The Saudi Initiative for Asthma
Guidelines for the Diagnosis and Management of
Asthma in Adults and Children
2013 update
On behalf of the SINA panel
Mohamed S. Al-Moamary, FRCP (Edin) FCCP
Dep. of Medicine, King Abdulaziz Medical City-Riyadh
King Saud bin Abdulaziz University for Health Sciences
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January 2013
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What is SINA?
SINA is developed by a task force originated from the Saudi
Initiative for Asthma Group under the umbrella of the Saudi
Thoracic Society
SINA is a practical approach for a comprehensive management
of asthma in adults and children and when to refer to a
specialist.
International recommendations were customized to the local
setting for asthma diagnosis and management
Directed to HCW dealing with asthma who are not specialists in
the field.
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Purpose of SINA
To provide a document that is easy to follow,
simple to understand yet totally updated and
carefully prepared for use by non-asthma
specialist including primary care doctors and
general practice physicians
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Where do you find SINA?
The SINA guideline was published in the Annals of
Thoracic Medicine (www.thoracicmedicine.org):
Al-Moamary MS, Alhaider SA, Al-Hajjaj MS, Al-Ghobain MO,
Idrees MM, Zeitouni MO, Al-Harbi AS, Al Dabbagh MM, AlMatar H, Alorainy HS. The Saudi initiative for asthma - 2012
update: Guidelines for the diagnosis and management of
asthma in adults and children. Ann Thorac Med 2012;7:175204
The SINA guidelines booklet is available at:
www.sinagroup.org
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Saudi Thoracic Society commitment
The STS is committed to improve the care of
asthma by a long term plan:
Periodic scientific meetings
Annual asthma meeting (since 2001)
Frequent asthma courses
Educational brochures
Publishing new and updated asthma guidelines
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January 2013
What is new in SINA-2012
Comprehensive revision with the addition of
new 125 references
Addition of charts and algorithms for asthma
diagnosis and management
Updating asthma management
Rewritten “asthma in children” section
New section on “difficult to treat asthma”
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January 2013
SINA Panel
Mohamed S. Al-Moamary (Chairman), King Saud bin Abdulaziz University for
Health Sciences, Riyadh
Sami Alhaider, King Faisal Specialist Hospital and Research Center, Riyadh
Mohamed S. Al-Hajjaj, King Saud University, Riyadh
Mohammed O. AlGhobain, King Saud bin Abdulaziz University for Health
Sciences, Riyadh
Majdy M. Idrees, Military Hospital, Riyadh
Mohamed O. Zeitouni, King Faisal Specialist Hospital and Research Center,
Riyadh
Adel S. Alharbi, Military Hospital, Riyadh
Hussain Al-Matar, Imam Abdulrahman Al Faisal, Dammam
Maha M. Al Dabbagh, King Fahd Armed Forces Hospital, Jeddah
Hassan S Alorainy, King Faisal Specialist Hospital and Research Center,
Riyadh
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January 2013
Acknowledgment
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The SINA panel would like to thank the following reviewers :
Prof. J. Mark FitzGerald from the University of British Columbia,
Vancouver, BC, Canada
Prof. Qutayba Hamid from the Meakins-Christie Laboratories, and
the Montreal Chest Research Institute
Prof. Sheldon Spier, the University of British Columbia, Vancouver,
Canada
Prof. Eric Bateman from the University of Cape Town Lung Institute,
Cape Town, South Africa (SINA 2009)
Prof. Ronald Olivenstein from the Meakins-Christie Laboratories
and the Montreal Chest Research Institute, Royal Victoria Hospital,
McGill University, Montreal, Quebec, Canada. (SINA 2009)
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SINA Documents
Published manuscript
Booklet
