Update asthma
guideline 2014
Rattapon Uppala, MD
Division of Pulmonology
Faculty of Medicine
Khon Kaen University
Scenario
Case เด็กหญิงอายุ 3 ปี
CC: หายใจหอบเหนื่อย 12 ชม.ก่อนมา รพ.
PI: 2 วันก่อนมา รพ. มีน้ามูกใส ไม่มไี ข้ ไม่มหี ายใจหอบเหนื่อย
อาการอื่นๆปกติ
1 วันก่อนมา รพ. มีไอเป็ นชุดๆ ไม่มหี ายใจหอบ ไม่มไี ข้
12 ชม.ก่อนมา รพ. เริม่ มีหายใจหอบ หน้าอกบุ๋ม ไม่มไี ข้
อาการอื่นๆปกติ
• PH: - G1/2 NL BW 2800 g., no complication after birth
- ไม่มปี ระวัติ foreign body aspiration
- เคยมีประวัตมิ ผี น่ื แดงตามตัวเป็ นๆ หายๆ เคยมาตรวจที่ OPD Dx allergic
rash ได้รบั การรักษาโดยให้ chlorpheniramine เวลามีอาการ
- เคยหายใจหอบตอนอายุ 1 ปี ครึง่ Dx viral pneumonia ได้พน่ Ventolin 3
วัน จากนัน้ ไม่มอี าการหอบ
- 1 เดือนก่อน มีไข้ไอ หายใจหอบ มาตรวจที่ AE รพ.ศรีนครินทร์ DDX
acute asthmatic attack, viral pneumonia
Rx: oxygen, dexamethasone iv, Ventolin, Beradual NB
home med: azithromycin, Ventolin MDI prn, prednisolone
นัด follow up OPD gen ped แต่ผปู้ ่ วย loss follow up
• FH: - บิดา มารดาและน้องชาย เป็ น allergic rhinitis
- บิดาสูบบุหรี่
Physical examination
A Thai girl, alert, good consciousness
BT 36.5 C, PR 151 bpm, RR 60 bpm, BP 109/63 mmHg
HEENT : not pale, no jaundice, pharynx and tonsils not
injected, no flaring alar nasi
Heart
: normal S1,S2 , no murmur
Lung
: dyspnea, suprasternal notch, subcostal
retraction, generalize wheezing both lungs,
no stridor
Abdomen : soft, not tender, liver and spleen impalpable,
no mass
Capillary refill <2 sec
Problem list
• Recurrent wheezing
Differential diagnosis
-Viral induced wheezing
-Asthma exacerbations
Probability of asthma diagnosis or response
to asthma treatment in children ≤5 years
Viral
induced
wheezing
GINA 2014, Box 6-1 (1/2)
Asthma
© Global Initiative for Asthma
Symptom patterns in children ≤5 years
GINA 2014, Box 6-1 (2/2)
© Global Initiative for Asthma
Scenario
Case เด็กหญิงอายุ 3 ปี
• 2 วันก่อนมา รพ. มีน้ามูกใส ไม่มไี ข้
• หายใจหอบเหนื่อย 12 ชม.ก่อนมา รพ.
• เคยหายใจหอบตอนอายุ 1 ปี ครึง่ และ 1 เดือนก่อน
• FH: บิดามารดาเป็ น allergic rhinitis บิดาสูบบุหรี่
Scenario
ประวัติเพิ่มเติม
• ผูป้ ่ วยมีอาการหายใจหอบ มาทัง้ หมด 3 ครัง้ แต่ละครัง้ เป็ นนาน
ประมาณ 5 วัน
• ผูป้ ่ วยมีอาการหอบ โดยเฉพาะเวลากลางคืนหรือช่วงทีอ่ ากาศเย็น
• มีอาการไอบ่อยๆเมือ่ ออกกาลังกายหรือวิง่ เล่น
• มักมีอาการไอนานเกือบ 2 สัปดาห์หลังเป็ นหวัด
The most likely diagnosis
Asthma
with acute
exacerbations
Definition of asthma
• A chronic inflammation disease of the airways
• Features :
- Variable and partially reversible airway
obstruction ( spontaneously or with
treatment)
- Bronchial hyper-responsiveness to triggers
- Structural changes in the airway ( airway
remodeling)
GINA 2014
Diagnosis
• A characteristic pattern of symptoms
• Confirmed the variable expiratory airflow
limitation by pulmonary function tests( if
possible)
GINA 2014
Features suggesting asthma
in children ≤5 years
Feature
Characteristics suggesting asthma
Cough
Recurrent or persistent non-productive cough that may be worse at
night or accompanied by some wheezing and breathing difficulties.
