Abdullah Kharbosh, B.sc. Pharm

Asthma
Abdullah Kharbosh, B.Sc. Pharm

OBJECTIVES
To understand asthma history, definition, epidemiology

To understand airway remodeling pathophysiology in asthma
To Identify the correct asthma severity class according the National
Heart, Lung, and Blood Institute. Guidelines for the Diagnosis &
Management of Asthma (EPR-3) 2007
To be familiar with the role & the appropriate use of asthma medications
in general & in ER
Presented By
Harry Mills / PRESENTATIONPRO
First Section
Introduction, Definition, Epidemiology,
Pathophysiology, Diagnosis
INTRODUCTION
The word asthma is of Greek origin: means “panting”

More than 2000 years ago, Hippocrates used the word asthma to describe
episodic shortness of breath
The 1st detailed clinical description of the asthmatic patient was made by
Aretaeus in the 2nd century
The New Zealand & Canadian Guidelines: the 1st clinical practice
guidelines for the assessment &management of asthma were published
over 20 years ago
United Kingdom Version of Asthma Guidelines (during the same period)
The NHLB institute (mid-1990s) participated in 2 BA guidelines:
 NAEPP: asthma guidelines for the United States
 The Global Initiative for Asthma (GINA): international task force

Presented By
DEFINITION
A common chronic disorder of the airways
“Involves a complex interaction of airflow obstruction,

bronchial hyperresponsiveness & an underlying
inflammation. This interaction can be highly variable
among patients & within patients over time”
Presented By
EIPIDEMIOLOGY
It is the most common chronic disease among children

WHO estimates, 300 million currently suffer from asthma
The prevalence, mortality & cost of asthma care are increasing worldwide1
In 2005 alone, 255 000 people died of asthma (US:4000/yr)
Most asthma-related deaths occur in low & lower-middle income countries
In North America 5-10% (adults & children)2, Australia 7% (adults) 3
Asthma is a major problem in K.S.A, prevalence has risen from 8% in 1986
to 25% in 20014 [Dammam (7%), Maraba/Ramlan(6.9%), Riyadh (12%),
Assir (19.5%), Jizan (24%)]
1. The Expert Panel Report 3 Report 2007: Guidelines for the Diagnosis &Management of Asthma
2. Cote J, Cartier A, Robichand P. et al. Am J Respir Care Med. 1998;155:1509-1514.
3. Abdulwadud, Abramson M, Forbes A. et al. Respir Med. 1997; 91:524-529.
4. The National Scientific Committee of Bronchial Asthma. The Kingdom of Saudi
Presented By Arabia. Ministry of
Harry Mills
Health. The National Protocol for the Management of Asthma 3rd edition. / PRESENTATIONPRO
2000:2.
EIPIDEMIOLOGY
Age Asthma Prevalence (%) 2004-2005 Deaths Per 1,000,000

0-4 yrs 6.2 2.0
5-10 yrs 9.3 2.3
11-17 yrs 10.0 3.3
Total 8.7 2.6
This means….
• In a class of 30 children, you can expect 2 to 3 students have asthma
• This number will vary depending on age & geographical location
Presented By
PATHOPHYSIOLOGY
Our Understanding Of Asthma Has Evolved Since 1970s

1990s ‫ـــ‬
1970s-1980s 1980s-1990s Bronchoconstriction
Bronchoconstriction Inflammation Inflammation
(Spirometry) Remodeling
Bronchial Fixed
Symptoms Hyperreactivity Obstruction
Prevent Symptoms Prevent Symptoms

Relieve Symptoms Prevent Attacks
Prevent Attacks
Prevent Modeling
Presented By
PATHOPHYSIOLOGY
Asthma Etiology
Presented By
Am J Pharm Educ. 2007 October 15; 71(5): 98.
PATHOPHYSIOLOGY
Asthma Triggers
Examples of these stimuli include:
Inhaled allergens
Respiratory viral infection
Smoke
Cold/Dry air
Smoke
Methacholine
Cockroaches
Other pollutants
Endogenous stimuli that can worsen asthma include:
Poorly controlled rhinitis
Sinusitis
GERD
Premenstrual asthma reported (exact hormonal mechanism is unknown)
Presented By
PATHOPHYSIOLOGY
Components of the early phase of asthma
Presented By
PATHOPHYSIOLOGY
Asthma & serum IgE level

