1. Guidance Based Asthma Management : twinning access with quality
Chakaya J.M.
Chief Research Officer, Centre for Respiratory Diseases Research, Kenya Medical Research Institute
Technical Advisor, Kenya Association for the Prevention of Tuberculosis and Lung Disease
Launch of the Ugandan Thoracic Society, Kampala, September 9,2011

2. Outline Justification for “ local guidelines”
Guideline development Process
Guideline Contents
Burden of Disease
Basic Pathophysiology
Diagnosis
Treatment
Service Organization: the Practical Approach to Lung
Monitoring and Evaluation

3. Justification for “Local Guidelines”
Need to define:
The peculiarities that may be important and likely to impact on asthma treatment outcomes.
The deviations that may need to be made to internationally recommended interventions but ensuring that patients do not receive sub standard care nor are they ( or the health system) subjected to excessively costly care
Need to ensure that recommendations assure most patients receiving care have the best possible outcomes
Local guidelines development constrained by
Paucity of robust local scientific data on the disease burden, risk factors, interventions and outcomes/impact of those interventions

4. Guideline Development Processes- Weighing the Evidence
Evidence Categories
A: Rich body of data from high quality Randomized Clinical Trials showing consistent effects
B: Limited body of data from Randomized Clinical Trials which may be small in size, or used a population that is somewhat different from the population where the recommendation will be applied or the results of these trials are somewhat inconsistent
C: Results from non randomized trials or observational studies
D: Expert opinion/Panel Consensus judgment

5. Grading of Recommendations Assessment Development and Evaluation(GRADE)

6. The Outcomes of Interest
Reduction in morbidity and mortality
Improvement in quality of life
Reduction in the burden of treatment ( monitoring tests, number of pills)
Reduced resource expenditures

7. GRADE SYSTEM’s STRONG RECOMMENDATION

8. GRADE SYSTEM’s WEAK ECOMMENDATION

10. Disease Burden

11. Epidemiologic Studies
Scanty for most of Africa
Standardization of methods for measuring disease burden critical
International Study of Asthma and Allergic Disease in Childhood

12. Prevalence of asthma in Africa
Addis Ababa, Ethiopia
10.7*
Ibadan, Nigeria
10.7*
Jima, Ethiopia
1.9*
Eldoret, Kenya
10.4*
Nairobi, Kenya
17.1*
Cape Town, South Africa
16.1*
ISAAC. Eur Respir J 1998;12:315–335
*% of study population

13. Asthma: A multi factorial disease
Non Modifiable Factors
Gender: early M>F; Later F>M
Atopy
AHR
Modifiable Factors
Allergen Exposure
Infections and Infestations
Breastfeeding
Air pollution
HIV infection
Occupational Exposures
Tobacco smoking including environmental tobacco smoke( passive smoking)

15. Vehicular Traffic Pollution and Wheeze in Jimma, Ethiopia
A Venn, H Yemaneberhan, S lewis et al. Occupp. Environ Med 2005; 62:

16. Duration of Breastfeeding and allergic disease, hay fever, asthma and eczema
CC Obihara, BJ Marais, RP Gie et al. Eur Respir J 2005; 25:

17. Tuberculous Infection and Allergic Disease
C.C Obihara, J.L.L Kimpen, R.P Gie et al. Clinical and Experimental Allergy, 2006; 36: 70-76

21. The Asthma Continuum
Stephen T Holgate et al. Clinical Science 2010; 118:

22. Epithelial – Mesenchymal – Immune System Interaction
Stephen T Holgate et al. Clinical Science 2010; 118:

23. Time for Paradigm Change?
Participating Cells
Airway Epithelial Cells
Antigen Presenting Cells
T – Lymphocytes
Eosinophils
Mast Cells
Airway smooth muscles
Endothelium
Fibroblasts and Myofibroblast
Mediator Soup
Chemokines
Cytokines
Cystenyl Leukotrienes
Nitric Oxide
Prostaglanding D2
Others
Effects
Broncho-constriction
Vascular leakage
Increased airway secretions
Air way Hyper responsiveness

24. Asthma Diagnosis

25. Diagnostic Step 1 Listen to the patient
Is there recurrent or episodic wheeze, cough, chest tightness or shortness of breath?
Are the symptoms particularly troublesome at night or early morning?
Are the symptoms triggered by factors such as dust, cold exposure, strong smells or exercise?
Is there a consistent response to asthma specific treatment?

