Bronchial Asthma Management

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Bronchial Asthma:

Bronchial Asthma Management 7/10/2012 1 Amr Badreldin Hamdy MD FCCP

Amr Badr Eldin Hamdy MD FCCP:

Amr Badr Eldin Hamdy MD FCCP Prof of Pulmonary Medicine Banha University, Egypt New Capital Medical Centre, Abu Dhabi 7/10/2012 2 Amr Badreldin Hamdy MD FCCP

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Objectives:

Objectives Define Bronchial Asthma. Define clinical picture of BA. Differentiate BA . Diagnose BA. Treat BA. Control BA. 7/10/2012 4 Amr Badreldin Hamdy MD FCCP

DEFINITION:

DEFINITION Asthma is chronic inflammatory disorder of the airway in which many cells play a role, in particular MAST CELLS , EOSINOPHILS , and T-LYMPHOCYTES. 7/10/2012 5 Amr Badreldin Hamdy MD FCCP

DEFINITION-cont’d:

DEFINITION-cont’d In susceptible individuals this inflammation causes recurrent episodes of wheezing, breathlessness , chest tightness , and cough, particularly at night or in the early morning. 7/10/2012 6 Amr Badreldin Hamdy MD FCCP

DEFINITION-cont’d:

DEFINITION-cont’d These symptoms are usually associated with widespread but variable airflow limitation that is at least partly reversible either spontaneously or with medical treatment. The inflammation also causes an associated increase in airway responsiveness to a variety of stimuli. 7/10/2012 7 Amr Badreldin Hamdy MD FCCP

TYPES OF BA:

TYPES OF BA Childhood asthma. Adult onset. Nocturnal. Occupational. Cough Variant. Exercise induced. Brittle. Aspirin sensitive . 7/10/2012 8 Amr Badreldin Hamdy MD FCCP

TYPES OF BA:

TYPES OF BA 7/10/2012 9 Amr Badreldin Hamdy MD FCCP

TYPES OF BA-cont’d:

TYPES OF BA-cont’d 7/10/2012 10 Amr Badreldin Hamdy MD FCCP

Possible Explanation For Changes In Prevalence of BA:

Possible Explanation For Changes In Prevalence of BA Indoor environment. Smoking. Family size. Pollution. Diet. 7/10/2012 11 Amr Badreldin Hamdy MD FCCP

Family History of Atopy:

Family History of Atopy 7/10/2012 12 Amr Badreldin Hamdy MD FCCP

Genetics and Asthma:

Genetics and Asthma 7/10/2012 13 Amr Badreldin Hamdy MD FCCP

WHAT IS ASTHMA?:

WHAT IS ASTHMA? 7/10/2012 14 Amr Badreldin Hamdy MD FCCP

Clinical Symptoms:

Clinical Symptoms Intermittent symptoms Cough Wheeze Shortness of breath Chest pain Diurnal variation Varying triggers Rescue medication use Exacerbations 7/10/2012 15 Amr Badreldin Hamdy MD FCCP

Biological Indicators:

Biological Indicators Bronchiolar obstruction 7/10/2012 16 Amr Badreldin Hamdy MD FCCP

Biological Indicators cont’d:

Biological Indicators cont’d Airway smooth muscle bronchial constriction . 7/10/2012 17 Amr Badreldin Hamdy MD FCCP

Biological Indicators cont’d:

Biological Indicators cont’d Airway inflammation ( eosinophilic ). Bronchial hyperresponsiveness (BHR). Airway remodeling. 7/10/2012 18 Amr Badreldin Hamdy MD FCCP

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Source: Peter J. Barnes, MD Asthma Inflammation : Cells and Mediators 7/10/2012 19 Amr Badreldin Hamdy MD FCCP

Common Clinical Features of BA:

Common Clinical Features of BA 7/10/2012 20 Amr Badreldin Hamdy MD FCCP

Clinical Features Lower Probability of BA:

Clinical Features Lower Probability of BA 7/10/2012 21 Amr Badreldin Hamdy MD FCCP

Signs:

Signs 7/10/2012 22 Amr Badreldin Hamdy MD FCCP

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7/10/2012 Amr Badreldin Hamdy MD FCCP 23 Points to seek in the history suggesting a different or supplementary diagnosis Are the child/family really describing wheeze Upper airway symptoms – snoring, rhinitis, sinusitis Symptoms from the first day of life Very sudden onset of symptoms Chronic moist cough/sputum production Worse wheeze or irritable after feed, worse when lying down, vomiting, choking on feeds Any feature of a systemic immunodeficiency Continuous, unremitting or worsening symptoms Symptoms which disappear when the child is asleep

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7/10/2012 Amr Badreldin Hamdy MD FCCP 24 Points to seek in the physical examination suggesting a different or supplementary diagnosis Digital clubbing, signs of weight loss, failure to thrive Upper airway disease – enlarged tonsils and adenoids, prominent rhinitis, nasal polyps Unusually severe chest deformity (Harrison’s sulcus , barrel chest) Fixed monophonic wheeze Stridor ( monophasic or biphasic) Asymmetrical wheeze Signs of cardiac or systemic disease

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Severity of Asthma:

Severity of Asthma 7/10/2012 26 Amr Badreldin Hamdy MD FCCP

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7/10/2012 Amr Badreldin Hamdy MD FCCP 27 Differential Diagnosis in Adults Chronic Obstructive Pulmonary Disease May be difficult to differentiate from chronic asthma in older smokers The pathology differs, as does the degree of responsiveness to steroids B . Large Airway Obstruction Caused by tumors, strictures and foreign bodies; often misdiagnosed as asthma initially Differential by flow volume loop Pulmonary Edema Once called “cardiac asthma” May mimic asthma, including the presence of wheezing and worsening at night.

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7/10/2012 Amr Badreldin Hamdy MD FCCP 28 Masqueraders of Asthma in Children Upper airway noise/congestion Cystic fibrosis (CF) Gastroesophageal Reflux disease (GERD) Bronchopulmonary Dysplasia (BPD) Foreign body aspiration Immunodeficiency (ID) Vocal cord dysfunction

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Amr Badreldin Hamdy MD FCCP 29 More frequent diseases other than asthma which could produce wheezing in children Newborn and very young infants (0-3 month) Bronchopulmonary dysplasia Congenital malformations of the laryngeal region ( laryngomalacia , vocal cord paralysis, laryngeal angiomatosis , cysts, tumors, etc) Congenital malformations of the trachea and greater airways ( tracheomalacia , bronchomalacia , tracheal or bronchial stenosis , tracheal-esophageal fistula) Vascular rings or laryngeal membranes Older Infants (3-12 months) Croup Gastroesophageal reflux / Aspiration Cystic fibrosis Heart malformations Children older than 1 year of age Foreign body aspiration Primary ciliary dyskinesia Bronchiolitis obliterans Congenital malformations of the lung and the airways Vocal cord dysfunction (adolescents) Note: any disease may be present at any age 7/10/2012

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7/10/2012 Amr Badreldin Hamdy MD FCCP 30 ASTHMA COPD Definition A chronic inflammatory disorder of the airways Disease state characterized by airflow limitation that is not fully reversible Onset (typical) Early in life Midlife Airflow limitation Widespread through variable; often reversible spontaneously or with treatment Usually progressive and associated with abnormal inflammatory response to particles or gases

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DIAGNOSIS:

DIAGNOSIS 7/10/2012 32 Amr Badreldin Hamdy MD FCCP

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Diagnosing Asthma:

Diagnosing Asthma What to look for : Episodic symptoms of airflow obstruction and BHR Airflow obstruction is at least partially reversible Alternative diagnoses are excluded How to Assess: Detailed medical history Physical examination (focus on upper respiratory tract, chest, skin) Spirometer to demonstrate obstruction and assess reversibility (>4 years of age Additional studies as necessary 7/10/2012 Amr Badreldin Hamdy MD FCCP 34

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Skin Testing:

Skin Testing 7/10/2012 37 Amr Badreldin Hamdy MD FCCP

Skin Testing-cont’d:

Skin Testing-cont’d 7/10/2012 38 Amr Badreldin Hamdy MD FCCP

Pros and Cons of Skin Testing:

Pros and Cons of Skin Testing 7/10/2012 39 Amr Badreldin Hamdy MD FCCP

RAST Test:

RAST Test 7/10/2012 40 Amr Badreldin Hamdy MD FCCP

PEFR:

PEFR 7/10/2012 41 Amr Badreldin Hamdy MD FCCP

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PER Recovery:

PER Recovery 7/10/2012 44 Amr Badreldin Hamdy MD FCCP

PER Variability:

PER Variability 7/10/2012 45 Amr Badreldin Hamdy MD FCCP

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Exercise Testing:

Exercise Testing 7/10/2012 53 Amr Badreldin Hamdy MD FCCP

Provocation Test:

Provocation Test 7/10/2012 54 Amr Badreldin Hamdy MD FCCP

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Chest X-ray - Pneumothorax:

Chest X-ray - Pneumothorax 7/10/2012 56 Amr Badreldin Hamdy MD FCCP

Pneumomediastinum:

Pneumomediastinum 7/10/2012 57 Amr Badreldin Hamdy MD FCCP

TREATMENT:

TREATMENT 7/10/2012 58 Amr Badreldin Hamdy MD FCCP

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The Aims of Treatment:

The Aims of Treatment To control symptoms to lead a full and active life. To restore normal lung function and reduce variations in peak flow. To minimize the requirement for bronchodilator therapy and prevent exacerbations. To enable normal growth and development and avoid adverse effects of medication . 7/10/2012 Amr Badreldin Hamdy MD FCCP 60

Categories of Drugs Used:

Categories of Drugs Used Bronchodilators: Inhaled beta agonists. Inhaled anti- cholinergics . Theophyllines . Long acting beta agonists. 7/10/2012 Amr Badreldin Hamdy MD FCCP 61

Cont’d:

Cont’d Preventers: Inhaled corticosteroids. Sodium chromoglycate . Nedocromil sodium. Leukotriene receptor agonists. 7/10/2012 Amr Badreldin Hamdy MD FCCP 62

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Types of Inhalers:

Types of Inhalers 7/10/2012 Amr Badreldin Hamdy MD FCCP 66

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Managing Asthma in Special Situations:

Managing Asthma in Special Situations Asthma Exacerbations Exercise-induced Bronchospasm ( EIB ) Common Co-Morbidities Rhinitis Gastroesophageal reflux (GERD) Smoking Asthma in Pregnancy 7/10/2012 Amr Badreldin Hamdy MD FCCP 68

Managing Exacerbations:

Managing Exacerbations Defined as an acute or sub acute episode of progressively worsening shortness of breath, cough wheezing, and chest tightness – or some combination of these symptoms Primary therapies are SABAs, oral corticosteroids, oxygen Early treatment is the best management strategy Patient education Recognition of early signs of worsening Removal of contributing environmental Prompt communication 7/10/2012 Amr Badreldin Hamdy MD FCCP 69

Managing Exercise-Induced Bronchospasm:

Managing Exercise-Induced Bronchospasm EIB occurs in 90% of patients with asthma and >10% of the general population EIB often indicates poorly controlled asthma Use long-term control therapy, if appropriate Pre-treatment prior to exercise SABAs, LABAs are effective in up to 80% of patients LTRAs are effective in up to 50% of patients Encourage patients to warm up prior to exercise and consider wearing a mask or scarf in cold weather 7/10/2012 Amr Badreldin Hamdy MD FCCP 70

Treating the Upper Airways Can Improve Asthma Symptoms:

Treating the Upper Airways Can Improve Asthma Symptoms Avoidance/environmental control is a key treatment for both diseases Intranasal corticosteroids reduce both asthma and allergic rhinitis symptoms in patients with mild asthma Treatment with an antihistamine alone or in combination with a decongestant may reduce asthma and allergic rhinitis symptoms Cysteinyl leukotrines are inflammatory mediators in both the upper and lower mediators Leukotriene modifiers treat symptoms or asthma and allergic rhinitis Immunotherapy may reduce development of asthma in patients with seasonal rhinoconjunctivitis 7/10/2012 Amr Badreldin Hamdy MD FCCP 71

