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BRONCHIAL ASTHMA

BRONCHIAL ASTHMA. Introduction to Primary Care: a course of the Center of Post Graduate Studies i n FM. PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847. 1. Objectives. To describe how to make the diagnosis of asthma utilizing the Saudi Asthma Guidelines.

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BRONCHIAL ASTHMA

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  1. BRONCHIAL ASTHMA Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847 1

  2. Objectives • To describe how to make the diagnosis of asthma utilizing the Saudi Asthma Guidelines. • To discuss the efficacy of nebulizers versus metered dose inhalers and other medications in the treatment of asthma • To describe the following methods for monitoring disease severity and any evidence supporting one method over the other • Symptoms based (i.e. medication frequency and dose based upon symptoms) • Daily peak flow meter monitoring (i.e. red, yellow, green zones)

  3. DEFINITION OF ASTHMA • CHRONIC INFLAMATORY DISORDER OF THE AIRWAY ASSOCIATED WITH WIDESPREAD BUT VARIABLE AIRFLOW LIMITATION (PARTLY REVERSIBLE WITH OR WITHOUT TREATMENT ) • AND WITH INCREASED AIRWAY HYPERRESPONSIVENESS TO VARIETY OF STIMULI

  4. WHAT IS THE PREVALENCE IN SAUDI ARABIA ?

  5. The prevalence of asthma among school children in KSA • Range 4%-23% • Riyadh 10% • Jeddah 12% ( AL Frayh, et al, 2001 )

  6. Diagnosis

  7. history • Required a full detailed medical history and clinical exam. Including peak expiratory flow (PEF)rate. • 1-Symptoms: • Cough • Wheezing • Shortness of breath

  8. How frequent, how severe, what intervention needed. • Interfere with sport or normal physical activity • Trouble some cough between attacks • Symptoms improve by asthma medication

  9. 2- atopy :skin eczema ,itchy eye,frequent nasal blockage,discharge or sneezing especialy in the morning • 3- family history of atopic diseases. • 4- environmental history • 5- exclusion of other medical conditions

  10. Physical examination • Hight and weight(growth in childern) • Nose,throat, sinusis(polyps,deviated nasal septum,post nasal drip,pale-pink or congested nasal turbinate. • Feature of atopy • Examination of the respiratory system • May be normal between attacks • wheeze brochi,tachypnea,chest deformity suggest asthma • Stridor,clubbing,heartmurmers ----other than bronchial astha

  11. Peak expiratory flow rate (PEF): • Should be performed in every patient>5 yrs • In certain patient measuring PEF prior to and after a bronchodilator may help in confirming the diagnosis. • Measuring PEF variability comparing the morning and evening PEF over a period of 2 weeks

  12. Variability over 15% conferms but not essential for diagnosis • PEF may be normal between attacks

  13. Investigation • Usually not necessary • CXR Usually not necessary except in • Severe cases • Foreign body • Infection • Arterial blood gases in severe cases

  14. Differential diagnosis In children < 5 yrs : • Upper airway allergies,rhinitis, sinusitis • GERD • Foreign body aspiration • Recurrent viral LRTI • Cystic fibrosis • Congenital heart disease

  15. Differential diagnosis In older children and adults: • Upper airway allergies, rhinitis, sinusitis • GERD • Heart disease • COPD • Vocal cord dysfunction • Inhalation of foreign body • Hyperventilation and panic attack • Cough secondary to drugs(β-blockers and ACE inhibtors) • Bronchiachtiasis • Laryngeal dysfunction

  16. classification

  17. classification • Etiology: • Allergic and non allergic asthma • Help in determining prognosis and in determining allergen to be avoided • Severity: • Intermittent, mild persistent, moderate persistent, severe persistent. • Management at the initial assessment of a patient • Control: • Useful for ongoing therapy

  18. Classification: asthma Severity:

  19. Classification: asthma control

  20. Management

  21. Goals of successful management • Achieve and maintain control of symptoms • Maintain normal activity level ,including exercise • Maintain (near) "normal" pulmonary function. • Prevent recurrent exacerbations of asthma • Avoid adverse effects from asthma medication • Prevent asthma medication

  22. Component of asthma therapy • Develop patient /doctor partenership asthma education • Identify and reduce exposure to risk factors • Assess treat and monitor asthma • Manage asthma exacerbation emergencies • Special consideration coexisting and related condition

  23. Component 1:Develop patient /doctor partnership asthma education • Asthma education • Asthma follow up and referal

  24. Component 1:Develop patient /doctor partnership asthma education Asthma education Objectives: 1- improving knowledge of asthma 2-changing attitude and behavior 3-Improving management skills 4- improving satisfaction and overall quality of life