26. Diagnostic Step 2
Obtain a lung function Test (measure FVC, FEV1 and PEF)
Is there airflow limitation (FEV1/FVC% less than 70?)
Is there a bronchodilator response (FEV1 or PEF improved by greater that 12% or 15%, 30 minutes after inhalation of a short acting bronchodilator)?
Measure PEF variability ( wide swings in the PEF between morning and evening or when at work and off work)

27. Diagnostic Step 3 Measure airway hyperresponsiveness.
Does the FEV1 drop below 20% with only small doses of an inhaled bronchoconstrictor such as methacholine, histamine or with exercise?

28. Consider Asthma Mimics
Hyperventilation syndrome and panic attacks
Upper airways obstruction and inhaled foreign bodies
Vocal cord dysfunction
Other forms of airways obstruction especially Chronic Obstructive Pulmonary Disease (COPD)
Non pulmonary causes of symptoms especially left ventricular failure
Non obstructive forms of lung disease such as diffuse parenchymal lung disease

29. Spirometers From To Simple hand held manual and digital devices
Complex computer based tests 29

30. Peak Expiratory Flow Meters
Hand Held Devices
Digital Devices 30

31. Lung Function Testing in Kenya: the aspiration
Level
Facility
Available Test 1
Community Units
Awareness/Referrals 2
Dispensary
Peak Expiratory Flow 3
Health Centre
PEF and Basic Spirometry 4
Sub and District Hospital
PEF, Spirometry, airway resistance and airway hyperresponsiveness 5
Regional Hospitals
Above plus lung volumes and capacities, gas transfer 6
Referral Hospitals
Above plus complex imaging and invasive tests

32. Treatment of Asthma

33. KAPTLD Asthma Symposia
Education
KAPTLD Asthma Symposia

34. KAPTLD Asthma Symposia

35. KAPTLD Asthma symposia

36. Beta2 agonists Short acting Fenoterol Salbutamol Terbutaline
Pirbuterol
Procaterol
Long acting inhaled ( LABA)
Long Acting and Fast Onset : Formoterol
Long Acting and Slow Onset : Salmetrol
Long
LABA always used with

37. Methylxanthines Theophylline Low dose – some anti-inflammatory effect
High Dose – bronchodilator effect
Recommended as add – on medicines
Recommended – sustained release preparations
Have a narrow therapeutic window

38. Leukotriene modifiers
Cysteinyl leukotriene receptor antagonist
Montekulast
Zafirlukast
Pranlukast
5-Lipooygenase inhibitor
Zileuton
Recommended as alternatives to low dose ICS and as add on treatment to low dose ICS

39. Cautionary Note
Inhaled Corticosteroids (especially Fluticasone) and Ritonavir based ART

40. Emphasize HCW familiarity with the use of various inhaler devices
Emphasized the need to train patients on devices prescribed.

41. Meter Dose Inhalers Deliver a specific dose of a spray of medicine
Maximum drug that is deposited in the lung is about 15% of inhaled dose
About 10% of the adult population cannot grasp the technique
Cheaper than dry powder devices 41

42. Volume Spacers Aid the inhalation of drug delivered via the MDI
Very useful in the very young and very old
Essential when high doses of inhaled steroids are used
Patients should be reminded about the appropriate care of their devices
May be used with a face mask 42

43. Dry Powder Devices Easier to use than MDIs
Generally more expensive than the MDIs
Require a minimum Peak Inspiratory Flow for drug delivery 43

44. The Famous Nebulizer Loved by health care workers but Wasteful
Not better than an MDI with a large volume spacer
Expensive way to deliver drug
May create infectious aerosols and contribute to nosocomial transmission of infections 44

45. Asthma Control Assessed using Symptoms - frequency Exercise capacity
Lung function
Exacerbation rates
Reliever medicine use - frequency

46. Level of Asthma Control
Characteristic
Controlled
Partly Controlled( any measure present in last one week
Uncontrolled
Day time Symptoms
None
> twice/week
Three or more features of partly controlled asthma present in any week
Limitation of Activities
Any
Nocturnal Symptoms/Awakening
Need for reliever/rescue medication
>twice/week
Lung Function(PEF or FEV1)
Normal
<80% of personal best
Exacerbations
One or more/year
One in any week

47. Acute Severe Asthma
Acute Severe Asthma

52. Monitoring and Evaluation
Adopted the TB model
Tools
Patient cards
Facility registers
Flow of data
Facility to District to Region to National
Key information
Patient numbers ( new and prevalent)
Outcomes : Controlled , Uncontrolled, Lost to follow , died

53. Conclusion
Asthma
A common disease but burden of disease poorly characterized in Kenya
Common sense approaches can diagnose and treat to control, most cases of asthma