40 N = 2657
Odds Ratio for Presence
of Asthma 20
10
5.0
ULN
2.5
1.0
0.32 1 3.2 10 32 100 320 1000 3200

Serum IgE (IU/ml)
Presented By
ULN=upper limit of normal Harry Mills / PRESENTATIONPRO
Burrows B, et al. N Engl J Med. 1989;320:271-277.
PATHOPHYSIOLOGY
Components of the late phase of asthma
Presented By
PATHOPHYSIOLOGY
Asthma Attack
Normal Airway Function
Environmental Exposure
“Asthma Trigger”
Genetic predisposition
“Hyperreactive airways”
Repair? Injury
Smooth muscle Remodeling

hypertrophy/hyperplasia Genetic predisposition for
remodeling
Matrix deposition
Angiogenesis
Epithelial and goblet Presented By
cell phenotype alterations
PATHOPHYSIOLOGY
Summary: Characteristics of Asthma
Presented By
DIAGNOSIS
Techniques to establish diagnosis

– History
– Physical exam (resp. tract, skin, chest)
– Spirometry to demonstrate reversibility
– Additional studies :
• Evaluate alternative dx., ID precipitating factors
• Assess severity, ID potential complications
Presented By
DIAGNOSIS
CLINICAL PRESENTATION OF CHRONIC ASTHMA
GENERAL
• Asthma is a disease of exacerbation & remission, so the patient may not have
any signs or symptoms at the time of exam
SYMPTOMS
• Dyspnea, chest tightness, coughing (particularly at night), wheezing, or a
whistling sound when breathing.
SIGNS
• Expiratory wheezing, dry hacking cough, or signs of atopy (allergic rhinitis &/or
eczema)
Other
• Spirometry demonstrates obstruction (FEV1/FVC < 80%) with reversibility
following inhaled SABA administration (at least a 12% improvement in FEV1)
Presented By
DIAGNOSIS
CLINICAL PRESENTATION OF ACUTE ASTHMA

GENERAL
• An episode progress over several days-hrs (usual scenario) or rapidly 1-2 hrs
SYMPTOMS
• Anxiety, severe dyspnea, SOB, chest tightness, or burning
• Unresponsive to usual measures (inhaled SABA administration)
SIGNS
• Expiratory & inspiratory wheezing, dry cough, tachypnea, tachycardia, pale or cyanotic
skin, hyperinflated chest with intercostal & supraclavicular retractions, hypoxic seizures if
very severe, normal or slightly elevated temperature
LABORATORY
• PEF and/or FEV1 < 50% of normal predicted values
  PaO2,  PaCO2
• ABGs, Sr electrolytes (β2-agonist & CS therapy can  Sr. K & Mg &  glucose)
Presented By
RISK FACTORS FOR LIFE-THREATENING
ASTHMA AND DEATH FROM ASTHMA
Long duration of asthma Inconsistent medical follow-up

Poor control of asthma Delayed medical care
Systemic dependence on CSs Older age
Noncompliance with medication Cigarette smoking
regimen Aspirin sensitivity
Psychosocial factors Prior hospitalization from asthma
Poor socioeconomic conditions Prior use of mechanical ventilation
Presented By
Second Section
Management
SEQUENCE OF ASTHMA MANAGEMENT
Initial Assessment Follow-up Assessments

ASSESS SEVERITY using criteria ASSESS CONTROL using criteria from the NIH
from the NIH guidelines guidelines and a validated tool, such as the
Asthma Control Test™
SELECT ASTHMA THERAPY

2007 NIH steps of asthma therapy
Presented By
THREE COMPONENTS OF ASSESSMENT & MONITORING
• Severity
– The chronicity & intrinsic intensity of the disease process
– Measured b/f receiving long-term control therapy (initial asthma assessment)
• Control
– The degree to which asthma’s manifestations are minimized & the goals of
therapy are met
– Guide decisions to maintain or adjust therapy
• Responsiveness
– The ease with which asthma control is achieved by therapy
Presented By
National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and
Harry MillsManagement of Asthma
/ PRESENTATIONPRO
(EPR-3) 2007.
SEVERITY: IMPAIRMENT AND RISK DOMAINS
Presented By
SEVERITY, CONTROL, & RESPONSIVENESS
ARE RELATED
Select Appropriate
Therapy Step
Step therapy up or down

