asthma, allergies and bhr in urban black teenagers: the ... · dose ics plus leukotriene modifier...

Asthma training

Mike Levin

Division of Asthma and Allergy

Red Cross Hospital

Overview • Introduction

• Physiology

• Diagnosis

• Severity

• Treatment

• Control

• Stage 3 of guidelines

• Acute asthma

• Drug delivery

• Conclusion

Asthma prevalence

• Asthma affects 20% of children

• Asthma is the commonest chronic disease in South African children.

• South Africa is ranked 25th worldwide in the prevalence of asthma

• South Africa is ranked fifth for asthma case fatality rates


• Physiology

• Diagnosis

• Severity

• Treatment

• Control


• Acute asthma

• Drug delivery

• Conclusion

What is asthma?

• Asthma is a disorder of the airways

• caused by reversible inflammation

• that leads to the air passages contracting

• in response to a wide range of stimuli

• with enhanced irritability of the airways

• and increased mucus secretion

Smooth muscle

Spasm

Swollen mucosa

Secretions

Set alight-ness

Scarring

Allergic inflammation

• Inflammation is the most important aspect of asthma

• Inflammation causes the other features

• That’s why asthma needs treatment with regular controller therapy given every day whether the patient is symptomatic or not … to control the inflammation.


• Physiology

• Diagnosis

• Severity

• Treatment

• Control


• Acute asthma

• Drug delivery

• Conclusion

How do we diagnose it ??

recurrent wheeze and/or cough and/or dyspnoea

responsive to bronchodilators

Has the patient had recurrent wheezing?

Does the patient have a cough at night?

Does the patient wheeze or cough after

exercise?

Does the patient experience symptoms

after exposure to allergens or pollutants?

Are symptoms seasonal?

Do the patient’s colds “go to the chest” or

take >10 days to clear up?

How do we diagnose it ??

recurrent wheeze and/or cough and/or dyspnoea

responsive to bronchodilators

Bedside test or < 5 Administer bronchodilator

Reassess after 10 minutes

Document respiratory rate

respiratory distress

auscultation

Bronchodilator and diary card over 2 weeks Trial of oral corticosteroids for 7 – 14 days

Bronchodilator response

Lung function tests 10 mins after bronchodilators

> 5 yrs FEV1 increase by > 12 % (15 %)

PEF increase by > 15 % (20%)

Diurnal variability > 20 %

Bronchodilator response

Respiratory

infections

worms

foreign body

lymph nodes

cystic fibrosis

Vocal cord

dysfunction

Exclude other conditions

Cardiac

pulmonary oedema

myocarditis

congenital abnormalities

GIT

G-O reflux disease

Mimics other diseases.

Asthma and atopy may coexist with other diseases.


• Physiology

• Diagnosis

• Severity

• Treatment

• Control


• Acute asthma

• Drug delivery

• Conclusion

Select initial treatment according to severity

Severity

(GINA Guide)

Days with

symptoms

Nights with

symptoms

PEFR / FEV1

1) Mild

intermittent

< 2 / week < 2 / month > 80 % predicted

< 20 % variability

2) Mild

persistent

3 – 6 / week 3 – 4 / month > 80 % predicted

20– 30 % variability

3) Moderate

persistent

daily > 5 / month 60 – 80 % predicted

> 30 % variability

4) Severe

persistent

continual frequent < 60 % predicted

> 30 % variability

Assign patients to the most severe category in which any feature occurs.


• Physiology

• Diagnosis

• Severity

• Treatment

• Control


• Acute asthma

• Drug delivery

• Conclusion

Step 1 Step 2 Step 3 Step 4 Step 5

Asthma education and environmental control

As needed reliever medication e.g. rapid-acting β2-agonist

No controller medication

required

Education

Goals of therapy

Minimal or no chronic symptoms day or night

Minimal or no exacerbations

No limitation on activity; school or parent’s work missed

Minimal use of inhaled B2 agonists

Minimal or no adverse effects from medication

Asthma medication

• Controllers (preventers) – Inhaled steroid pumps

– Long acting B2 agonists

– Leukotriene receptor antagonists

– Theophylline

• Relievers – SABA

– Ipratropium bromide





required Select one

Low-dose inhaled steroid

(ICS)