Cough occurring with exercise, laughing, crying or exposure to
tobacco smoke in the absence of an apparent respiratory infection
Wheezing
Recurrent wheezing, including during sleep or with triggers such as
activity, laughing, crying or exposure to tobacco smoke or air pollution
Difficult or heavy
breathing or
shortness of breath
Occurring with exercise, laughing, or crying
Reduced activity
Not running, playing or laughing at the same intensity as other
children; tires earlier during walks (wants to be carried)
Past or family history
Other allergic disease (atopic dermatitis or allergic rhinitis)
Asthma in first-degree relatives
Therapeutic trial with
low dose ICS and
as-needed SABA
Clinical improvement during 2–3 months of controller treatment and
worsening when treatment is stopped
GINA 2014, Box 6-2
© Global Initiative for Asthma
A characteristic pattern of symptoms
• Increase the probability
- More than one symptom
- Symptoms often worse at night or the early
morning
- Symptoms vary over time and in intensity
- Symptoms are triggered by viral
infection, exercise, allergen exposure, changes
in weather, laughter, or irritants such as car
exhaust fumes, smoke or strong smells
A characteristic pattern of symptoms
• Decrease the probability
- Isolated cough with no other respiratory
symptoms
- Chronic production of sputum
- Shortness of breath associated with
dizziness, light-headedness or peripheral
tingling (paresthesia)
- Chest pain
- Exercise-induced dyspnea with noisy inspiration
(stridor)
Confirmed the variable expiratory
airflow limitation
Documented excessive variability in
lung function (one or more of the test
below) AND documented airflow
limitation
The greater the variations, or the more occasions
excess variation is seen, the more confident the
diagnosis
At least once during diagnostic process when FEV1
is low, confirm that FEV1/FVC is reduced (normally
>0.75-0.8 in adults,>0.9 in children)
Positive bronchodilator (BD)
reversibility test (more likely to be
positive if BD medication is withheld
before test: SABA≥4hr, LABA≥15hr
Adults: increase in FEV1 of >12% and >200 ml from
baseline, 10-15 minutes after 200-400 mcg
albuterol or equivalent (greater confidence if
increase is >15% and >400ml).
Children: increase in FEV1 of >12% predicted
Excessive variability in twice-daily PEF
over 2 weeks
Adults: average daily diurnal PEF variability >10%
Children: average daily diurnal PEF variability >13%
ในกรณีไม่มี spirometry ใช้ PEF variability แทนได้
Typical spirometric tracings
Volume
Normal
FEV1
Flo
w
Asthma
(after BD)
Normal
Asthma
(before BD)
Asthma
(after BD)
Asthma
(before BD)
1
2
3
4
5
Time (seconds)
Volume
Note: Each FEV1 represents the highest of
three reproducible measurements
GINA 2014
© Global Initiative for Asthma
GINA guideline 2014
• Children 5 years and younger
• Children 6 years and older
(adults, adolescents)
Draft
*ในเด็กอายุน้อยกว่ า 5 ปี ที่มีอาการ หายใจเสียงหวีดที่ตอบสนองดีต่อยา
ขยายหลอดลมที่มีอาการรุ นแรง ต้ องได้ รับการรักษาในโรงพยาบาลหรือต้ อง
ได้ รับ systemic corticosteroids ตัง้ แต่ 2 ครัง้ ขึน้ ไปใน 6 เดือน
Thai guideline
Draft
Thai guideline
Scenario
Management at AE
 แรกรับ Dx acute bronchiolitis
 Rx: O2 canula, ventolin 1 NB q 4 hr, iv fluid
 วันต่อมา ยังมีอาการไอ และหอบ แพทย์สายนึกถึง acute asthmatic
attack จึง start hydrocortisone 65 mg iv q 12 hr
 หลัง treat as acute asthmatic attack วันต่อมาผูป้ ่ วยสบายดี ไอ
เล็กน้อย ไม่หอบ จึง discharge
 Home med :
 prednisolone 1 MKDay
 budesonide (100 mg/puff) 1 puff bid
 ventolin MDI 1 puff prn for dyspnea
Management of asthma
• Management of Asthma exacerbations
• Long term management
- Medication
- Treating modifiable risk factors
- Non- pharmacologic therapies
Asthma flare-ups
(exacerbations)
GINA Global Strategy for Asthma
Management and Prevention 2014
This slide set is restricted for academic and educational purposes only.