Presented By
SEVERITY TABLE: HOW IS IT ORGANIZED?
Classification of Asthma Severity >12 yrs of age

Component
Of Severity Intermittent Persistent
Mild Moderate Severe
Severity Classification
Presented By

Component Intermittent Persistent
of Severity Mild Moderate Severe
Impairment
Symptoms
Nighttime
awakening IMPAIRMENT DOMAIN
SABA use
Interference
with activity
Lung function
Presented By
SABA=short-acting β-agonist

Impairment
Symptoms
Nighttime
awakening
SABA use
Interference
with activity
RISK DOMAIN
Lung function Considers exacerbation severity, frequency, interval
RISK Exacerbations since last exacerbation, & potential link between FEV1
Presented By
requiring PO & relative annual
Harry risk
Mills / PRESENTATIONPRO
steroids

Impairment
Symptoms
Nighttime
awakening
SABA use
Interference
with activity
Lung function
Exacerbations ≥2/yr
RISK requiring PO Treatment Step
Presented By
steroids Step of treatment recommended for initial therapy,
Harry with follow-up in 2-6
Mills / PRESENTATIONPRO
wks
Component Classification of Asthma Severity (>12 yrs)
of Severity
Intermittent Persistent
Mild Moderate Severe
Symptoms <2 d/wk >2 d/wk but not Daily Throughout the
daily day
HS awake <2 d/mo 3-4x/mo >1x/wk but not nightly Often 7x/wk
Impairment
SABA use <2 d/wk >2 d/wk but not Daily Several times
daily & not >1x on per day
any day
Interference NONE Minor limitation Some limitation Extremely
with activity limited
Lung • Normal FEV1 • FEV1 : >80% • FEV1: >60% but <80% • FEV1: <60%
function predicted predicted
betn. exacer • FEV1/FVC: reduced 5% • FEV1/FVC:
• FEV1/FVC:
• FEV1: >80%
normal reduced 5%
predicted
• FEV1/FVC: N
RISK Exacerbations 0-1/yr ≥2/yr
requiring oral
Consider severity and interval since last exacerbation as they may fluctuate
steroids
over time in any severity category
Presented By
Recommended Step 1 Step 2 Step 3 Step 4 or 5
Treatment Step
GOALS OF THERAPY
Decreasing Impairment
• Prevent symptoms
– No need for reliever medications (2x or less per week)
– No daytime symptoms (2x or less per week)
– No nighttime symptoms (2x or less per week)
• Maintain “normal” pulmonary function
• Maintain normal activity/lifestyle
– No limitations in daily activities
– No limitations in exercise
• Decrease ED visits and hospitalizations
• Prevent progressive loss of lung function
• Achieve maximal pharmacotherapeutic benefit with ADRs
Presented By
EPR-3 Harry Mills / PRESENTATIONPRO
GOALS OF THERAPY
Decreasing Risk
• Prevent recurrent exacerbations

• Decrease ED visits and hospitalizations
• Prevent progressive loss of lung function
• Achieve maximal pharmacotherapeutic benefit with ADRs
Presented By
GOALS OF THERAPY:
Classification of Me
Quick Relief Long-Term Control

Short-Acting ß2-Agonists Inhaled Corticosteroids
Short-Acting ß2-Agonists Cromolyn and Nedocromil
Systemic Corticosteroids Long-Acting ß2-Agonists
Methylxanthines
Leukotriene modifiers•
Immunomodulators
Presented By
LONG-TERM CONTROL MEDICATIONS
Presented By
LONG-TERM CONTROL: CORTICOSTEROIDS
Examples Indications Potential Adverse Effects
Inhaled • Beclomethasone • Long-term prevention of • Cough
• Budesonide symptoms • Dysphonia
• Fluticasone • Control of inflammation • Candidiasis
• Mometasone • Reduce need for PO CS
• Triamcinolone
Systemic • Methylprednisolone • Reversible metabolic disorders
• Prednisolone • Fluid retention
• Short-term control of • Mood alteration
persistent asthma • Hypertension
• Peptic ulcer
• Weight gain
• Long-term control of • Adrenal axis suppression

inflammation in severe • GTH supp. Muscle weakness
persistent asthma • Dermal thinning
• Hypertension, DM
• Cushing’s syndrome
• Cataracts
Adapted from 2007 NHLBI Expert Panel Guidelines (EPR-3).

