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Longterm Asthma

Management

Module 7

Training of Inhalation Therapy

& Pediatric Asthma Management

Departemen IKA FKUI-RSCM

UKK Respirologi PP IDAI

Dr. Darmawan Budi Setyanto, Sp.A(K)

Born: 11 April 1961

Education:

1. Faculty of Medicine University of Indonesia, 1986

2.Medical Postgraduate (Pediatrics), Faculty of Indonesia, 1993

3. Pediatric Pulmonology Subspecialty, Faculty of Indonesia, 2002

Recent position :Recent position :

� Head of Division of Respirology, Dept of Child of Medicine, University of Indonesia

� Lecturer on Pediatric Respirology, Dept of Child Health, Faculty of Medicine University of Indonesia

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Asthma : chronic respiratory disease that can have acute attack (two in one disease)

AsthmaAcute Asthma

Chronic Asma

Asthma, 2 aspects

Classification of pediatric asthma

Chronic asthma

1. Infrequent episodic asthma

2. Frequent episodic asthma

3. Persistent asthma

Acute asthma

1. Mild attack

2. Moderate attack

3. Severe attack

Asthma labelling

• Chronic condition + present condition

• Chronic condition: infrequent -- persistent

• Present condition:

(-)

Symptom attack (-)

(+)

attack (+)

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Chronic Asthma

not optimal medication

Acute Asthma

trigger exposure

Asthma managements

Chronic asthma

Long term management

Algorithm diagnosis

& treatment

Acute asthma

Attack

management

Algorithm attack

management

Asthma managements

Chronic asthma

Long term management

Reliever &

Controller

Acute asthma

Attack

management

Reliever

Asthma medication

Controller

drug to control asthma ie attack or symptom not easily emerge

• Inhaled steroid

• LABA, ALTR

Reliever

drug to relieve asthma attackor symptoms

• β-agonist• Xanthine

• anticholinergic

Criteria of severity of childhood asthma

• Infrequent episodic symptoms – Exacerbation 3-4 x/year, there is no sign and symptom in between

– Quality of life good

• Frequent episodic symptoms– Exacerbation 1 x/month, there is no sign and symptom in between

– Quality of life good, sometimes affected

• Persistent symptoms– Exacerbation > 1 x/month, there is sign and symptom in between

– Quality of life limited

Objectives of asthma management

• Minimal chronic symptoms (ideally none)

• Minimal acute attacks (seldom)

• No visit to ER

• Minimal ß2-agonist using

• Activity is not inhibited

• Normal lung function test (mendekati)

• Minimal drugs side effects

Increasing Quality

of Life

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Asthma management principles

1.Avoidance

2.Avoidance

3.Avoidance

4.Drugs ���� inhalation therapy

Avoidance of allergens

• For all asthma: infrequent episodic, frequent episodic, and persistent asthma

• Avoid the triggers: house dust mite

• Keep away from pets

• Before and during pharmacologic treatment

GINA, 2002

Education for Patient/Family

• Knowledge of asthma

• Compliance

• Practical management guidelines at home

• Doctor-family-patient relationship

GINA,2002

Pharmacotherapy

Reliever:• β2 agonist : inhaler, nebulized,

oral• Epinephrine : subkutan• Teophyllin/aminophyllin : oral, I.V.• Anticolinergic (ipratropium br) : inhaler • Steroid : oral, I.M.

Controller:• Steroid : inhaler• LABA : inhaler, oral• Antileukotrien : oral PNAA, 2002

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Classification Controller Reliever

Infrequent episodic asthma

No Yes

Frequent episodic asthma

Yes Yes

Persistent asthma

Yes Yes

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Chronic asthma management

• Asthma attack / symptoms present:

– First line therapy

• beta-2 agonist

• ipratropium bromida

• Chronic asthma (long term management)

– First line therapy

• inhaled steroid

• Long-acting beta-2 agonist (LABA)

Medicine

• Bronchodilator• Anti-inflammation• Antiremodeling• Anti IgE

Bronchodilator

• Short Acting Beta-2 Agonist (SABA)– Reliever

• Long Acting Beta-2 Agonist (LABA)– Controller

TREATING ASTHMA

with Bronchodilators alone

is likeis likeis likeis like

Painting over rust !!!

TREATING ASTHMA

with Bronchodilators alone

is likeis likeis likeis like

Anti-Inflammation

is likeis likeis likeis like

• Antihistamine• Disodium Cromoglycate (DSCG)• Corticosteroid• Anti PDE 4 (Phosphodiesterase)

Inflammation in asthma

Barnes PJ

Chronic inflammation

Structural changes

Inflamasi akut

Steroid response

Time

Long-term placebo-controlled trial of ketotifen in the management of preschool children with asthma

Loftus BG, Price JF

J Allergy Clin Immunol 1987; 79:350-5

The results suggest that:

“Ketotifen has no place in the management of young children with frequent asthma”

Inhaled disodium cromoglycate (DSCG) as maintenance therapy in children with asthma:

a systematic review.

