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ASTHMA MANAGEMENT UPDATE �asthma education empowers

Tola Bayisa , MD

Consultant internist and PCCM subspecialist

associate professor of medicine

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Disclaimer�

Employer: Washington Medical center
Educator fee, travel :Astra-Zeneca, Sanofi, Pfizer ,
Not relevant

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WAD (GINA 30 years -WHO, NHLBI)

May,1^st Tuesday
20yr global & 10 yr. Ethiopia

Purpose

increase awareness, promote lung health , asthma care

2024

the theme “Asthma Education Empowers”.

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Outline

Definition
Burden
Basics of asthma
Diagnosis
Assessment and Management
Asthma education
Difficult to treat asthma

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Objectives �

At the end lecture , you will be able:

Describe core concepts in asthma definitions
Describe important pathogenic mechanism of asthma
Outline asthma treatment goals , appropriate drugs , inhalers(ICS)
Describe asthma education
Describe work up of Difficult to treat asthma

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Definition of asthma�

Asthma heterogeneous disease usually characterized by air way inflammation. It is defined by airway symptoms ,wheeze, SOB ,chest tightness and cough ,that vary overtime and intensity , together with variable expiratory air flow limitation .

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The Burden of asthma �

Prevalence –common, serous

World 1-30%
315 Mill(GINA) &262mill (WHO)
Africa 7-10%
Ethiopia 3-5%

Underdiagnosed/misdiagnosed
Childhood, all ages
Increasing
Mortality

High 300-400K/yr
Majority LMIC
Preventable

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Costs of asthma

Expensive – direct and indirect costs
Uncontrolled asthma is more expensive
Asthma is a factor and result economic deprivation-in LMIC
psychosocial , education, relationship ,stigma, job
Health care burden-LMIC

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Etiology /triggers

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Basics of asthma�

Pathogenesis of Asthma

Inflammation/mediators
AHR
Remodeling, structural change

Very important understanding

New treatment development
Treatment evolution

Pathophysiology

Obstruction
Hyperinflation

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GINA guideline/treatment evolution

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Diagnosis�

Establish diagnosis

History ,physical examination

Chronic sx , childhood
Variability

Typical feature
Less likely feature

Risks: triggers, comorbidities
Family Hx
Occupational risks

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Diagnosis…

Confirm the Diagnosis

Spirometer
Peak flow meter ( less reliable better than only clinical )

Document obstruction with
Responsiveness
Diurnal variability

Remember the importance
But not accessible , not available , expensive
But also underestimated , underused (where available )

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Spiro and PEF procedure

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Normal and abnormal spirometery study

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Diagnosis…

Provocative tests:

Asymptomatic :CVA
Methacholine challenge

Allergy Skin test

immunotherapy ,avoidance

Imaging :

CXR, CT, ECG, ECHO,

Blood tests: eosinophil , IgE
Sputum- eosino,neutro

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Differential diagnosis �

Mimics ( over diagnosis )
when no confirmatory test or imaging done or sometimes mixed conditions

All wheezes are not asthmatics

Upper airway cough syndrome
Cardiogenic pulmonary edema
Carcinoid syndrome
Tuberculosis
Bronchiectasis
COPD
Foreign body

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Assessment of asthma

Symptom control/future risk of adverse outcome

Assess treatment issues

Assess multimorbidities

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Management of asthma �

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Asthma management cycle �personalized control based asthma care

Step based initiation
Cycle based continual

Assessment
Adjustment
Review after intervention based on level of control

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Asthma management …

Symptom control and risk reduction domain
Asthma treatment Outcomes improved with control based treatment ( GINA 2014)
Emphasize initiation of ICS at initial diagnosis(GINA ) :

Reduced exacerbation , prevent lung function decline
Better sx control, decrease ER visit and hospitalizations,
Improve occupational asthma remission
Avoid over use and reliance of SABA and use of SABA alone ( risk for exacerbations , decline function and mortality )

Patient physician partnership

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ALL TREATMENT CONTAIN ANTIINFLAMATORY DRUGS(ICS)

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NO MORE SABA ALONE!