Use of the slide set, or of individual slides, for commercial or promotional
purposes requires approval from GINA.
© Global Initiative for Asthma
Risk factors for exacerbations
Potentially modifiable independent risk factors
• Uncontrolled asthma symptoms
• Excessive SABA use (>1 x 200dose canister/month)
• Inadequate ICS: not prescribed
ICS; poor adherence; incorrect
inhaler technique
• Low FEV1, especially if <60%
predicted
• Major psychological or
socioeconomic problems
• Exposures: smoking;
allergen exposure if
sensitized
• Comorbidities: obesity;
rhinosinusitis; confirmed
food allergy
• Sputum or blood
eosinophilia
• Pregnancy
GINA 2014
Objective assessments
• Measurement of lung function
– this is strongly recommended. If possible, and without unduly
delaying treatment.
• Oxygen saturation:
– this should be closely monitored, preferably by pulse oximetry.
This is especially useful in children if they are unable to perform
PEF.
– In children, oxygen saturation is normally >95%, and saturation
<92% is a predictor of the need for hospitalization(Evidence C).
– Saturation levels <90% in children or adults signal the need for
aggressive therapy.
• Arterial blood gas measurements are not routinely
• Chest X-ray (CXR) is not routinely
GINA 2014
Initial assessment of acute asthma
exacerbations in children ≤5 years
Symptoms
Mild
Severe*
Altered consciousness
No
Agitated, confused or drowsy
Oximetry on
presentation (SaO2)**
>95%
<92%
Sentences
Words
<100 beats/min
>200 beats/min (0–3 years)
>180 beats/min (4–5 years)
Central cyanosis
Absent
Likely to be present
Wheeze intensity
Variable
Chest may be quiet
Speech†
Pulse rate
*Any of these features indicates a severe exacerbation
**Oximetry before treatment with oxygen or bronchodilator
† Take into account the child’s normal developmental capability
GINA 2014, Box 6-8
© Global Initiative for Asthma
Managing exacerbations in acute care
settings
NEW!
GINA 2014, Box 4-4 (1/4)
© Global Initiative for Asthma
GINA 2014, Box 4-4 (2/4)
© Global Initiative for Asthma
GINA 2014, Box 4-4 (3/4)
© Global Initiative for Asthma
GINA 2014, Box 4-4 (4/4)
© Global Initiative for Asthma
Managing exacerbations in primary care
NEW!
GINA 2014, Box 4-3 (1/3)
© Global Initiative for Asthma
GINA 2014, Box 4-3 (2/3)
© Global Initiative for Asthma
GINA 2014, Box 4-3 (3/3)
© Global Initiative for Asthma
© Global Initiative for Asthma
Therapy
Dose and administration
Supplemental
oxygen
24% delivered by face mask (usually 1L/min) to maintain oxygen
saturation 94-98%
Short-acting beta2agonist (SABA)
2-6 puffs of salbutamol by spacer, or 2.5 mg of salbutamol by
nebulizer, every 20 minutes for first hour, then reassess severity.