Tasche MJA, Uijen JHJ, Bernsen RMD, de Jongste JC, van der Wouden JC.

Thorax 2000; 55:913-20

“Insufficient evidence that DSCG has a beneficial effect as maintenance treatment

in children with asthma ”

• Restores asthma controlling in children

• Evidences from study:

� Increases PEF (morning and afternoon)

� Increases FEV1 (morning and )

� Reduces FEV1 diurnal variation

� Reduces symptoms

� Reduces asthma attack frequency

� Reduces reliever using (β2 agonis)

� Increases quality of life

Corticosteroid

FEV1, forced expiratory volume in 1 secondPEF, peak expiratory flow

Side Effects

• Hoarse voice• Pharynx irritation• Candidiasis• Headache• Growth disturbance??

Longterm steroid……

Treatment

Reliever (treatment of attack) :• ββββ2 agonist : inhaled, nebulized, oral• Ephinephrin : subcutan• Theophyllin/aminophyllin : oral, I.V.• Steroid : oral, I.M.

Controller (prevention of attack) :• Avoidance : triggers (including enhancers,

inducers) especially improve indoor environment.

• Medicine : inhaled steroid, antileukotrien.

Steroid efficacy in asthma

Benefit

Steroiddose

Side-effects

LABA’s and ICS - complementary modes of action

Smooth muscledysfunction

Airwayinflammation

• Bronchoconstriction• Bronchial hyperreactivity• Hyperplasia• Inflammatory mediator release

• Inflammatory cell infiltration / activation

• Mucosa oedem• Cellular proliferation• Epithelial damage• Basement membrane thickening

�

� �

�

�

�

� �

�

�

�

Symptoms / exacerbations

LABA CS

Percentage of days (+ SE) on wich wheezing was noticed, medication was given, and abnormally low peak expiratory flow rate (PEFR) was recorded during 4 week study period

% Days50

40

30

20

10

0

WheezingMedicationLow PEFR

Dust freeBedroom

ControlBedroom

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Adding LABA to budesonide reduces rate of

severe exacerbations

Pauwels et al, NEJM 1997

0

0.5

1.0

Budesonide100 µg bid

Exa

cerb

atio

ns /

patie

nt /

year

Budesonide 100 µg bid+ Formoterol 9 µg bid

Budesonide400 µg bid

Budesonide 400 µg bid+ Formoterol 9 µg bid

Increasing Budesonide dose: p <0.001Adding Formoterol : p = 0.014 Budesonide 800 vs. Budesonide 200 + Formoterol: p = 0.031

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Adding LABA to budesonide improves FEV1

Pauwels et al, NEJM 1997

Budesonide100 µg bid

Budesonide400 µg bid

Budesonide100 µg bid+ Formoterol 9 µg bid

Budesonide400 µg bid

+ Formoterol 9 µg bid

% p

redi

cted

70

75

80

85

90

-1 0 1 2 3 6 9 12Months

Quality of life (CS +LABA)

*p<0.01 vs baseline†p<0.05 vs placeboStatus fungsional

meningkat

Status fungsiona lmenurun

Mea

n F

SIIR

scor

e

Mahajan et al. Pediatr Asthma Allergy Immunol 1998

0

Anak sakit kronik

Anak sehat

80

90

100

0 12Waktu (minggu)

84

PlaceboSalmeterol 50 µg bid

**

*

*

*

207 anak, 57% menerima steroid inhaler

FSIIR, functional status IIR

† †

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Long term treatment

ββββ2-agonist or theophyllineinhaled/oral intermittently

Add controller drug

Replace with low dose inhaled steroidsContinue ββββ2-a or/and

theophylline inhaled/oral intermittently

4-6 weeks>3 episodes/week

6-8 weeksresponse (-)

Infrequent EpisodicSymptoms

Frequent episodicSymptoms

3-6 monthsEvaluation

3-6 monthsresponse (+)

6-8 weeksresponse (-)

3-6 monthsresponse (+)

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Consider :• Long acting ββββ2-agonists, or• Slow release ββββ2-agonists, or• Slow release theophyllines

Increase dose of inhaled steroid

Add oral steroids ����

6-8 weeksrespons (-)

Persistent Symptoms

3-6 monthsrespons (+)

6-8 weeksrespons (-)

3-6 monthsrespons (+)

6-8 weeksrespons (-)

3-6 monthsrespons (+)

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Low dose steroid

Medium dose steroid

Low dose steroid + LABA

Low dose steroid + ALTR

Low dose steroid +TSR

High dose steroid

Medium dose steroid + LABA

Medium dose steroid + ALTR

Medium dose steroid + TSR

ORAL STEROID

Longterm management

Conclusion

• Asthma prevalence: increase

• Classifications of childhood asthma: infrequent episodic asthma, frequent episodic asthma, and persistent asthma

• Longterm management: Inhalation therapy

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Thanks for

your attention