More exacerbation and
lung function decline

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Asthma management …

Before initiating:

confirm Diagnosis
record level of control and risk factor
Factors influencing choice and adherence to ICS
choose suitable inhaler device and check skill
schedule appointment

Once initiated :

review response 2-3 month /as necessary,
Check adherence and inhaler skill
Step down or up based on control level

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Choosing asthma treatment options

Population level medication choice

Preferred medication

Efficacy and Effectiveness and safety from research

Availability and cost
Formulary, national guideline

Individual level medication choice

Preferred medication
Patient character
Modifiable risk factors & morbidities
Patient view
Practical issues(available , technique, adherence , affordability ,lowest environmental impact)

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MART is the preferred

track 1

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Dose comparison between different inhalers

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Starting treatment

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SPEAKERS:

MART was originally called SMART, with the ‘S’ coming from the brandname of the medication used in most of the studies. The ‘S’ can now stand for ‘single inhaler’, but this may cause confusion because patients may have two ICS-formoterol inhalers, one at home for their maintenance treatment, and one in their bag/pocket for as-needed doses when they are away from home.
Step 5: The dotted line for MART is to indicate that there is no evidence, in a patient taking Step 5 treatment, for switching from a SABA reliever to an ICS-formoterol reliever. However, if a patient already prescribed MART is stepped up from Step 4 to Step 5, e.g. with addition of biologic therapy, there is no need to swjtch their reliever from ICS-formoterol to SABA.
In Step 5, ‘add-on LAMA’ can be combination (triple) or separate inhalers. If a patient is prescribed triple therapy with a non-formoterol LABA, the reliever should be SABA or ICS-SABA (not ICS-formoterol).

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Stepping management of Asthma �

Remember the cycle (A,A,R)
Up and down based on control level during follow up 2-3 months
Up

uncontrolled , poor outcome , expensive
assess the pt. , adjust mx and review
Increase the dose or add drugs
Treat excaebations
Short and sustained

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Stepping management of Asthma

Down

Minimize side effects , drug burden
When well controlled

sustained ,stable
assess &adjust triggers, morbidities
no exacerbations
previous attempts
patient preference ( motivated ,good literacy )

Strategy depends on

what step ,drugs , combinations, add on drugs

Reduce fist the add on , OCS

then LABA ?
then decrease ICS by 25 % gradually

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Don’t withdraw completely ICS unless temporary for Diagnosis

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Other and Add on treatment

LTRA
Azithromycin
Biologics
Bronchial Thermoplasty
OCS
Immunotherapy- SLIT , SCIT
Vaccination - flu , pneumo

Less evidence for effective or safety

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Non recommended treatments

SAMA ,SABA alone with out ICS

More Exacerbation , decline

Oral SABA and theophylline
LABA /Formoterol alone :increase risk of exacerbation

Safety ,efficacy

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Non-pharmacologic treatment

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Difficult to treat and severe Asthma

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When to Refer to specialist

Confirm diagnosis difficulty

Occupational asthma

Uncontrolled asthma with exacerbation

Risk factors with death

Severe asthma- phenotyping and treatment

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Asthma education �Principles of asthma education

Important treatment component

Improves function decline and symptom control

Improves patients literacy, partnership
Use simple languages

based in level of literacy

Continuous process
Consider sociocultural factors
Shared information ,shared goals
Discuss expectation , beliefs, fears , concerns

Whom to educate ?

Patients
Children
Guardian
Families
Teachers

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Topics for asthma education

Asthma diagnosis
Rationale and drugs for treatment and side effects,

importance of anti-inflammatory drugs

Prevention of exacerbation and Recognizing worsening
Management of comorbidities and triggers
Adherence with medications

Identify poor, factors and intervene

Written action plan

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Guided Self management

Guide Self management and monitoring

symptom and PEF

Written action plan

Recognize & manage exacerbations

Regular review of asthma control, treatment by HCW

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Choice of inhalers

Shared decision making on choice inhaler device

PMDI , DPI, mist inhalers, nebulizers
patient skill ,ability , availability , preference, ages of the pt ,comorbidity ,propellants(PMDI) environmental issue

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Choice of inhaler devices and skill training

Choose
Check
Correct-train, demo
Confirm-feedback

Skill training inhaler

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Spacer use, nebulizers

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Asthma care LMIC

Barriers/challenges -huge

Diagnostic availability , and experts ,equity ,accessibility
Treatment Availability and affordability

Solutions

Multi-stakeholder action- WHO,GINA
Avail or use alternative ,innovative diagnostic
Avail Essential drugs

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Management Guidelines�

Why ?

Progressive , updating ,evidence based

Which ?

global ,regional ,local- availability , cost

GINA
WHO
NICE
NCD

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Summary�

Asthma is heterogeneous
Inflammatory process is most important pathogenesis in asthma
Confirm dx –underused /Spirometer/Peak flow meter
Have clear Goals of asthma treatment (pt, family, parents &physicians )
Anti-inflammatory drugs ( ICS ) is cornerstone in Asthma treatment
Emphasize on Patient empowering , education and action plan in asthma care and Inhaler technique
Difficult to treat asthma approach