Electronic version
Slides kit
Flyers
Website: www.sinagroup.org
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Sections of SINA – update cover
Epidemiology
Pathophysiology
Diagnosis
Medications
Approach to Management
Treatment Steps
Special Situations
Acute Asthma
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Prevalence
Prevalence of
asthma has
increased between
1986 – 1995
Alfrayyah et al. Ann Allergy Asthma
Immunol 2001;86:292–296
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Burden of Asthma
Asthma is among the most common chronic illnesses
in Saudi Arabia
53% had missed school or work (AIRKSA-2007)
35% attempted Unconventional therapy (Al Moamary, ATM
2008)
46% were controlled in Riyadh (AIRKSA-2007)
36% were controlled in 5 tertiary care centers in
Riyadh (Aljahdali SMJ-2008)
48% were controlled in one center (Al Moamary, ATM 2008)
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AIRKSA report (Ministry of Health)
78 % of adults & 84% of kids reported acute asthma
over 12 months (AIRKSA)
54 % of adults & 80% of kids reported ER over 12
months (AIRKSA)
45-68% of adults & 37-56% of kids reported
limitation of activity over 12 months (AIRKSA)
76 % of adults & 78% of kids never had
spirometry(AIRKSA)
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The prevalence of wheeze and
associated symptoms in the study group
Al-Ghobain et al, NBC Pulm Med 2012;12:39
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Pattern of asthma treatment
Al-Shimemeri, Ann Thorac Med 2006;1:20-5
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Pathology of Asthma
Inflammation
Airway Hyper-responsiveness
Airway Obstruction
Symptoms of Asthma
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Pathophysiology
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Inflammation  Remodeling
Inflammation
Airway Hypersecretion
Subepithelial fibrosis
Angiogenesis
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Diagnosis - History
Episodic attacks:
Cough
Breathlessness
Wheezing
Nocturnal symptoms
Patient could be asymptomatic between attacks
co-existent conditions: GERD, rhinosinusitis.
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Relevant Questions
Does the patient or his/her family have a history of asthma
or other atopic conditions, such as eczema or allergic
rhinitis?
Does the patient have recurrent attacks of wheezing?
Does the patient have a troublesome cough at night?
Does the patient wheeze or cough after exercise?
Does the patient experience wheezing, chest tightness, or
cough after exposure to pollens, dust, feathered or furry
animals, exercise, viral infection, or environmental smoke?
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Relevant Questions
Does the patient experience worsening of symptoms after
taking aspirin/nonsteroidal inflammatory medication or use
of B-blockers?
Does the patient's cold “go to the chest” or take more than
10 days to clear up?
Are symptoms improved by appropriate asthma treatment?
Are there any features suggestive of occupational asthma
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Physical Examination
Normal between attacks
Bilateral expiratory wheezing
Examination of the upper airways
Other allergic manifestations: e.g., atopic
dermatitis/eczema
Consider alternative Dx when there is localized
wheeze, crackles, stridor, clubbing
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Investigations
Measurements of lung function:
Spirometry
Peak expiratory flow (PEF)
Normal Spirometry does not role out asthma
Spirometry is superior to PEF
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Bronchodilator response
Proper instructions on how to perform the forced
expiratory maneuver must be given to patients, and
the highest value of three readings taken.
The degree of significant reversibility is defined as an
improvement in FEV1 ≥12% and ≥200 ml from the
pre-bronchodilator value.
