1. Philippine Consensus Report on Asthma Diagnosis and Management 2009

2. Clinical Diagnosis of Asthma Variability: – Episodic breathlessness, wheezing, cough, chest tightness – Precipitation by allergens or non-specific irritants” e.g. smoke, fumes, strong smells or exercise Nocturnal worsening of symptoms Positive family history of asthma & atopic disease Response to appropriate asthma therapy

3. Physical Examination Findings in Asthma Most usual abnormal PE finding: – Wheezing on auscultation – confirms presence of airflow limitation PE: – May be normal – because asthma symptoms are variable – Wheezing detected only on forced exhalation – Wheezing may be absent in severe cases due to severely reduced airflow and ventilation but usually with other signs

4. Objective measurements in Asthma diagnosis Rationale: – Demonstration of reversibility of airflow limitation enhances diagnostic confidence – Patients esp. those with long-standing asthma, frequently have poor recognition of symptoms and poor perception of severity – Physicians may inaccurately assess dyspnea and wheezing

5. Lung Function Measurement in Asthma Provides an assessment of severity of airflow limitation, its reversibility and variability Provides confirmation of the diagnosis Provides complementary information about different aspects of asthma control

6. Spirometry in Asthma Diagnosis of asthma: – Degree of reversibility of FEV1 should be >12% and >200ml from pre-bronchodilator value Spirometry: – Reproducible but effort-dependent – Pre- & post test lacks sensitivity esp. those on treatment, so repeated testing at different visits is advised – Proper instructions on maneuver must be given

7. PEF measurement in Asthma Important in both diagnosis and monitoring Peak flow meters are relatively inexpensive, portable, plastic and ideal for use in home settings for day-to-day objective measurement of airflow limitation Can underestimate degree of airflow limitation particularly in severe cases

8. PEF measurement in Asthma Can be helpful to confirm the diagnosis of asthma: – 60 L/min (or 20% or more pre-BD PEF) improvement after inhalation of a bronchodilator – A diurnal variation of >20% (with twice daily readings >10%)

9. PEF measurement in Asthma Can help to improve asthma control esp. in those with poor perception of symptoms: – Self-monitoring using a PEF chart Can help to identify environmental/occupational causes of asthma symptoms: – PEF daily or several times a day over periods of suspected exposure to risk factors (at home, workplace, during exercise or other activities)

10. Controller Medications Inhaled glucocorticosteroids Long-acting inhaled β2-agonists Systemic glucocorticosteroids Leukotriene modifiers Theophylline Cromones Long-acting oral β2-agonists Anti-IgE

11. Reliever Medications Rapid-acting inhaled β2-agonists Systemic glucocorticosteroids Anticholinergics Theophylline Short-acting oral β2-agonists

12. Asthma Exacerbations Episodes of progressive worsening of shortness of breath, cough, wheezing or chest tightness or some combination of these symptoms Characterized by significant decreases in PEF or FEV1 which are more reliable indicators of severity of airflow obstruction than degree of symptoms May range from mild to life-threatening

13. Severity of Asthma Exacerbations MildModerateSevereRespiratory Arrest Imminent BreathlessWalkingTalkingAt rest Talks inSentencesPhrasesWords AlertnessMay be agitatedUsually agitated Drowsy or confused Respiratory rateIncreased Often >30/min Accessory muscles & suprasternal contractions Usually notUsually Paradoxical thoraco- abdominal movement WheezeModerate, often only end-expiratory LoudUsually loudAbsence of wheeze Pulse/min<100100-120>120Bradycardia Pulsus paradoxusAbsent <10mmHgMay be present 10- 25mm Hg Often present > 25 mm Hg PEF after initial BD % predicted or % personal best Over 80%Approx 60-80%<60% predicted or personal best (<100/min or response lasts 2 hrs) PaO2 and/or PaC02Normal <42 mm Hg< 42 mm hg< 60 mm Hg Possible cyanosis >42 mm Hg possible resp failure Sa02> 95%91-95%<90%

14. Features of Patients at high-risk for asthma-related death Current use of or recent withdrawal from systemic corticosteroids Emergency care visit for asthma in the past year History of near-fatal asthma requiring intubation or mechanical intubation Not currently using inhaled steroids Overdependence on rapid acting inhaled β2-agonists, esp. those with more than one canister monthly Psychiatric disease or psychosocial problems, incl. the use of sedatives Noncompliance with asthma medication plan

15. Management of Asthma Exacerbations Treatment of exacerbations depends on: – The patient – Experience of health care professional – Therapies that are the most effective for the particular patient – Availability of medications – Emergency facilities