ORAL BIOAVAILABILITY OF INH CORTICOSTEROID
Corticosteroid Oral Bioavailability

Beclomethasone dipropionate 20%
Budesonide 11%
Triamcinolone acetonide 10%
Fluticasone propionate <1%
Mometasone furoate <1%
NOTE: Approximately 80% of the dose from an MDI without a

spacer is swallowed; the rest of the dose is delivered to the lungs
and is considered bioavailable.
Presented By
TIPS ABOUT CSs
• Benefits of INH CS generally outweigh potential risks of ADRs

• To reduce adverse effect potential:
– Administer INH CS with spacer (local & systemic ADRs)
– Rinse mouth thoroughly following inhalation (mouth thrush)
– Use lowest effective CS dose
• Consider adding a long-acting beta-agonist to low-to-med. dose of INH
CS before maximizing INH CS dose
• Monitor growth in children
• Consider osteoporosis prophylaxis (vitamin D & Calcium)
• Use steroid inhaler SCHEDULE not PRN
• Budesonide (Pulmicort) is the only nebulized approved steroids
Presented By
LONG-TERM CONTROL:
LONG ACTING BETA2 AGONISTS

Formoterol • Long-term prevention of symptoms, added to • Tachycardia
Salmeterol ICS • Skeletal muscle tremor
• Prevention of EIB • Hypokalemia
• Not for acute symptoms or exacerbations • Hyperglycemia
• Not sole treatment for asthma • Loss of therapeutic effect
• Rare severe exacerbations
Presented By
Adapted from 2007 NHLBI Expert Panel Guidelines (EPR-3)
ALBUTEROL VS LABA’S: PHARMACOKINETICS
Albuterol Salmeterol Formoterol

Onset 5 min 20 min 5 min
Duration 4-8 hrs 12 hrs 12 hrs
LABA’ should not be used alone or to treat acute symptoms!
Presented By
LABA USE IN CHILDREN
• Salmeterol
– FDA approved for prevention of bronchospasm and EIB in
children as young as 4 years of age
– Dosage: one inhalation every 12 hours
• •Formoterol
– FDA approved for prevention of bronchospasm and EIB in
children as young as 5 years of age
– Dose: one 12mcg capsule via inhalation every 12 hours
Presented By
LABA SAFETY
• Several trials raise safety issues

– Daily salmeterol added to usual therapy was associated with an increased
risk of asthma-related mortality1
– Formoterol associated with increased numbers of severe asthma
exacerbations2
– Black Box warning required by FDA for preparations containing LABAs
• LABAs can produce cardiovascular effects (tachycardia, QTc interval
prolongation and hypokalemia) at 4−5x recommended dose, as well as tremor
and hyperglycemia
1. Nelson HS, et al. Chest. 2006;129:15-26.

2. Mann M, et al. Chest. 2003;124:70-74. Presented By
CURRENT CONTROVERSY IN ASTHMA
MANAGEMENT: LABA SAFETY PROFILE
• The “Black Box”Warning:

– LABA’s“should ONLY be used as additional therapy for patients
not adequately controlled on other asthma-controller medications”
– LABA’sare “NOT a substitute for ICS”
– LABA’s“should NOT be used to treat acute symptoms”
– LABA’s“should NOT be initiated in patients with significantly
worsening or acutely deteriorating asthma, which may be a life-
threatening condition”
NHLBI Expert Panel Report-3. 2007. Presented By

COMBINATIONS OF CSs & LABAS
Dose Formulation Frequency Comments
(mcg)
Budesonide / 80/4.5 HFA MDI 2 puf q12h Asthma not controlled with
formoterol low/med dose ICS
160/4.5 Asthma not controlled with
med/high dose ICS
Fluticasone / 100/50 DPI 1 INH q12h Asthma not controlled with
salmeterol low/med dose ICS
250/50 Asthma not controlled with
med/high dose ICS
500/50 ---
45/21 HFA MDI 2 puf q12h Asthma not controlled with

low/med dose ICS
115/21 Asthma not controlled with
med/high dose ICS
230/21 ---
Presented By
Adapted from 2007 NHLBI Expert Panel Guidelines (EPR-3). Harry Mills / PRESENTATIONPRO
LONG-TERM CONTROL: CROMOLYN/NEDOCROMIL