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Clinical Assessment
Measurements of allergic status to identify
risk factors (if indicated)
Chest X-ray is not routinely recommended
Routine blood tests are not routinely
recommended
IgE measurement is indicated in severe cases
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Assessment of Asthma Control
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Asthma Control Test
Level of Control:
• Total:
25
• Control:
20-24
• Partial control: 16-19
• Uncontrolled:
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< 16
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Differential Diagnosis
Upper airway diseases
Allergic rhinitis and sinusitis
Obstructions involving large airways
Foreign body in trachea or bronchus
Vocal cord dysfunction
Vascular rings or laryngeal webs
Laryngotracheomalacia, tracheal stenosis, or bronchostenosis
Enlarged lymph nodes or tumor
Obstructions involving small airways
Viral bronchiolitis or obliterative bronchiolitis
Cystic fibrosis
Bronchopulmonary dysplasia
Heart disease
Other causes
Recurrent cough not due to asthma
Aspiration from swallowing mechanism dysfunction or GERD
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Management of Acute Asthma
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Acute Asthma in Adults
Most patients who present with an acute asthma
exacerbation have chronic uncontrolled asthma
The following should be carefully checked:
previous history of near fatal asthma
patient taking three or more medications
heavy use of SABA and frequent ER visits
Patient should be assessed to determine the severity
of acute attacks
PEF and pulse oximetry measurements are
complementary to history taking and physical
examination
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Levels of severity of acute asthma
exacerbations in adults
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Initial Assessment of Acute Asthma
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Medications used in acute asthma
Oxygen
High concentration of inspired oxygen to correct
hypoxemia (do not miss COPD)
Pulse oximetry should be used to tailor oxygen
therapy
Failure to achieve oxygen saturations of more than
92% is a good predictor of the need for
hospitalization
Normal or high PaCO2 is an indication of a severe
attack, and need for specialist consultation
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Bronchodilators
Inhaled salbutamol is the preferred choice
Repeated doses is recommended at 15–30
minute intervals.
Alternatively, continuous nebulization
(Salbutamol at 5–10 mg/hour) may be used
for one hour if there is an inadequate
response to initial treatment.
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January 2013
Bronchodilators
Patients who are able to use the inhaler
devices, 6–12 puffs of MDI with a spacer are
equivalent to 2.5 mg of Salbutamol by
nebulizer
In moderate to severe acute asthma,
combining ipratropium bromide with
Salbutamol has some additional
bronchodilation effects, in reducing
hospitalizations and greater improvement in
PEF or FEV1
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January 2013
Steroid therapy
Systemic steroids: reduce relapses and
subsequent hospital admission
Oral steroid = injected steroids
Oral prednisolone: 40–60 mg daily
Systemic steroids should be given for seven
days for adults and three to five days for
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January 2013
Magnesium sulphate
A single dose of IV magnesium sulphate (1.2–
2 gm IV infusion over 20 mins) is safe and
effective
Routine use of IV magnesium sulphate in
patients with acute asthma presenting to
emergency department is not recommended.
Its use should be limited to those with sever
exacerbation who fail to respond to
treatment after an hour
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January 2013
Intravenous aminophylline
In acute asthma, the use of intravenous
aminophylline did not result in any additional
bronchodilation compared to standard care
with B2-agonists
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Antibiotics
Viral infection is the usual cause of asthma
exacerbation
The role of bacterial infection has been
probably overestimated, and routine use of
antibiotics is strongly discouraged
They should be used when there is
associated pneumonia or bacterial bronchitis
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Initial Management of Acute Asthma
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If there is an adequate response
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If there is a partial response
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If there is a poor response
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Referral to a specialist center
Status asthmatics
Deteriorating PEF
Persisting or worsening hypoxia
Hypercapnea, respiratory acidosis (pH <7.3)
Severe exhaustion
Increase work of breathing
Drowsiness
Confusion
Coma
Respiratory arrest
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Criteria for admission
Patients whose peak flow is ≥ 60% best or predicted
one hour after initial treatment can be discharged
from the emergency department
Criteria for admission:
Any feature of a life threatening, near fatal attack
Any feature of a severe attack that persists after initial
treatment.
unless any of the following is present:
still suffering from significant symptoms
previous history of near fatal or brittle asthma
concerns about compliance and pregnancy
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Asthma in children < 5 years
No tests can diagnose asthma with
certainty.
Lung function testing is not very helpful
CXR may help to exclude structural
abnormalities of the airway.
A trial of treatment with short-acting
bronchodilators and inhaled
corticosteroids (ICS) for at least 8 to 12
weeks may provide some guidance as to
the presence of asthma.
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January 2013
Acute asthma in children < 5 years
Immediate medical attention should be
taken in case of children less than two
year who had a history of poor response to
three doses of SABA within 1–2 hours,
saturation less than 92%, or the child is
acutely distressed.
In this age group, the risk of fatigue,
respiratory compromise and dehydration is
considerable
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January 2013