Asthma During Pregnancy:

Asthma During Pregnancy Cohort study followed 140,299 pregnancies in Tennessee Medicaid program from 1995-2003 23% of white women and 40% black women had a hospitalization or ED visit during pregnancy Black women were 1.6 (95% Cl 1.5-1.7) times more likely than white women to receive care for an exacerbation 77% of women did not use asthma control medication Dose response trend (P<0.001) between lower birth weight and increasing use of oral corticosteroids Asthma prescriptions may not be prescribed or refilled during pregnancy 7/10/2012 Amr Badreldin Hamdy MD FCCP 72

National Guidelines for Monitoring and Treating Asthma During Pregnancy:

National Guidelines for Monitoring and Treating Asthma During Pregnancy Monthly evaluation of asthma history and pulmonary function Albuterol is preferred SABA ICSs are preferred controller treatment Budesonide has most established safety profile Cromolyn , LTRAs, and LABAs may be alternatives but have lower efficacy ( cromolyn ) or less safety data available (LTRAs, LABAs) Comorbid allergic rhinitis can be managed with intranasal corticosteroids, LTRAs, loratadine , or cetirizine 7/10/2012 Amr Badreldin Hamdy MD FCCP 73

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7/10/2012 Amr Badreldin Hamdy MD FCCP 77 Common aggravating factors in Asthma Aggravating Factor Comments Rhinitis Avoidance of precipitants such as pollen Use of nasal steroids and antihistamines may be helpful Gastro Esophageal Reflux Disease Trial of proton pump inhibitor may be considered in patients with suggestive symptoms though trials have not suggested therapeutic efficacy for improving asthma control Drugs Commonly prescribed medication include aspirin, ACE inhibitors and NSAIDs All these medication should be withdrawn and replaced with available alternatives if they exacerbate symptoms Beta-Blocker should always be withdrawn Common aero-allergens Common examples include pollen, pet allergens, house dust mite and fungal spores Avoidance measures are recommended though efficacy in improving asthma control is variable

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7/10/2012 Amr Badreldin Hamdy MD FCCP 78 Common aggravating factors in Asthma – Cont’d Aggravating Factor Comments Smoking Smoking cessation should be strongly encouraged and referral to a smoking cessation service is recommended Occupational allergens Dust smoke and poor ventilation can all contribute to deterioration in asthma control In contrast occupational agents that have been identified in the development o f asthma include isocyanates (spray painting); flour; wood dust; glutaraldehyde (nursing); solder/colophony (welding and soldering In all cases occupational exposures should be considered and investigated appropriately. Employers have a statutory duty to provide safe employment in cases of occupational asthma

Common Co-Morbidities That Make Asthma Worse:

Common Co-Morbidities That Make Asthma Worse Allergic Rhinitis 17% to 38% with allergic rhinitis have asthma; 5% to 8% of general population has asthma 60% to 80% of asthma patients have allergic rhinitis 20% of general population has allergic rhinitis GERD One-third of adults with asthma have GERD; 20% of general population has GERD Patients with asthma are at a significantly increased risk of developing GERD Smoking ~20% of patients with asthma are regular smokers, comparable to adult population (~22% are regular smokers ) 7/10/2012 Amr Badreldin Hamdy MD FCCP 79

CAUSES OF NONRESPONSIVE ASTHMA:

CAUSES OF NONRESPONSIVE ASTHMA 7/10/2012 AMR BADRELDIN HAMDY MD 80

1. Wrong diagnosis :

1. W rong diagnosis COPD Bronchiectasis, Cystic fibrosis, Inhaled FB Recurrent aspiration. Obliterative bronchitis. Tumors involving the central airway. Tracheobronchomalacia . Vocal cord dysfunction. 7/10/2012 AMR BADRELDIN HAMDY MD 81