16. Treatment of Exacerbations The aims of treatment are to: – Relieve airway obstruction as quickly as possible – Relieve hypoxemia – Restore lung function to normal as early as possible – Plan and avoidance of future relapses – Develop a written action plan in cases of future exacerbations

17. Management of Asthma Exacerbations Primary therapies for exacerbations: – Repetitive administration of rapid-acting inhaled β2-agonists – Early introduction of systemic glucocorticosteroids – Oxygen supplementation Closely monitor response to treatment with serial measures of lung function

18. Criteria for Hospitalization Inadequate response to therapy within 1-2 hours Persistent PEF <50% after 1 hour of treatment Presence of risk factors Prolong symptoms prior to ER consult Inadequate access to medical care and medications Difficult home condition Difficulty in obtaining transport to hospital in event of further deterioration

19. Asthma Exacerbations and Hospitalization Despite appropriate therapy ~10 to 25% of ER patients with acute asthma will require hospitalization The response to initial treatment in the ER is a better predictor of the need for hospitalization than is severity on presentation FEV1 or PEF appears to be more useful in adults for categorizing severity of exacerbation and response to treatment

20. Management of Acute Exacerbations: Hospital Setting Initial Assessment: History, PE, PEF or FEV1, Sa02 PEF or FEV1 >40% predicted Oxygen to achieve Sa02 >90% Inhaled SABA by nebulizer or MDI with valve holding chamber up to 3 doses in 1 st hour Impending or actual respiratory arrest Intubation and mechanical ventilation with 100% 02 Nebulized SABA and Ipratropium Intravenous corticosteroids Consider adjunct therapies PEF or FEV1 <40% predicted Oxygen to achieve Sa02 >90% High dose inhaled SABA + Ipratropium by nebulizer or MDI with valve holding chamber every 20 min or continuously for 1 hour Repeat Assessment: PE, PEF, Sa02, other tasks as needed Admit to hospital intensive care Moderate Episode: PEF or FEV1 -40-69% predicted or personal best PE: moderate symptoms Treatment: Inhaled SABA every 60 mins Oral systemic corticosteroids Continue treatment 1-3 hrs provided there is improvement: make decision in < 4 hours Severe Episode: PEF or FEV1 < 40% predicted or personal best PE: Severe symptoms at rest, accessory muscle use, chest retraction History: high-risk for asthma related death No improvement after initial treatment Treatment: Oxygen Nebulized SABA+Ipratropium hourly or continuous Oral systemic corticosteroids Consider adjunct therapies

21. Management of Acute Exacerbations: Hospital Setting Good Response Response sustained for 1 hr after last treatment No risk factors S/Sx: no distress, normal PE PEF > 70% predicted or personal best Sa02 >90% Poor Response Within 1 hr &/or (+) risk factors S/Sx: severe drowsiness, confusion PEF < 30% predicted or personal best ABG: paC02 >45mm Hg Pa02< 60 mm Hg Incomplete Response Within 1 hr &/or (+) risk factors S/Sx: mild to moderate PEF >50% but <70% predicted or personal best Sa02 not improving Admit to Hospital Improved PEF >70% Sustained on meds Discharge Home Continue inhaled SABA q 3- 4 hrs (or oral B2-agonist or theophylline) Continue oral steroids Patient education Admit to ICU: Continue inh SABA+ inh anti-cholinergic Consider SQ,IV or IM B2-agonist IV steoirds IV aminophylline Continue oxygen Possible intub ation/mechanical ventilation Moderate EpisodeSevere Episode Not improved within 6-12 hrs Discharge home Admit to ICU

22. Management of Asthma Exacerbations: Home Treatment Assess Severity Initial Treatment Inhaled SABA: up to two treatment 20 min apart of 2- 6 puffs of MDI or nebulizer treatment Good Response No wheezing or dyspnea PEF > 80% predicted or personal best Contact clinician for follow-up Instructions & further management May continue inhaled SABA over 3-4 hrs for 24-48 hrs Consider short course of oral systemic corticosteroids Incomplete Response Persistent wheezing & dyspnea (tachypnea) PEF 50-79% predicted or personal best Add oral systemic corticosteroids Continue inhaled SABA Contact clinician urgently (this day) for further instructions Poor Response Marked Wheezing & dyspnea PEF <50% predicted or personal best Add oral systemic corticosteroids Report inhaled SABA immediately If distress is severe & non- responsive to initial treatment: call your doctor AND ambulance transport To ER