If symptoms persist or recur, give an additional 2-3 puffs per hour.
Admit to hospital if > 10 puffs required in 3-4 hours.
Systemic
corticosteroids
Give initial dose of oral prednisolone (1-2 mg/kg up to a maximum)
Additional options in the first hour of treatment
Ipratropium bromide
For children with moderate-severe exacerbations, 2 puffs of
ipratropium bromide 80 mcg (or 250 mcg by neulizer) every 20
minutes for 1 hour only
Magnesium sulfate
Consider nebulized isotonic magnesium sulfate (150 mg) 3 doses in
the first hour of treatment for children aged ≥ 2 years with severe
exacerbation
GINA 2014
Oxygen
 Oxygen should be administered by nasal cannula or mask
to achieve arterial O2 sat of 93–95% (94–98% for children
6–11 years)
 In severe exacerbations, controlled low flow oxygen
therapy using pulse oximetry to maintain saturation at 93–
95% is associated with better physiological outcomes than
with high flow 100% oxygen therapy (Evidence B).
Inhaled short-acting beta2-agonists
 Inhaled SABA therapy should be administered frequently
for patients presenting with acute asthma.
 Systematic reviews of intermittent versus continuous
nebulized SABA in acute asthma provide conflicting results.
 There is no evidence to support the routine use of
intravenous beta2-agonists in patients with severe asthma
exacerbations (Evidence A).
GINA 2014
Epinephrine (for anaphylaxis)
 Intramuscular epinephrine is indicated in addition to
standard therapy for acute asthma associated with
anaphylaxis and angioedema.
 It is not routinely indicated for other asthma
exacerbations.
Systemic corticosteroids
 Systemic corticosteroids speed resolution of
exacerbations and prevent relapse.
 Systemic corticosteroids should be administered to
the patient within 1 hour of presentation.
 Route of delivery:
 oral administration is as effective as intravenous.
.
GINA 2014
Inhaled corticosteroids
 Within the emergency department: high-dose ICS given within
the first hour after presentation reduces the need for
hospitalization in patients not receiving systemic corticosteroids
(Evidence A).
 On discharge home: the majority of patients should be
prescribed regular ongoing ICS treatment since the occurrence
of a severe exacerbation is a risk factor for future exacerbations
(Evidence B).
Ipratropium bromide
 For adults and children with moderate-severe exacerbations,
treatment in the emergency department with both SABA and
ipratropium, a short-acting anticholinergic, was associated with
fewer hospitalizations and greater improvement in PEF and
FEV1 compared with SABA alone.
GINA 2014
Aminophylline and theophylline
 Intravenous aminophylline and theophylline should not be used
in the management of asthma exacerbations, in view of their
poor efficacy and safety profile, and the greater effectiveness
and relative safety of SABA.
Magnesium
 Intravenous magnesium sulfate is not recommended for routine
use in asthma exacerbations.
 however, when administered as a single 2 g infusion over 20
minutes, it reduces hospital admissions in some patients,
including adults with FEV1 <25–30% predicted at presentation;
adults and children who fail to respond to initial treatment and
have persistent hypoxemia; and children whose FEV1 fails to
reach 60% predicted after 1 hour of care (Evidence A).
GINA 2014
Using an MDI
Need a proper hand-lung synchronism
MDIs must be used
with spacer in
children
Follow-up after an exacerbation
• Follow up all patients regularly after an exacerbation, until
symptoms and lung function return to normal
• The opportunity
– Exacerbations often represent failures in chronic asthma care,
and they provide opportunities to review the patient’s asthma
management
• At follow-up visit, check:
–
–
–
–
–
The patient’s understanding of the cause of the flare-up
Modifiable risk factors, e.g. smoking
Adherence with medications, and understanding of their purpose
Inhaler technique skills
Written asthma action plan
GINA 2014, Box 4-5
Long term management
of asthma in children
5 years and younger
GINA Global Strategy for Asthma
Management and Prevention 2014
This slide set is restricted for academic and educational purposes only.