2. Poor Adherence To Therapy:

2. Poor Adherence To Therapy Patient related. Drug related. 7/10/2012 AMR BADRELDIN HAMDY MD 82

3. Unidentified Exacerbation Factors:

3. Unidentified Exacerbation Factors Unidentified allergies Occupational exposure GERD Systemic diseases ( thyrotoxicosis , carcinoid syndrome, Churg -Strauss Syndrome) Drugs (Beta-blockers, ACE-inhibitors) Rhinitis/sinusitis/sleep apnea Psychological factors 7/10/2012 AMR BADRELDIN HAMDY MD 83

4. Unstable Asthma:

4. Unstable Asthma Nocturnal asthma Pre-menstrual asthma Brittle asthma 7/10/2012 AMR BADRELDIN HAMDY MD 84

5. Corticosteroid Dependant/Resistant Asthma.:

5. Corticosteroid Dependant/Resistant Asthma . 7/10/2012 AMR BADRELDIN HAMDY MD 85

Causes of Near- Fatal Bronchial Asthma:

Causes of N ear- F atal B ronchial A sthma 7/10/2012 AMR BADRELDIN HAMDY MD 86

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High medication use. Overuse of inhaled beta2 agonists. A history of recurrent hospitalizations. Previous occurrences of life-threatening attacks. Marked fluctuations in morning and evening PEFR measurements . 7/10/2012 AMR BADRELDIN HAMDY MD 87

Who Is The High Risk Patient?:

Who Is The High Risk Patient? 7/10/2012 Amr Badreldin Hamdy MD FCCP 88

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Validated Tools for Assessment & Monitoring:

Validated Tools for Assessment & Monitoring Asthma Control Questionnaire Asthma Therapy Assessment Questionnaire Asthma Control Test Asthma Control Score 7/10/2012 AMR BADRELDIN HAMDY MD 92

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Amr Badreldin Hamdy MD FCCP What Are Benefits Of Long Term Preventive Treatment Of Asthma?

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Amr Badreldin Hamdy MD FCCP Improved quality of life . Reduced frequency and severity of asthma exacerbations . Reduced risk of emergency room visits . Reduced risk of hospital admission .

Cont’d:

Amr Badreldin Hamdy MD FCCP Cont’d Prevent loss of productivity from day missed at work/school. Reduce total cost of asthma treatment in the longer term. Reduce risk of death from asthma.

Asthma Control Test:

Asthma Control Test 2 . During the past 4 weeks, how often have you has shortness of breath (SOB)? __ more than once a day __ 3 – 6 times a week __ not at all __ once a day __ once or twice a week 1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work or at home? __ all of the time __ some of the time __ none of the time __ most of the time __ a little of the time 7/10/2012 AMR BADRELDIN HAMDY MD 96 3 . During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, SOB, chest tightness, pain) wake you up at night or earlier than usual in the morning? __ 4 or more nights a week __ once a week __ not at all __ 2-3 nights a week __ 2 – 3 nights a week 4 . During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication __ 2–3 more times per day __ 2 – 3 times a week __ not at all __ 1 or more times per day __ once a week or less 5 . How would you rate you asthma control during the past 4 weeks? __ not controlled at all __ somewhat controlled __ completely controlled __ poorly controlled __ well controlled

Score:

Score Total control= 25 . Well controlled= 20-24 . Not (well) controlled= Less than 20 . 7/10/2012 Amr Badreldin Hamdy MD FCCP 97

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7/10/2012 AMR BADRELDIN HAMDY MD 98 The guidelines suggest that control of asthma should be assessed against the following standards: Minimal symptoms during day and night Minimal need for reliever medication No exacerbations Normal lung function (in practice FEV1 and/or PEF> 80% predicted or best This degree of control would be the aim for the first three steps in the guideline. At steps four to five such freedom from symptoms may not be achievable without side effects, and the objectives are: Fewest possible symptoms Least possible need for relief bronchodilators Least possible limitation of activity Least possible PEF variation Best PEF Fewest adverse effects of treatment

Assessing Asthma Control (0 – 4 Years of Age):

Assessing Asthma Control (0 – 4 Years of Age) 7/10/2012 99 AMR BADRELDIN HAMDY MD Components of Control Well Controlled Not Well Controlled Very Poorly Controlled IMPAIRMENT Symptoms ≤ 2 days/w > 2 days/w Throughout the day Night time Awakenings 1x month > 1x month > 1x week Interference with normal activity None Some Extreme SABA use for symptom control ≤ 2 days/w > 2 days/w Several times per day RISK Exacerbations 0-1x year 2-3x year > 3 x year Treatment-related adverse effects Medication side effects can vary in intensity from none to troublesome or worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.

