‬

‫( قرص بردنيزلون ) )‪Prednisolone‬‬ ‫‪ /1‬أخذ )‬ ‫‪ ‬في حالة عدم الستجابة لما سبق أو حدث ما يلي‪:‬‬
‫( أيام‬ ‫( ملجم لمدة )‬ ‫)‬
‫‪ ‬عدم القدرة على إتمام كلمتين في نفس واحد‪.‬‬
‫(‬ ‫‪ /2‬زيادة استخدام البخاخ الواقي )‬
‫( يوميا لمدة‬ ‫( شفطة )‬ ‫(إلى )‬ ‫ذو اللون )‬ ‫‪ ‬عودة أعراض الربوة بعد أقل من نصف ساعة من‬
‫عشرة أيام ثم الرجوع إلى الجرعة في الحالة المتوسطة‪.‬‬ ‫استخدام البخاخ الموسع للشعب الهوائية‪.‬‬
‫‪ /3‬طلب الستشارة الطبية بصورة عاجلة‪.‬‬ ‫‪ ‬القدرة على نفخ الهواء أقل ‪ %50‬من الحد الطبيعي‪.‬‬
The Physician-Asthma Patient
Partnership Agreement

OBJECTIVE:

A morally and mutually beneficial gentleman’s agreement to

enhance physician and
patient medical knowledge and
communication, set standards and targets for care and
impart a stronger sense of accountability on both.
The Physician-Asthma Patient
Partnership Agreement

You canDUTIES/RESPONSIBILITIES
PHYSICIAN expect your physician to
provide the following services, which
are an essential part of asthma
management.
OFFICE VISITS - every three to twelve months
for reviewing your progress or as frequently as your
condition dictates.
MONITORING in every Visit – Weight, lung
function, oxygen saturation and other vital signs.
EDUCATION: Provision of educational material,
education by a pulmonary educator, review of
inhaler technique, provision of a self-management
The Physician-Asthma Patient
Partnership Agreement

PERSONAL GOALS
 PERSONAL GOALS
Current Weight/ Goal for 3
Body Mass months:
Index:

•Current PEFR: Goal for 3 months:

Ideal PEFR
Goal for 3
months:

Current FEV1: Goal for 3 months:

Ideal FEV1

•Current Goal for 3 months:

Asthma
symptoms:
Smoking: Y/N Goal for 3 months:

Frequency of Goal for 3 months:

attacks/ER visit:
The Physician-Asthma Patient
Partnership Agreement

PATIENT DUTIES/RESPONSIBILITIES
YOUR RESPONSIBILITIES
•Adhere to your allergen avoidance/smoke cessation instructions,
prescribed drugs and exercise advice.
•Schedule follow-up appointments every three months or as
indicated by your doctor.
•Monitor Peak Expiratory Flow Rate at home at the agreed testing
frequency: _______.
•Always bring your prescribed medications with you.
•Work toward attaining the personal goals noted above.
PATIENT SIGNATURE/ Date:
PHYSICIAN SIGNATURE/Date:
 Asthma Care Plan
Monitoring Asthma Control
Follow-up Indices of Control (Follow-up Form)
 Symptoms: Daytime and nighttime symptoms
 Severity: subjective and PEFR/Spirometry
 Compliance to therapy/Preventive Measures
– Use of inhaler/inhaler technique
– Medication refills
– Frequency of oral corticosteroid “burst” therapy

– Side effects of medications

 Exacerbations/ER visits
 Psychofunctional /Social Impact: Missed work or school
 Asthma Care Plan

 Indications for specialist referral:

■ Patient has had a life-threatening
asthma exacerbation.
■ Patient is not meeting the goals of
asthma therapy.
■ Signs and symptoms are atypical.
■ Other conditions complicate asthma.
 Asthma Care Plan

 Indications for specialist referral:

■ Additional diagnostic testing is indicated.
■ Patient requires additional education.
■ Patient is being considered for
immunotherapy.
■ Patient has severe persistent asthma.
 Asthma Care Plan

 Indications for specialist referral:

■ Patient requires continuous oral
corticosteroid therapy or high-dose
inhaled corticosteroids.
■ Child <5 and requires step 3 or 4 care. When
child is <5 and requires step 2 care, referral
should be considered.
Patient is not improving:

 Wrong diagnosis
 Inadequate/deficient treatment
 Poor inhaler technique
 Uncontrolled aggravators
 Continuous exposure to allergens
 S/E of asthma therapy.
Effect of Therapy on Remodelling?

•Influence of pharmacotherapy on natural history of

disease still not well understood
 Asthma in Sudan

 No studies on epidemiology
 Set-up for asthma care is not
satisfactory
Asthma Education
Outpatient care
Emergency care