  25. Component 1:Develop patient /doctor partnership asthma education Elements of patient education : 1- basic facts about asthma: Disease, medication and goal of therapy 2- socio-cultural misconception: Asthma as infectious disease,asthma medication are addictive, 3- medication Advantage of inhaled over systemic medications The need for more than one inhaler

  26. Component 1:Develop patient /doctor partnership asthma education • 4- management skills Technique: • Inhalation devices,spacer, PEF Asthma self management: • Name and dose of the medication • Monitoring of asthma • Sign suggest worsening of asthma • Action in exacerbation • How and when adjust medication • How and when to seek medical attention

  27. Component 1:Develop patient /doctor partnership asthma education Follow up Initial phase: • Last until asthma control is optimum • The diagnnosis is established • Patient need to be seen at least every 3-6 weeks during this phase

  28. Component 1:Develop patient /doctor partnership asthma education • Second phase: • The asthma is well controlled • Interval history, examination ,medication • Special attention include: 1-need for emergency care 2-loss of time in work or school 3-freq. of β2 agonist usage 4-wheezing interfere with normal physical activity

  29. Component 1:Develop patient /doctor partnership asthma education 5-use of oral steroid 6-Perform spirometry or PEF in clinic 7-go over PEF chart with the patient 8- observe inhalation technique 9- step up or down anti-inflammatory therapy 10-provide written instruction to certain patients Patient need to be seen every 3-6 months Or earlier if patient deteriorate

  30. Component 1:Develop patient /doctor partnership asthma education Referral Primary health care centers: Manage asthma whose diagnosis is striaght forward and are easily controlled If asthma is partialy controlled or uncontrolled --refer to secondary care

  31. Component 2: Identify and reduce exposure to risk factors • Domestic dust mites • Air pollution • Tobacco smoke • Occupational irritants • Cockroach • Animal with fur • Pollen

  32. Respiratory (viral) infections • Chemical irritants • Strong emotional expressions • Drugs ( aspirin, beta blockers)

  33. Component 3:Assess treat and monitor asthma • asthma Severity • asthma control

  34. Asthma control test

  35. Component 4:Manage asthma exacerbation emergencies • Home management: • Frequent β2 agonist preferaply via spacer device q 4h • Dose of ICS to be increased 4 folds • Action plan

  36. Management of severe attack

  37. Peak Flow Meter Zones • Green Zone(80 to 100 percent of your personal best) signals good control. Take your usual daily long-term-control medicines, if you take any. Keep taking these medicines even when you are in the yellow or red zones. • Yellow Zone(50 to 79 percent of your personal best) signals caution: your asthma is getting worse. Add quick-relief medicines.You might need to increase other asthma medicines as directed by your doctor. • Red Zone(below 50 percent of your personal best) signals medicalalert! Add or increase quick-relief medicines and call your doctor now.

  38. Component 5:special consideration • Rhinitis • Sinusitis • Nasal polyps • Respiratory infection • GERD • Asprin induced asthma(AIA) • Pregnancy • surgery

  39. B. This patient has mild persistent asthma, which is defined as having asthma symptoms more than two times a week but less than one time a day. These patients also have nocturnal

  40. Is the asthma of the patient in the previous question controlled or not? What recommendations might you give her regarding her therapy? • A. Controlled, do not change her therapy • B. Controlled, educate regarding triggers • C. Not controlled, give a short burst of oral prednisone • D. Not controlled, add a long-acting bronchodilator such as salmeterol • E. Not controlled, add a low-dose inhaled corticosteroid or leukotriene antagonist

  41. E. This patient is not well controlled since she is using her inhaler more than twice a week and experiencing symptoms so frequently. Addition of a low-dose inhaled corticosteroid or a leukotriene antagonist are appropriate options for mild persistent asthma.

  42. The same 23-year-old patient comes in to your office 2 months later after having a kitchen fire at home and is complaining of shortness of breath. What factor on your history and physical might make you consider admitting her to the hospital? • A. Wheezing on lung exam • B. Pulse oximetry less than 93% • C. Respiratory rate of 30 breaths per minute • D. No response to one treatment with an albuterol nebulizer • E. PaCO2 of 25

  43. C. A respiratory rate of greater than 28 or pulse of greater than 110 beats per minute would both indicate a severe episode. Wheezing is an unreliable indicator of the severity of attack. A pulse oximetry measurement of 90% is the goal unless the patient is pregnant or has cardiac disease. A PaCO2 of 25 is expected in a patient who is hyperventilating. A PaCO2 that is normal or elevated may be a sign of impending respiratory failure and such patients should be monitored closely in the intensive care unit

  44. Thanks 47

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