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7/10/2012 AMR BADRELDIN HAMDY MD 100 Assessing Asthma Control (5 - 11 Years of Age) Components of Control Well Controlled Not Well Controlled Very Poorly Controlled IMPAIRMENT Symptoms ≤ 2 days/w but not >1x on each day > 2 days/w or multiple times ≤2 days/w Throughout the day Night time Awakenings ≤1x month ≥ 2x month ≥ 2x month Interference with normal activity None Some Extreme SABA use for symptom control ≤ 2 days/w > 2 days/w Several times per day FEV1 or peak flow FEV/FVC >80% predicted / personal best >80% 60-80% predicted/ personal best 75-80% <60% predicted/ personal best <75% RISK Exacerbations 0-1x year > 2x year Consider severity and interval since last exacerbation Reduced lung growth Evaluation requires long-term follow up Treatment-related adverse effects Medication side effects can vary in intensity from none to troublesome or worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.

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7/10/2012 AMR BADRELDIN HAMDY MD 101 Assessing Asthma Control (≥12 Years of Age) Components of Control Well Controlled Not Well Controlled Very Poorly Controlled IMPAIRMENT Symptoms ≤ 2 days/w > 2 days/w Throughout the day Night time Awakenings 1x month > 1x month > 1x week Interference with normal activity None Some Extreme SABA use for symptom control ≤ 2 days/w > 2 days/w Several times per day FEV1 or peak flow >80% predicted / personal best 60-80% predicted/ personal best <60% predicted/ personal best ATAQ 0 1-2 3-4 ACQ ≤0.75 ≥1.5 N/A ACT ≥20 16-19 ≤15 RISK Exacerbations 0-1x year 2-3x year > 3 x year Treatment-related adverse effects Medication side effects can vary in intensity from none to troublesome or worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.

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Part 4: Long-term Asthma Management Stepwise Approach to Asthma Therapy - Adults Reliever: Rapid-acting inhaled β 2 - agonist prn Controller: Daily inhaled corticosteroid Controller: Daily inhaled corticosteroid Daily long-acting inhaled β 2 - agonist Controller: Daily inhaled corticosteroid Daily long –acting inhaled β 2 - agonist plus (if needed) When asthma is controlled, reduce therapy Monitor STEP 1: Intermittent STEP 2: Mild Persistent STEP 3: Moderate Persistent STEP 4: Severe Persistent STEP Down Outcome: Asthma Control Outcome: Best Possible Results Alternative controller and reliever medications may be considered (see text). Controller: None -Theophylline- SR -Leukotriene -Long-acting inhaled β 2 - agonist -Oral corticosteroid 7/10/2012 102 Amr Badreldin Hamdy MD FCCP

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Stepwise Approach to Asthma Therapy: Adults Step 1: Intermittent Asthma None required Rapid-acting inhaled  2 -agonist for symptoms (but < once a week) Rapid-acting inhaled  2 -agonist, cromone, or leukotriene modifier before exercise or exposure to allergen Continuously review medication technique, compliance and environmental control Review treatment every three months. Step up if control is not achieved; step down if control is sustained for at least 3 months Preferred treatments are in bold print Daily Controller Medications Reliever Medications 7/10/2012 103 Amr Badreldin Hamdy MD FCCP