Cromolyn MDI • Slow onset – 2wks. May take 4-8wks • Cough & irritation
Nedocromil MDI for expected effect • Unpleasant taste (15-20%)
(2 puffs or qid) • Long-term prevention of symptoms in
mild persistent asthma
• Alternative to steroid INH in children
• Preventative prior to exercise or allergen
exposure
• Not for rapid relief
Presented By
LONG-TERM CONTROL: IMMUNOMODULATOR
Example Indications Potential Adverse Effects

Omalizumab • Long-term prevention of symptoms • Inj. site pain & bruising
(sc q 2-4 wks in adults (≥ 12 years of age) with • Very rare anaphylaxis
based on pre- moderate or severe persistent
treatment IgE allergic asthma inadequately
levels & weight) controlled with ICS
Presented By
LONG-TERM CONTROL: LEUKOTRIENE MODIFIERS
Examples Indication Potential SEs
LTRA Montelukast • Possible initial therapy in mild persistent No specific SE identified
asthma as an alternative to ICS or
cromolyn
> Not superior to ICS alone
Zafirlukast • Possible adj. therapy to ICS at any • Reversible hepatitis
level of asthma severity • Rarely irreversible
> Not superior to LABA when combined hepatic failure
with ICS
5-LPO Zileuton • Control & prevention of symptoms in mild • Elevation of liver enz.
inhibitor persistent asthma for patients > 12y • Case reports of
• Combo with ICS in moderate persistent reversible hepatitis &
asthma for patients > 12y hyperbilirubinemia
Presented By
LONG-TERM CONTROL: LEUKOTRIENE MODIFIERS
Consideration Zafirlukast Zileuton Montelukast

Age ≥ 5 yrs ≥ 12 yrs ≥ 1 yrs
Usual dose 5-11 yr: 10mg bid 600mg qid(im. release) 1-5 yr: 4mg qpm
≥12 yr- adult: 20mg bid 1200mg bid (CR) 6-14yr: 5mg qpm
Adult: 10mg qhs
Drug interaction warfarin, erythromycin, Phenobarbital
theophylline
Warning ? Churg- Strauss  LFTs (Req. monitor) None
? LFT
Dosing consideration empty stomach food  None None
absorption 40%
Presented By
Low-Dose Fluticasone vs. Oral Montelukast
for First-Line Treatment of Persistent Asthma
Presented By
Busse W, et al. J Allergy Clin Immunol 2001;107:461-8. Harry Mills / PRESENTATIONPRO
Salmeterol vs. Oral Montelukast
in Patients Using ICS
Presented By
Fish J, et al. Am J Respir Crit Care Med 2000;161-163:A203.
LEUKOTRIENE MODIFIERS: PLACE IN THERAPY
• Possible initial therapy in mild persistent asthma as an

alternative to INH CS or cromolyn
– Not superior to INH CS alone
• Possible adjunctive therapy in addition to INH CS at any level
of asthma severity
– Not superior to LABA when combined with INH CS
• May be useful in children or adults with poor inhaler technique,
or in younger children in whom LABA are not indicated
Presented By
LONG-TERM CONTROL: METHYLXANTHINES
Indications Potential Adverse Effects

Theophylline Long-term control and prevention of Effects assoc. with therap. doses:
symptoms, especially nocturnal • Insomnia
symptoms • GI upset/ aggravate GERD or ulcer
Serum conc:
• Difficulty of urination in elderly males
5-15 mcg/mL The main use of theophylline is as with prostatism
In the middle of adjunctive therapy to ICS in • Possible hyperactivity in children
the dosing moderate persistent asthma Effects assoc. with toxic doses (dose-
interval, at least related):
3–5 days after SR theophylline: non-preferred • Tachycardia, tachyarrhythm. (SVT)
initiation alternative for long-term prevention • Nausea & vomiting
cost or a patient’s aversion to • CNS stimulation
inhaled medication) • Headache
• Seizures
• Hyperglycemia
• Hypokalemia
Presented By
METHYLXANTHINES: PLACE IN THERAPY
• Due to availability of better agents, theophylline is the preferred

adjunctive or alternative drug
• Overall, relatively weak bronchodilating properties
• Mild to moderate anti-inflammatory properties (Cost?)
• Difficult to use:
– Numerous potential drug interactions
– Serum concentration monitoring mandatory (narrow therapeutic
range: 5-15mcg/mL)
Presented By
QUICK-RELIEF MEDICATIONS
Class Mechanism Use

