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Bronchial Asthma

Marshell Tendean, MD
Departemen of Internal Medicine
UKRIDA - Jakarta

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Objective:

To discuss the natural history of bronchial asthma

To discuss the clasification of bronchial asthma

regarding GINA guidelines

To discuss the current treatment for bronchial ashtma

stable exacerbation if different setting

Test case

Who Regulatory on Smoking Cessation

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Definition :

Asthma is a disease with many variations

(heterogeneous), usually characterized by chronic airway
inflammation.

A flare-up or exacerbation is an acute or sub-acute

worsening in symptoms and lung function from the patients
usual status.

The dominant feature that leads to clinical symptoms is

smooth muscle contraction and inflammation, which
results in narrowing of the airway and obstruction.

Numerous triggers can induce bronchoconstriction,

including allergic responses, respiratory infections,
exercise, irritants, and nonsteroidal anti-inflammatory
drugs in select patients.

Persistent inflammation in the airway may lead to

structural changes, such as mucus hypersecretion,
smooth muscle hyperplasia, subepithelial fibrosis, blood
vessel proliferation, and infiltration of inflammatory cells.

Clinical Science; 439-450;

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Molecular Pathogenesis of
Ashtma

American Osteopathic Association,Vol. 111, S11-S17.

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Autonomic Model

Respiratory Medicine (2006) 100, 1688170

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Diagnosis :
1. A history of variable respiratory symptoms

Typical symptoms are wheeze, shortness of breath, chest

tightness, cough (variably; worse at night or on waking; triggered
by exercise, laughter, allergens or cold air (viral infections))

2. Evidence of variable expiratory airflow limitation

Reduced FEV1/FVC ratio.

Reversibility : FEV1 increases > 12% and 200mL (in children,

>12% of the predicted value) post bronchodilator or 4 weeks of
anti inflamatory treatment.

Average daily diurnal PEF variability* is >10% (in children, >13%)

Asthma classification regarding

severity

Eur Respir J 2015;

How to Assess patient with

Asthma :

1. Asthma control

Assess symptom control over the last 4 weeks

Identify any other risk factors for poor outcomes

Measure lung function before starting treatment, 36 months later,

and then periodically, e.g. yearly

2. Treatment issues

Record the patients treatment, and ask about side-effects

Watch the patient using their inhaler, to check their technique

Have an open empathic discussion about adherence

Check that the patient has a written asthma action plan

Ask the patient about their attitudes and goals for their asthma

3. Are there any comorbidities?

These include rhinitis, rhinosinusitis, gastroesophageal reflux

(GERD), obesity, obstructive sleep apnea, depression and anxiety.

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Treatment in Special
Population :

Pregnancy

Rhinitis

Obestity (weight reduction)

Elderly

GERD

Anxiety and depression

Aspirin exacerbated respiratory disease (AERD)

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Non Pharmacological :

Smoking cessation

Physical activity

Occupational asthma

NSAID including aspirin

Emotional hazzard

Infectious agent

Consider :
Provide guide self management education
Treat modifiable factors and comorbidities
Consider stepping up (comorbities, adherence)
Consider stepping down (low risk exacerbation +
risk controled for3 month); avoid cease
corticosteroid

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New Recommendation :

Provide written asthma action plan :

The patients usual asthma medications

When and how to increase medications, and start OCS

How to access medical care if symptoms fail to respond

Medication changes for written asthma action plans

Increase frequency of inhaled reliever (SABA, or low dose

ICS/formoterol); add spacer for pMDI.

Increase controller:

ICS: At least double dose, consider increasing to high dose.

Maintenance ICS/formoterol: Quadruple maintenance ICS/formoterol

dose (to maximum formoterol dose of 72 mcg/day).

Maintenance ICS/salmeterol: Step up at least to higher dose formulation;

consider adding separate ICS inhaler to achieve high ICS dose.

Maintenance and reliever ICS/formoterol: Continue maintenance dose;

increase as-needed ICS/formoterol (maximum formoterol 72 mcg/day).

Oral corticosteroids (preferably morning dosing):

Adults - prednisolone 1mg/kg/day up to 50mg, usually for 57 days.

For children, 12 mg/kg/day up to 40mg, usually for 35 days.

Tapering not needed if treatment has been given for less than 2 weeks.