Leukotriene modifier





required Select one Select one


(ICS)

Medium-dose ICS


Medium or Low-dose ICS plus

long-acting β2-

agonist

Low-dose ICS plus leukotriene

modifier





required Select one Select one Select one


(ICS)

Medium-dose ICS

Medium or high-dose ICS plus

long-acting β2-agonist



long-acting β2-

agonist

Medium or high-dose ICS plus Leukotriene

modifier


modifier

Medium or high-dose ICS plus theophylline





required Select one Select one Select one add either


(ICS)

Medium-dose ICS



Oral steroid (lowest dose)



long-acting β2-

agonist


modifier

Anti-IgE treatment


modifier



• Physiology

• Diagnosis

• Severity

• Treatment

• Control


• Acute asthma

• Drug delivery

• Conclusion

Asthma Control Characteristic

Follow up regularly.

Assess and move up and down treatment

algorithm according to control.

Daytime symptoms

Limitation of activities

Nocturnal symptoms/awakening

Need for reliever/rescue medication

Lung function (PEF or FEV1)

Assessing

Treating Monitoring

Asthma Control Characteristic Controlled

(all of the following) Partly controlled (any measure present)

Uncontrolled

Daytime symptoms None (twice or less/week)

More than twice/week Three or more characteristics of partly controlled asthma

Limitation of activities None Any

Nocturnal symptoms/awakening

None Any

Need for reliever/rescue medication

None (twice or less/week)

More than twice/week

Lung function (PEF or FEV1)

Normal <80% predicted or personal best (if known)

Reasons for poor asthma control

Incorrect diagnosis

Incorrect choice of inhaler and poor inhaler technique

Patient belief and adherence

Individual variation in response to

treatment

Smoking

Co-morbid rhinosinusitis

Before altering medication consider Is the diagnosis correct? Is there objective evidence of

asthma?

Are there any correctable trigger factors, e.g.

occupational sensitisers, does the patient smoke?

Other factors: Gastro-oesophageal reflux, ABPA

Does the patient have allergic rhinosinusitis? Treatment of

this may improve asthma control

Is the patient adherent to their existing therapy?

Is the patient able to use their inhaler properly?



required Select one Select one Select one add either


(ICS)

Medium-dose ICS



Oral steroid (lowest dose)



long-acting β2-

agonist


modifier

Anti-IgE treatment


modifier



• Physiology

• Diagnosis

• Severity

• Treatment

• Control


• Acute asthma

• Drug delivery

• Conclusion

Controller medications

Inhaled glucocorticoids

(e.g. budesonide, fluticasone propionate)

Leukotriene modifiers

(e.g. montelukast, zileuton)

Long-acting inhaled

β2-agonists (LABA) (e.g. salmeterol,

formoterol)


• The most effective controller medication, delivering drugs directly to the airways





Long-acting inhaled


formoterol)

Most asthmatics well controlled with low dose

inhaled steroids.

Side effects uncommon.

Inhaled corticosteroids

Low dose Medium High dose

Budesonide 100 – 200 200 - 400 400 – 800

(Budeflam, Pulmicort, Inflammide)

Beclomethasone 100 – 200 200 - 400 400 – 800

(Becotide, Beclate)

Fluticasone 50 – 125 125 – 250 250 – 500

(Flixotide)

Steroid doses

Document dose of MDIs accurately





• Used as add on particularly in children < 5

• Particularly appropriate for patients unwilling or unable to take ICS, or those that experience side effects with ICS



Long-acting inhaled


formoterol)

Uses for LTRA’s

• Monotherapy for mild asthma

• Monotherapy if patient noncompliant or steroid phobic

• Mild asthma with exercise induced component

• Aspirin sensitive asthma.

• Add on therapy for moderate persistent asthma

• Potential for steroid sparing effects

• Add on therapy for severe uncontrolled asthma.





• Used as add on particularly in children < 5

• Particularly appropriate for patients unwilling or unable to take ICS, or those that experience side effects with ICS



• Synergistic effects

• Not monotherapy

• Not below 5

Long-acting inhaled


formoterol)

Anti-inflammatory action is synergistic with steroids.