SABA • Beta2 adrenergic receptor • Tx of choice for acute symptoms and
agonist prevention of EIB
• Bronchodilation
Anticholinergics • Inhibit muscarinic receptors • Adjunct to SABA for moderate-
• Reduce airway intrinsic vagal severe exacerbations
tone, bronchodilation • Alternative for SABA intolerant pts
Systemic • Block allergen Rxn • Moderate-to-severe persistent
Corticosteroids • Reduce airway asthma in acute exacerbations or to
hyperresponsiveness prevent recurrence of exacerbations
• Inhibit inflammatory cells
Presented By
SHORT-TERM CONTROL: ANTICHOLINERGIC
Example Indications Potential Adverse Effects
Ipratropium • Relief of acute • Drying of mouth and mucus secretions

2-4 puff TID QID bronchospasm • Increased wheezing
Not • Blurred vision (upon eye contact)
Tiotropium
Combination inhaled formulation of anticholinergic and SABA

• Ipratropium/albuterol MDI (2-3 puffs q6h), solution (3 ml q4-6h)
Presented By
SHORT-TERM CONTROL:
SHORT-ACTING BETA2 AGONISTS (SABA)
Albuterol • Relief of acute symptoms • Tachycardia

Levalbuterol • Prevention of EIB prior to exercise • Skeletal muscle tremor
Pirbuterol • Hypokalemia
• Increased lactic acid
• Headache
• Hyperglycemia
• Fewer systemic effects with inhaled
form
Presented By
Steps of Asthma Management
Persistent Asthma: Daily Medication

Intermittent
Consult with asthma specialist if step 4 care or higher is required.
Asthma
Step Up If Needed
Consider consultation at step 3.
Step 6
Step 5 Preferred:
Step 3 Step 4 Preferred: High-dose
Preferred: Preferred: High-dose ICS + LABA
Step Down If Possible

Low-dose Medium-dose ICS + LABA + oral
Step 2 ICS + LABA ICS + LABA corticosteroid
AND
Preferred: OR Alternative:
Consider AND
Low-dose Medium-dose Medium-dose
ICS Omalizumab Consider
Step 1 ICS ICS + either
for Omalizumab
Preferred: Alternative: Alternative: LTRA,
patients who for
SABA PRN Cromolyn, Low-dose ICS Theophylline,
have allergies patients who
Nedocromil, + either LTRA, or Zileuton
have allergies
LTRA, or Theophylline,
Theophylline or Zileuton
Intermittent Mild Moderate
Severe Patients ≥ 12 yrs
EMERGENCY DEPARTMENT TREATMENT
• Start treatment when asthma exacerbation recognized

• While tx is being given:
– Take a more detailed history
– Complete physical examination
– Perform laboratory studies
• PEF on presentation, after initial tx. and at frequent intervals)
Presented By
– Perform laboratory studies

• FEV1 or PEF <50% pred. then assess oxygenation
by pulse oximetry
• Lab studies will vary with situation (CBC,
electrolytes, serum theophylline level. CXR, ECG).
These lab studies are NOT routinely recommended
Presented By
– Treatment:
• O2 (Sa O2 90-95),
• Inhaled short-acting bronchodilator for all pts. (3 tx Q 20
min, continuous therapy an option)
• Consider anti-cholinergics
• Oral systemic corticosteroids (unresponsive to initial beta2
agonist therapy, moderate-to-severe asthma, people who
are on steroids)
• Systemic steroids administered when admitted
• Methylxanthines are not recommended?
Presented By
– Treatment:
• Aggressive hydration NOT recommended for older children
and adults (may be necessary with infants and sm. children)
• Antibiotics NOT recommended unless infection present
(fever, purulent sputum)
• CPT NOT recommended
• Mucolytics NOT recommended
• Sedation NOT recommended
Presented By
Hospitalization
• Decision to hospitalize depends upon:

• Duration
• Severity (symptoms & airflow obstruction)
• Course & severity of previous exacerbations
• Medication use at time of exacerbation
• Access (medical care & meds)
• Home conditions
• Psychiatric illness
Presented By
ASTHMA MANAGEMENT DURING PREGNANCY
• Treatment:
– Emergency dept. treatment
– Intubation shouldn’t be delayed once ARF is identified
• Permission hypercapnia is recommended ventilator strategy
Presented By
ASTHMA MANAGEMENT IN ER
• Lack of familiarity
• Lack of agreement
• Lack of self-efficacy
• Lack of outcome expectancy
• Presence of external barriers
– Lack of equipment or space
– Lack of time
– Lack of educational materials
– Lack of reimbursement
– Lack of appropriate infrastructure
Presented By
Cabana MD, et al. Arch Pediatr Adolesc Med. 2001;155:1057-1062.
ASTHMA MANAGEMENT IN ER
• Lack of familiarity
• Lack of agreement
• Lack of self-efficacy
• Lack of outcome expectancy
• Presence of external barriers
– Lack of equipment or space
– Lack of time
– Lack of educational materials
– Lack of reimbursement
– Lack of appropriate infrastructure
Presented By
Cabana MD, et al. Arch Pediatr Adolesc Med. 2001;155:1057-1062.
Questions
Presented By

Abdullah Kharbosh, B.sc. Pharm

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Asthma

Abdullah Kharbosh, B.Sc. Pharm

To understand asthma history, definition, epidemiology

The word asthma is of Greek origin: means “panting”

 The Global Initiative for Asthma (GINA): international task force

A common chronic disorder of the airways

“Involves a complex interaction of airflow obstruction,

It is the most common chronic disease among children

Age Asthma Prevalence (%) 2004-2005 Deaths Per 1,000,000

Our Understanding Of Asthma Has Evolved Since 1970s

Prevent Symptoms Prevent Symptoms

Components of the early phase of asthma

Asthma & serum IgE level

0.32 1 3.2 10 32 100 320 1000 3200

Components of the late phase of asthma

Smooth muscle Remodeling

Summary: Characteristics of Asthma

Techniques to establish diagnosis

CLINICAL PRESENTATION OF CHRONIC ASTHMA

CLINICAL PRESENTATION OF ACUTE ASTHMA

Long duration of asthma Inconsistent medical follow-up

Initial Assessment Follow-up Assessments

SELECT ASTHMA THERAPY

Step therapy up or down

Classification of Asthma Severity >12 yrs of age

Classification of Asthma Severity >12 yrs of age

Classification of Asthma Severity >12 yrs of age

Classification of Asthma Severity >12 yrs of age

• Prevent recurrent exacerbations

Quick Relief Long-Term Control

• Long-term control of • Adrenal axis suppression

Adapted from 2007 NHLBI Expert Panel Guidelines (EPR-3).

Corticosteroid Oral Bioavailability

NOTE: Approximately 80% of the dose from an MDI without a

• Benefits of INH CS generally outweigh potential risks of ADRs

Examples Indications Potential Adverse Effects

Albuterol Salmeterol Formoterol

LABA’ should not be used alone or to treat acute symptoms!

• Several trials raise safety issues

1. Nelson HS, et al. Chest. 2006;129:15-26.

• The “Black Box”Warning:

NHLBI Expert Panel Report-3. 2007. Presented By

45/21 HFA MDI 2 puf q12h Asthma not controlled with

Examples Indications Potential Adverse Effects

Example Indications Potential Adverse Effects

Consideration Zafirlukast Zileuton Montelukast

• Possible initial therapy in mild persistent asthma as an

Indications Potential Adverse Effects

• Due to availability of better agents, theophylline is the preferred

Class Mechanism Use

Example Indications Potential Adverse Effects

Ipratropium • Relief of acute • Drying of mouth and mucus secretions

Combination inhaled formulation of anticholinergic and SABA

Examples Indications Potential Adverse Effects

Albuterol • Relief of acute symptoms • Tachycardia

Persistent Asthma: Daily Medication

Step Down If Possible

• Start treatment when asthma exacerbation recognized

– Perform laboratory studies

• Decision to hospitalize depends upon:

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