Identifying patients at risk of asthma-related

death

A history of near-fatal asthma requiring intubation and ventilation

Hospitalization or emergency care for asthma in last 12 months

Not currently using ICS, or poor adherence with ICS

Currently using or recently stopped using OCS (this indicates the

severity of recent events)

Over-use of SABAs, especially more than 1 canister/month

Lack of a written asthma action plan

History of psychiatric disease or psychosocial problems

Confirmed food allergy in a patient with asthma

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Ashtma control test

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Asthma Medication :
Controler Medication

Actions / Side effect

Inhaled corticosteroids
(ICS) (pMDIs or DPIs) e.g.
beclometasone, budesonide,
ciclesonide, fluticasone
propionate, fluticasone furoate,
mometasone, triamcinolone

Maristay for asthma

medications
Local side-effects include
oropharyngeal candidiasis and
dysphonia

ICS and long-acting beta2

agonist bronchodilator
combinations (ICS/LABA)
(pMDIs or DPIs) e.g.
beclometasone/ formoterol,
budesonide/formoterol,
fluticasone furoate/ vilanterol,
fluticasone
propionate/formoterol,
fluticasone propionate/
salmeterol, and
mometasone/formoterol.

Indicated when low dose ICS

fails to improve symptoms
Is it saver to use in the form of
combination with ICS

+Asthma Medication :
Controler Medication

Actions / Side effect

Leukotriene modifiers
(tablets) e.g. montelukast,
pranlukast, zafirlukast, zileuton

Used alone less efective than low

dose ICS
Inc combination with ICS less
efective than ICS Laba
Few side-effects except elevated
liver function tests with zileuton
and zafirlukast

Chromones (pMDIs or DPIs) e.g.

sodium cromoglycate and
nedocromil sodium

Very limited role in long-term

treatment of asthma. Require
meticulous inhaler maintenance

Anti IgE (Omalizumab)

A treatment option for patients

with severe persistent allergic
asthma uncontrolled on Step 4
treatment (high dose ICS/LABA).
Side effect rare (anaphylaxis)

Anti-IL5 (mepolizumab)

An add-on option for patients aged 12 yrs

with severe eosinophilic asthma uncontrolled
on Step 4 treatment (high dose ICS/LABA)

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Asthma Medication :
Reliever Medications

Actions / Side effect

Short-acting inhaled beta2agonist bronchodilators

(SABA) (pMDIs, DPIs and,
rarely, solution for nebulization
or injection) e.g. salbutamol
(albuterol), terbutaline.

Inhaled SABAs are medications

of choice for quick relief of
asthma symptoms and
bronchoconstriction

Short-acting
Long-term use: ipratropium is
anticholinergics (pMDIs or
a less effective reliever
DPIs) e.g. ipratropium bromide,
medication than SABAs.
oxitropium bromide

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Test case :

A-25 yo F. come to ER with Chief complaint of cough

and breathlessness 3 days PTC

She has the episode of breathlessness since childhood

and it may reccur when rainy season or going to higher
altitude. It might not related with physical activity

PE: Patient in moderate illnessess, BP: 120/90, HR:

100/min, RR: 24/min, FEV1 prediciton 65%.

Lung : minimal wheeze in both lung field

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Question ?

What other information u need to obtain from the

patients

What kind of examination will you refer to the patients

What kind of medication will u start on the patients

How will u educate the patients

Smoking Cessation :
Marshell Tendean.
Department of Internal Medicine
UKRIDA Jakarta

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Recommendations :

Ask about and record smoking status, keep record up to date;

Advise smokers of the benefit of stopping in a per- sonalised

and appropriate manner (this may include linking the advice
to their clinical condition);

Assess motivation to stop;

Assist smokers in their stop attempt if possible; this

might include the offer of support, recommenda- tion to use

NRT or bupropion and accurate infor- mation and advice about
them, referral to a specialist cessation service if necessary;

Arrange follow up if possible.

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Counseling

If help can be offered a few key points can be covered

in a few minutes:

set a stop day and stop completely on that day

review past experience and learn from it (what helped?

what hindered?)

make a personalised action plan

identify likely problems and plan how to cope with them

ask family and friends for support

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Pharmacotherapies :

NRT (Nicotine Replacement Therapy) :

Patch, gum, nasal spray, inhalator, tablet, lozenge

Indicated in patients who smoke 10 or more cigaretes per

day and ready to stop smoke

Bupropion

Vernecletine

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Ineffective or unproven
approach

Hipnoterapi

Accupunture

Naltrexone

Biomedical feedback

Aversive or rapid smoking

Physical activity

Allen car method

St John wort

Nicotine blocker related agent