Use of the slide set, or of individual slides, for commercial or promotional
purposes requires approval from GINA.
GINA 2014
© Global Initiative for Asthma
General principles of asthma
management
• The long term goals of asthma management
are:
- To achieve good control of symptoms and
maintain normal activity levels
- To minimize future risk of exacerbations,
fixed airflow limitation and side-effect
GINA 2014
GINA assessment of asthma control in
children ≤5 years
GINA 2014, Box 6-4 (1/2)
© Global Initiative for Asthma
Risk factors for poor asthma outcomes in
children ≤5 years
Risk factors for exacerbations in the next few months
•
•
•
•
Uncontrolled asthma symptoms
One or more severe exacerbation in previous year
The start of the child’s usual ‘flare-up’ season (especially if autumn/fall)
Exposures: tobacco smoke; indoor or outdoor air pollution; indoor allergens (e.g.
house dust mite, cockroach, pets, mold), especially in combination with viral infection
• Major psychological or socio-economic problems for child or family
• Poor adherence with controller medication, or incorrect inhaler technique
Risk factors for fixed airflow limitation
• Severe asthma with several hospitalizations
• History of bronchiolitis
Risk factors for medication side-effects
• Systemic: Frequent courses of OCS; high-dose and/or potent ICS
• Local: moderate/high-dose or potent ICS; incorrect inhaler technique; failure to protect
skin or eyes when using ICS by nebulizer or spacer with face mask
GINA 2014, Box 6-4B
© Global Initiative for Asthma
Control-based asthma management cycle in
children ≤5 years
GINA 2014, Box 6-5
© Global Initiative for Asthma
Strategies for asthma symptom
control & risk reduction
• Medication
• Treating modifiable risk factors
• Non- pharmacologic therapies
GINA 2014
Stepwise approach – pharmacotherapy
(children ≤5 years)
GINA 2014, Box 6-5
© Global Initiative for Asthma
© Global Initiative for Asthma
Stepwise approach – pharmacotherapy
(Children 6 years and older)
*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
GINA 2014, Box 3-5, Step 1
© Global Initiative for Asthma
Low dose inhaled corticosteroids
(mcg/day) for children ≤5 years
Inhaled corticosteroid
Low daily dose (mcg)
Beclometasone dipropionate (HFA)
100
Budesonide (pMDI + spacer)
200
Budesonide (nebulizer)
500
Fluticasone propionate (HFA)
100
Ciclesonide
160
Mometasone furoate
Triamcinolone acetonide
GINA 2014, Box 6-6
Not studied below age 4 years
Not studied in this age group
Low, medium and high dose inhaled
corticosteroids Children 6–11 years
Inhaled corticosteroid
Total daily dose (mcg)
Low
Medium
High
Beclometasone dipropionate (CFC)
100–200
>200–400
>400
Beclometasone dipropionate (HFA)
50–100
>100–200
>200
Budesonide (DPI)
100–200
>200–400
>400
Budesonide (nebules)
250–500
>500–1000
>1000
80
>80–160
>160
Fluticasone propionate (DPI)
100–200
>200–400
>400
Fluticasone propionate (HFA)
100–200
>200–500
>500
110
≥220–<440
≥440
400–800
>800–1200
>1200
Ciclesonide (HFA)
Mometasone furoate
Triamcinolone acetonide
– This is not a table of equivalence, but of estimated clinical comparability
– Most of the clinical benefit from ICS is seen at low doses
– High doses are arbitrary, but for most ICS are those that, with prolonged use, are associated with
increased risk of systemic side-effects
GINA 2014, Box 3-6 (2/2)
Low, medium and high dose inhaled
corticosteroids Adults and adolescents
(≥12 years)
Inhaled corticosteroid
Total daily dose (mcg)
Low
Medium
High
Beclometasone dipropionate (CFC)
200–500
>500–1000
>1000
Beclometasone dipropionate (HFA)
100–200
>200–400
>400
Budesonide (DPI)