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Inhaled glucocorticosteroid (< 500 μ g BDP or equivalent) Other options ( order by cost ): sustained-release theophylline, or Cromone, or leukotriene modifier Rapid-acting inhaled  2 -agonist for symptoms (but < 3-4 times/day) Other options: inhaled anticholinergic, or short-acting oral  2 -agonist, or short-acting theophylline Continuously review medication technique, compliance and environmental control. Review treatment every three months Step up if control is not achieved; Step down if control is sustained for at least 3 months Preferred treatments are in bold print Stepwise Approach to Asthma Therapy: Adults Step 2: Mild Persistent Asthma Daily Controller Medications Reliever Medications 7/10/2012 104 Amr Badreldin Hamdy MD FCCP

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Inhaled glucocorticosteroid, (200 – 500 μg BDP or equivalent) plus long-acting inhaled β 2 agonist Other options (order by cost) : Inhaled glucocorticosteroid (500 – 1000 μg BDP equivalent) plus sustained-release theophylline, or Inhaled glucocorticosteroid (500 – 1000 μg BDP equivalent) plus long-acting inhaled β 2 - agonist, or inhaled glucocorticosteroid at higher doses (> 1000 μg BDP equivalent), or Inhaled glucocorticosteroid (500 – 1000 μg BDP equivalent) plus leukotriene modifier Rapid-acting inhaled  2 -agonist for symptoms (but < 3 - 4 times/day) Other options: inhaled anticholinergic o r short-acting oral  2 -agonist or short-acting theophylline Continuously review medication technique, compliance and environmental control. Review treatment every three months. Step up if control is not achieved; Step down if control is sustained for at least 3 months. Preferred treatments are in bold print. Stepwise Approach to Asthma Therapy: Adults Step 3: Moderate Persistent Asthma Daily Controller Medications Reliever Medications 7/10/2012 105 Amr Badreldin Hamdy MD FCCP

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Inhaled glucocorticosteroid, (> 1000 μg BDP or equivalent) plus long-acting inhaled β 2 agonist plus one or more of the following, if needed (order by cost) : sustained-release theophylline, or leukotriene modifier or oral glucocorticosteroid Rapid-acting inhaled  2 -agonist for symptoms (but < 3-4 times/day) Other options: inhaled anticholinergic o r short-acting oral  2 -agonist or short-acting theophylline Continuously review medication technique, compliance and environmental control. Review treatment every three months. Step up if control is not achieved; Step down if control is sustained for at least 3 months. Preferred treatments are in bold print. Stepwise Approach to Asthma Therapy: Adults Step 4: Severe Persistent Asthma Daily Controller Medications Reliever Medications 7/10/2012 106 Amr Badreldin Hamdy MD FCCP

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Component 4: Asthma Management and Prevention Program Controller Medications Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β 2 -agonists Systemic glucocorticosteroids Theophylline Cromones Long-acting oral β 2 -agonists Anti- IgE Systemic glucocorticosteroids 7/10/2012 107 Amr Badreldin Hamdy MD FCCP

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7/10/2012 AMR BADRELDIN HAMDY MD 108

Further Treatment of Bronchial Asthma:

Further Treatment of Bronchial Asthma 7/10/2012 Amr Badreldin Hamdy MD FCCP 109

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7/10/2012 AMR BADRELDIN HAMDY MD 110

Things to Avoid:

Things to Avoid Known allergens Active and passive smoking Areas of high pollution (particularly avoid exercising at times of high air pollution). Beta-blockers Aspirin and NSAID Obesity 7/10/2012 AMR BADRELDIN HAMDY MD 111

Drugs That Induce Asthma:

Drugs That Induce Asthma Beta-blockers (including eye drops) Aspirin and NSAID Inhaled asthma drugs Nebulizer solutions , hypotonic or with preservatives Angiotensin converting enzyme inhibitors 7/10/2012 AMR BADRELDIN HAMDY MD 112

We should be able to answer the following questions:

We should be able to answer the following questions What is asthma? What causes asthma? Who gets asthma? What are the symptoms of asthma? Is it asthma? How to treat asthma? How is asthma prevented? How to control asthma? 7/10/2012 AMR BADRELDIN HAMDY MD 113

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THANK YOU:

THANK YOU 7/10/2012 Amr Badreldin Hamdy MD FCCP 116

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