Reduce bronchial hyperresponsiveness and inhibit

release of inflammatory mediators and prevent plasma

exudation.

12 hour bronchodilation. Receptor desensitisation and

downregulation.

This effect prevented by concomitant steroid

administration.

Long acting B 2 agonists

Improves outcomes when added to medium or high

dose inhaled steroids.

Not first line agents

Use only as combination, never mono-therapy

Use as steroid sparing agents or as step up before

increasing steroids

Contraindicated below age of 5

Uses for LABAs

SMART therapy

• LABAs are formoterol and salmeterol

• Both have long duration of action

• Salmeterol has delayed onset of action

• Formoterol is rapid acting

• Symbicord maintenance and reliever therapy

• To “blunt” attacks


• Physiology

• Diagnosis

• Severity

• Treatment

• Control


• Acute asthma

• Drug delivery

• Conclusion

Drugs in acute asthma

Adrenaline B2 receptors relaxation

+ SABA’s relaxation

Acetylcholine Cholinergic receptors spasm

- Anticholinergics relaxation

Oxygen therapy

• Monitor all patients

• Achieve O2 saturation of 95%, >93% in children

Inhaled rapid-acting β2-agonists

• MDI with spacer (unless hypoxic)

• Repeat (at least) 3 doses in first hour

Oral glucocorticoids

• Early administration

• Oral

Acute exacerbations

Acute asthma

Administration of B2 agonists

• MDI/spacer 6-10 puffs – Each puff separately – Repeat every 20 minutes

• Drug (approved name) Salbutamol • Dose 6 or 10 puffs • Route INHAL via Spacer • Other directions 100 microgram MDI

• How frequently should I prescribe multidoses? • Multidose of bronchodilator gives an equivalent effect as a

nebuliser and therefore does not require to be given more frequently than you would give nebulised medication

Severe exacerbations

The attack is severe Cyanosis, sats < 94, prev ICU,

drowsy, confused, silent chest, tachycardia, pulsus paradoxus,

impaired speech / feeding breathless at rest, and/or PEF is

<60% of predicted or personal best

The response to the initial bronchodilator treatment is not

prompt and sustained for at least three

hours

There is no improvement within 2 to 6 hours

after oral glucocorticoid treatment is initiated

There is further deterioration

Give adequate inhaled therapy before considering anything else


• Physiology

• Diagnosis

• Severity

• Treatment

• Control


• Acute asthma

• Drug delivery

• Conclusion

Using a MDI is not easy

Effective deposition of aerosols requires

– Slow inspiratory flow

– Deep inhalation and breath hold

– Quiet, non-distressed breathing

Timing is critical Actuation 1 second before inhalation

reduces inhaled mass by 90%

Late actuation results in the lung being filled with medication-free air and aerosol merely reaching the “dead space” and being exhaled

Delivery of medication via a MDI without a spacer is highly ineffective

Using a MDI is not easy

Spacers

Problems with spacers Spacer is less portable than MDI alone

Multiple actuations into spacer

Need comfortable but well sealed mask

Inspiratory flow to open holding valve with tidal breathing

Issues with nebulisers

• Flow rate of 6-8 l/min – Driven by O2 or air

• Dead volume of 0.5-1ml

• When a nebuliser starts “sputtering” delivery is minimal

• Filling volume of 4-5 ml


• Physiology

• Diagnosis

• Severity

• Treatment

• Control


• Acute asthma

• Drug delivery

• Conclusion

Inhaler technique

Prepare the device

• Check the orientation

• Actuate the device

• Shake the device if it is an MDI

Inhaler technique

Prepare the device




Prepare the body

• Breathe out fully away from the mouthpiece

• Consider differences between MDI and DPI devices

Inhaler technique

Prepare the device




Prepare the body



mouthpiece in mouth

• Ensure a good seal and make sure the teeth are not in front of the device

Inhaler technique

Prepare the device




Prepare the body



mouthpiece in mouth

• Ensure a good seal and make sure the teeth are not in front of the device

DPI

• Breathe as fast and as hard as possible from the beginning

MDI

• Start breathing slowly and actuate. Breathe in over 5 seconds and hold breath for 5 seconds

OR

asthma, allergies and bhr in urban black teenagers: the ... · dose ics plus leukotriene modifier...

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