200–400
>400–800
>800
Ciclesonide (HFA)
80–160
>160–320
>320
Fluticasone propionate (DPI or HFA)
100–250
>250–500
>500
Mometasone furoate
110–220
>220–440
>440
400–1000
>1000–2000
>2000
Triamcinolone acetonide
– This is not a table of equivalence, but of estimated clinical comparability
– Most of the clinical benefit from ICS is seen at low doses
– High doses are arbitrary, but for most ICS are those that, with prolonged use, are
associated with increased risk of systemic side-effects
GINA 2014, Box 3-6 (1/2)
Choosing an inhaler device for children ≤5 years
Age
Preferred device
Alternate device
0–3 years
Pressurized metered dose
inhaler plus dedicated spacer
with face mask
Nebulizer with face mask
4–5 years
Pressurized metered dose
inhaler plus dedicated spacer
with mouthpiece
Pressurized metered dose
inhaler plus dedicated spacer
with face mask, or nebulizer
with mouthpiece or face mask
GINA
Box6-7
6-6
GINA2014,
2014, Box
© Global Initiative for Asthma
video
© Global Initiative for Asthma
Treating modifiable risk factors
• Provide skills and support for guided asthma selfmanagement
- This comprises self-monitoring of symptoms and/or PEF,
a written asthma action plan and regular medical review
• Prescribe medications or regimen that minimize
exacerbations
- ICS-containing controller medications reduce risk of
exacerbations
- For patients with ≥1 exacerbations in previous year,
consider low dose ICS/formoterol maintenance and reliever
regimen
GINA 2014
Treating modifiable risk factors
• Encourage avoidance of tobacco smoke
• For patients with severe asthma : refer to
specialist center, if available.
• For patients with confirmed food allergy:
- Appropriate food avoidance
- Ensure available of injectable epinephrine
for anaphylaxis
GINA 2014
Non- pharmacologic therapies
• Avoidance of tobacco smoke exposure
• Physical activity
• Occupational asthma : remove sensitizer as
soon as possible
• Avoid medications that may worsen asthma:
NSAIDs ,beta-blocker
• Breathing technique
• Allergen avoidance
GINA 2014
If poor symptom control and/or
exacerbations despite treatment
Watch patient using their inhaler
Confirm the diagnosis of asthma
Remove potential risk factors &
assess and manage comorbidities
Consider treatment step-up
GINA 2014
Stepwise approach – pharmacotherapy
(children ≤5 years)
GINA 2014, Box 6-5
© Global Initiative for Asthma
© Global Initiative for Asthma
General principles for stepping down
controller treatment
• Aim : to find the lowest dose that controls
symptoms and exacerbations, and minimizes
the risk of side-effects
• When to consider stepping down
- When symptoms have been well controlled and
lung function stable for ≥3 months
- no respiratory infection, patient not travelling, not
pregnant
GINA 2014
General principles for stepping down
controller treatment
• Prepare for step-down
- record the level of symptom control and consider risk factors
- make sure the patient has a written asthma action plan
- book a follow-up visit in 1-3 month
• Step down through available formulations
- stepping down ICS doses by 25-50% at 3 month intervals is
feasible and safe for most patients
• Stopping ICS is not recommended in adults with
asthma
GINA 2014
Scenario
• หลัง start controller ผูป้ ่ วยอาการดีขน้ึ
• หลังอาการ stable ประมาณ 6 เดือน ผูป้ ่ วย loss follow up 6 เดือน
• มา admit อีก 2 ครัง้ ด้วย asthma with exacerbation จึงได้เปลีย่ น
จาก budesonide เป็ น seretide ร่วมกับ treat Allergic rhinitis ร่วม
ด้วย หลังจากนัน้ ไม่มี acute exacerbation อีก
• บิดายังคงสูบบุหรี่
• Current med :
– Avamys 1 puff hs
– Seretide evohaler (125/25) 1 puff bid